Integrating and Improving Care Across the Continuum

How Dartmouth-Hitchcock Health Built a Foundation for Seamless Care Delivery

Dartmouth-Hitchcock Health (D-HH) worked with Huron to integrate and improve care across the continuum, increase access to care, and further its community-focused mission.


Operational challenges, including inefficiencies in patient throughput and limited post-acute options, were driving significant capacity constraints at D-HH. In the ambulatory setting, siloed care specialties, the minimal utilization of advanced provider practitioners at the top of their licensure, and a low level of participation with centralized scheduling were further restricting care access and disrupting smooth and timely hospital-to-clinic care transitions.

The medical center was turning away 200 to 300 patients per month due primarily to limited inpatient bed capacity, which sometimes required sending members of the community to hospitals hundreds of miles away.

Amid these challenges, COVID-19-related staff and bed shortages within the system and across the organization’s post-acute networks exacerbated length-of-stay issues and further stressed the organization’s capacity.

As the key provider of care in the region with a strong community-focused mission, it was critical for D-HH to improve care coordination and care access to better support the health of its community by creating additional capacity.

Our work with Huron – including reinventing processes, procedures, and virtual rounds during COVID-19 – has led to amazing improvements for our organization.


D-HH and Huron worked together to implement an integrated set of process and accountability improvements to address workflow and communication inefficiencies contributing to throughput delays and care access challenges. Simultaneously, the team established a future-state care progression design to support well-coordinated patient transitions from the hospital to the clinic and post-acute care settings.

These combined initiatives ultimately helped the organization reduce capacity denials while improving care quality, patient and family experience, and provider and staff satisfaction.

The organization’s journey to integrate and improve care across the entire care continuum included the following:

Developing a long-term, future-state vision: D-HH leaders and Huron began the transformation with a comprehensive assessment of the organization’s acute care facilities, ambulatory access, and surgical scheduling.

The teams worked together to create both near-term and long-term plans for the organization to improve access and transitions of care across the care continuum. In the initial phase of the project, D-HH was able to immediately address throughput issues to decrease the length of stay, which ultimately built the foundation to improve transitions from the hospital to the clinic/ambulatory and post-acute settings.

Optimizing key processes and care access: Leaders from D-HH worked with Huron to improve key processes, workflows, and communication, resulting in an increased capacity for more consumer visits across the system.

This work included the rapid implementation of virtual processes and virtual care delivery at the onset of the COVID-19 pandemic. D-HH set a goal to increase virtual visits by 50%. Together, D-HH and Huron were able to quickly build the infrastructure to support telehealth offerings and scale virtual services, including the development of a tool that helped determine if patients needed to see a physician or other provider.

Huron and D-HH focused on elevating the health system’s advanced provider practitioners to a top-of-licensure model, resulting in improved patient access to primary care services.

Improving coordination and communication across care settings: To achieve better alignment, D-HH and Huron focused on improving patient handoffs, bringing together care team members and leaders in collaborative work groups to redesign inefficient processes and address other transition issues.

The team launched a pilot program to improve documentation and increase communication at handoff between the medical center and local skilled nursing facilities. Another work group redesigned a process for securing post-acute clinic appointments and facilitating communications between the acute and ambulatory providers.

At the onset of COVID-19 social distancing protocols, the team integrated virtual interdisciplinary rounds (IDRs) into its care delivery model. This virtual approach furthered alignment as more members of both the inpatient and ambulatory care teams were included throughout the patient journey, ultimately fostering stronger connections and better transitions of care. In one example of this work, oncology nurse navigators from the ambulatory setting joined IDRs remotely to strengthen patients' inpatient-to-ambulatory care transitions.

Dartmouth-Hitchcock Health (D-HH) serves a population of 1.9 million patients across northern New England and is the only academic health system in New Hampshire. D-HH provides access to more than 1,800 providers in almost every area of medicine.

*Excludes three months when transfer requests were reduced due to COVID-19 impacts.

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