Margin notes from the COVID-19 pandemic for the future of healthcare innovation

Duress and disruptive innovation

Disruptive innovation in healthcare has been more elusive than suggested by what has been called its “epidemic of inauthenticity,” ¹ with venture capital playing a significant role in both the hype and the cultivation of disconnected point solutions.^2-4 Christensen’s application of his field-defining concept of “disruptive innovation” ⁵ to healthcare has been underexplored and is prescient to revisit as healthcare systems recover and reorient as they emerge from the COVID-19 pandemic. Disruptive innovation is reflected in the ability of entrepreneurial organizations to leverage their dexterity, speed and initial marginal market positions to rapidly evolve new services or products capable of restructuring entire industry dynamics and trajectories. While Christensen first identified potential disruptive innovator candidates in ambulatory surgery centres, specialty hospitals and retail clinics,^6,7 none of these structurally disrupted the healthcare sector. ⁸ He later turned to community health workers, care coordination, and Medicare Advantage (i.e. “value-based care”) as the real disruptive forces on the horizon, ⁹ upending the nature of health work through task-shifting, ¹⁰ promoting clinical and social care integration ¹¹ and shifting funding from fee-for-service to risk-bearing accountability for outcomes. ¹²

The COVID-19 pandemic was a characteristic “big-event disruption” ¹³ challenging the safety and sustainability of healthcare delivery and forcing the reconfiguration of care from the direct towards the virtual.^14,15 Virtual care has proved to be a successful disruptive innovation, even considering that new venture investment in 2022 captured less than 50% of the previous year. ¹⁶ While virtual care has been the dominant disruptive figure through COVID-19, there are lessons that pick up on Christensen’s earlier work on community health workers, health and social care coordination and integration, and value-based care, that are born out of the duress experienced on the complex margins of the mainstream of healthcare and society.

Visibility and value

The most publicly visible community impact of the COVID-19 pandemic has been its devastating toll on the frail elderly in Long-Term Care (LTC) facilities. ¹⁷ Less “visible” was the disproportionate morbidity and mortality experienced by low-income, racialized and underhoused communities.^18,19

The >600,000 unhoused people in Canada and the US each night (580,000 in the US ²⁰ and 35,000 in Canada ²¹ ) evinced unique experiences and health system responses. Structurally similar, the biosocial environment of LTC homes and shelters predictably predisposed residents to the rapid transmissibility and health impacts of COVID-19. Shelters across North America faced recurring waves of outbreaks, with high rates of morbidity, acute and intensive care utilization, and mortality.^22-24 These outcomes remained initially largely invisible to the public. Unlike LTC facilities, however, most unhoused people are highly mobile, often forced to leave each morning to find work, food, and social support. As outbreaks overcame shelters, many exercised their mobility to seek what were felt to be safer alternatives: encampments in public parks and under bridges and emergency departments. As a result, unhoused people instantly became highly “visible”.

Urban centres across Canada and the US managed encampments by resorting mostly to either relative neglect or heavy policing with none adhering to established human rights protocols. ²⁵ The Centers for Disease Control and Prevention (CDC) cautioned that forced evictions both risked worsening COVID-19 spread across communities and predisposed residents to avoidable increased health risks. ²⁶ Emergency departments, already strained by COVID-19 in the wider population, were similarly flooded with unhoused people ²⁷ who were often unable comply with standard public health protocols.

The “visibility” of unhoused people in encampments and emergency departments staked a claim to their value and the policing and emergency warehousing responses that dominated initial reactions were neither evidence-based nor cost-efficient. Under the significant duress of COVID-19, health and social care agencies working for these communities were forced to innovate and did so in exactly the kind of disruptive ways foreshadowed by Christensen only a few years earlier.

Venue variation and versatility: Disrupting the presumptions of place

Healthcare has traditionally been a “bricks and mortar” operation with hospitals in the acute sector, clinic buildings in the community, and community diagnostic and laboratory facilities. ²⁸ Such operational configurations rest on a dual-premise: that such facilities are operationally necessary for the safe and effective delivery and coordination of care and that such proximity and concentration of services is more cost-efficient. These operational and economic assumptions have largely not been tested. It is likely, however, that life-threatening acute illness, trauma, surgery, and intensive care require traditional healthcare facilities.

