The Problem Isn’t What You Think
There are patients at McLaren Port Huron who touched every part of the organization in a single care episode. They were admitted through the hospital, transferred to the skilled nursing facility for recovery, and followed up with a physician from the integrated medical group. On paper, that is exactly what an integrated health system is supposed to do. In practice, making it happen smoothly required work that nobody had automated.
When administrators talk about coordination, they usually mean communication: getting the right information to the right person at the right time. That matters. But the coordination problem Eric Cecava of Fort Gratiot encountered running McLaren Port Huron’s three-entity system was structural, not informational. The entities had different incentives, different vocabularies, and different cultures built over decades before anyone decided they should work together.
You can fix communication with technology. You fix structural misalignment by changing what people are accountable for, which is considerably harder and takes considerably longer.
How Patient Flow Actually Works
A patient comes into the hospital with a hip fracture. They have surgery. They need post-acute care. Whether they go to the skilled nursing facility, a different SNF in the region, or home with outpatient services depends on a series of decisions that happen fast, involve multiple parties, and have consequences that stretch out over weeks.
The hospital care manager is thinking about discharge. The surgeon is thinking about clinical appropriateness. The patient and family are thinking about location, cost, and convenience. The SNF is thinking about staffing capacity and clinical complexity. None of those perspectives are wrong. But they don’t naturally resolve into a clean handoff without someone designing the process that connects them.
Why the Data Doesn’t Help As Much As It Should
One thing Cecava brought from his business intelligence background at Adena Health System was a clear-eyed view of what data could and couldn’t tell you. Data can tell you what happened. It can tell you where patients went after discharge and how they did when they got there. It can surface patterns that aren’t visible at the unit level.
What data can’t tell you is why the transfer coordinator and the SNF intake team have a three-hour lag in their handoff process. That’s a conversation, not a query. The operational fix usually starts with someone sitting in a room with both parties and asking what’s in the way.
What Good Coordination Looks Like
Good coordination in a multi-entity system is mostly invisible. Patients move through the care continuum without being aware of the organizational complexity underneath. Clinicians on one side of a transfer have the information they need when they need it. Families aren’t repeating the same history to three different teams.
Getting there requires what Cecava of Fort Gratiot describes as building the connective tissue: shared processes, metrics, and accountabilities that cross entity lines. It’s not complicated in theory. In practice, it requires someone with the authority and the patience to hold both sides of every seam accountable for what happens in the gap between them.