Born out of the necessity of accessibility, healthcare for the most socially and medically complex individuals and communities has always challenged such presumptions of place. ²⁹ During the pandemic, healthcare providers for unhoused communities significantly broadened and deepened this tradition. ³⁰ Outreach to encampments grew significantly, with heavily policed evictions turning encampment work into zones of conflict medicine, requiring the co-management of chronic illness, substance use, and COVID-19 risks alongside the physical and psychological trauma of forcible and often violent displacement. Outreach in such circumstances became tactical, leveraging direct and social media relationships to respond rapidly, to locate dispersed patients, and to provide at times clandestine care to those criminalized for their publicity.

The other major disruption to place during the pandemic was the pressing need for new indoor spaces to meet public health distancing guidelines and increased numbers of unhoused populations resulting from global economic instability and acutely competitive housing markets. ³¹ With the collapse of the tourism industry, North American municipalities turned to vacant hotels to establish new shelter and housing options. Community health organizations serving underhoused communities adapted by bringing supports directly to the thousands of people living in hotels in most large cities.

The disruption brought by the deployment of hotels during the COVID-19 pandemic involved not just new clinical places of care, but also altered the cadence and approach to change: distributed care became increasingly “modular.” The temporality of changing places of care throughout the pandemic had both predictable and unpredictable rhythms:

One scenario involved hotels rapidly filling upon opening, followed by a brief period of weeks to months of residential stability, only to be closed unpredictably as leases were terminated or public pressure mounted to identify alternative locations. Clinical and community health teams learned to complete rapid community health assessments, to triage immediate needs, and to ensure complex chronic medical and mental health needs were addressed as quickly as possible. ³² Teams providing care to these communities developed an increasingly nuanced ability to determine the kind of clinical and social care required based on the size and type of location, anticipated duration of stay, available physical space, and demographic and health profile of the community. Teams would deploy, set-up, stabilize, and coordinate care while planning in parallel for inevitable redeployment. This was a whole new way of responding to community needs that was person and community-centred, dynamic, and organized into units and configurations of selectable service elements—an example of what in another context has been called “precision community health”. ³³

The other scenario involved hotels becoming entrenched as new forms of permanent supportive housing. ³⁴ While the degree of stability wasn’t always clear from the outset, this stability afforded distributed clinical and social care programs a time horizon that permitted their embeddedness within the broader community. It also provided the opportunity to develop care pathways with acute care institutions and more established home care provider agencies. ³²

What both scenarios demonstrated was a robust ability to identify and leverage atypical places of care with precise community health responses. Beyond their operational versatility, most such care models were operationally lean with negligible capital costs and low administrative overhead owing to their increasingly protocolized modularity.

Changing channels: Dual transformation with purpose and perseverance

While virtual care well predated COVID-19, the disruption brought by the pandemic ushered in the current era of mainstream virtual care. ³⁵ The channel shift from direct to virtual care that was so pronounced for the majority, however, was not experienced in the same way on the margins. Like LTC facilities, shelters and community spaces for underhoused communities were hit early and hard by COVID-19. Within the first three months, many organizations were struggling to maintain staff, supplies, and effective safety protocols to remain open. Unlike many small commercial organizations, however, community service agencies are built for purpose, and most were willing to radically adapt to persevere, exhibiting the grit to survive organizationally. ³⁶

Healthcare providers for complex marginalized populations shared this commitment to perseverance and knew that mainstream virtual care was not designed to provide effective access for their patients. Instead, they undertook a path of dual transformation, ³⁷ deepening core direct outreach service models with the versatility and modularity described earlier while developing the tools and skills to integrate modified forms of virtual care into their practice. Virtual care was slowly built into distributed programs as an adjunct to direct outreach, this inversion of “virtual first”^38,39 approaches being critical to the success of virtual care with these communities.

The power of partnerships: Deep integration of health and social care

If the innovator’s dilemma is the challenge of disruptive innovation to sustainable organizational growth, ⁴⁰ the healthcare provider’s dilemma is that healthcare contributes approximately only 20% to the improvement, maintenance, and restoration of health. ⁴¹ While acute care consumes most health budgets with capital-intensive, specialized and reactive care, primary care has long been known to be both operationally and economically the necessary foundation of strong, effective, and efficient health systems.^42-44

Shifting the configuration of health systems from acute to community care is far from simple. The central challenge involves addressing ongoing immediate acute needs while simultaneously driving a shift towards expanded community care (“dual transformation”), a prospect that can be addressed by two complementary strategies. In the first, community care models develop the capacity to provide increasingly effective hospital-level acute care in the community (“hospital at home”). ⁴⁵ The other involves deepening the intensity and complexity of broader non-acute community care to shift the capacity and health profile of communities over time. ⁴⁶ Both strategies require the substantial integration of health and social care, the latter including interventions addressing income and food security, shelter and housing, childcare, employment and training, peer support and care navigation among many others. ¹¹

Distributed community healthcare organizations have always worked closely at the intersection of health and social care with a dense web of partnerships beyond the mainstream “healthcare sector” to ensure clients receive the supports they need. ³⁰ What occurred during the pandemic, however, involved both a quantitative escalation in the scope and volume of collaborative work and a qualitative structural shift to more formal partnerships with social care organizations involving governance relationships that integrated care not only at the level of delivery but also in the oversight, planning, and coordination of services.

Distributed healthcare models are becoming increasingly integrated with social care providers. The complexities include establishing new cultures of practice integrating care across hierarchies and traditions, the logistical challenges of coordinating expanded scales and types of supports, and establishing mechanisms to securely share personal health information in the delivery and planning of care. Care coordination, whether by professional case managers or the broad range and types of community health workers, has been a central feature of the disruptive potential of integrated care. ⁴⁷ While care coordination cannot necessarily drive efficiencies sufficient to reduce total costs of care or acute care dependence, ⁴⁸ it is central to the effectiveness of high-functioning integrated health and social care. ⁴⁹

What constitutes circle of care for the sharing of health information at the delivery level is matched at larger system scales by the need to link large datasets to rationally plan and coordinate the delivery of integrated health and social care. ⁵⁰ Challenges faced to information sharing on the ground are manageable through shared intake and consenting processes and by obtaining express and implied verbal consent as part of natural flow of the shared delivery of care. Large-scale data mergers across health and social care agencies have proved more difficult in many jurisdictions, reflective of divergent legislative and regulatory privacy regimes across health and “non-health” sectors. ⁵¹

What has been clear during the COVID-19 pandemic is that deep integration of health and social care is possible. If we are to successfully shift from acute care dependence to the community, it will be necessary to sustainably scale solutions that enable precision community health, replacing “patient-centred medical homes” with “primary care community health homes.” It is the value and impact of this decentred integration of primary care into the community production of health that is one of the central lessons of the COVID-19 pandemic for integrated health and social care.

From the margin to mainstream: Value-based care and health innovation

The COVID-19 pandemic ushered in a new visibility of socially and medically complex communities on the margin of society and healthcare. This visibility was accompanied by a sense of urgency demanding rapid innovation that leveraged decades of experience in distributed and integrated primary and social care across North America. Most provider organizations pursued paths of dual transformation that increased the resilience of pre-existing core operational models through increased intensiveness of care team composition and care venue variety, while also undergoing transformative change through embedded virtual care, care configuration modularity, and structurally deeper integration of health and social care.

Whether and to what extent “value-based care” (Medicare advantage and accountable care organizations among others in the US; complexity-modified capitated and bundled funding in Canada) will constitute disruption or diversification remains unclear.^52,53 As a funding model designed to incentivize outcomes, while value-based care may risk significant payor upcode gaming ⁵⁴ and opportunities for significant profit-margin expansion within corporate owned primary care practices, ⁵⁵ it better enables distributed integrated health and social care than fee-for-service payment. ⁵⁶ The competitive advantage of distributed integrated health and social care models depend on the implementation of tight controls of code gaming, improved complexity modification, and accounting for the time horizon of impact for different types of interventions.^57,58 The effective regulation of value-based care is both complex and politicized, but it makes the big disruption of care towards health, home, and community possible. The cost of failing to meet the challenges of health inequity, however, amounts to >$500B USD annually. ⁵⁹

It is encouraging that some of the most innovative healthcare organizations in North America are developing distributed, tech-enabled healthcare with deeper social care integration. While virtual-first organizations often lack the community penetrance to engage and serve the most equity-deserving medically and socially complex communities, they are still evolving and can be expected to build-out their direct distributed care offerings to sustain themselves for the long-run. The rise of platform integration of health and social care by organizations like Unite US that fully integrates social care assessments, referrals, and coordination into clinical services is a transformational event in integrated care coordination. ⁶⁰ The advent of “big data” analytics and data linkages across spaces of health and social care, digitally facilitated precision mobility of people, products and services, and the rapidly increasing sophistication of machine learning and artificial intelligence tools like GPT and MedPaLM have changed what care for health can and should be and are critical to scaling the impact of distributed community health and social care.^61-63

Christensen was right in the end to have identified the disruptive potential of community health workers, care coordination, and value-based care. He couldn’t have anticipated the further disruptions to “bricks and mortar” healthcare these enabled in the forms of distributed, modular, precision community health, or virtual care, as these only became more fully apparent through the broader societal disruption of the COVID-19 pandemic, particularly on the margins where the future of healthcare continues to be incubated.