The “Last Mile” of Delivery System Innovation


The “last mile problem” generally refers to the difficulty of delivering goods or services to customers across that last, short segment of a supply chain. For a large, online retail giant, it’s getting products from the local warehouse to homes and offices. For the telecommunications industry, it’s bridging the gap from the network hub to providing connectivity to the individual user. In both cases, it’s a “problem” because that last leg is often the most complex and costly part of the journey. It strikes me that this is an apt analogy for achieving widespread adoption of innovations in health care delivery. Developing an innovation and telling others about it is relatively easy when compared to the last leg of change in the health care system—getting other providers to adopt it.

I’ve been thinking about this particular issue because New York State is nearing the end of its Delivery System Reform Incentive Payment (DSRIP) program and is in the process of seeking a waiver amendment to extend it. The goal of the initial program was to create and sustain integrated high-performing delivery systems—with collaborations across health care settings and with the community and community-based organizations—that could deliver better quality care, improve population health, and ultimately reduce costs through the reduction of avoidable hospital use. 

Although there are differing opinions as to whether the DSRIP program was an overall success, one clear, positive outcome is the emergence of numerous delivery system innovations. After combing through over 500 DSRIP projects, the staff at United Hospital Fund identified and published 32 such “promising practices,” and I suspect that there are many more that could be highlighted if space allowed.

How to Spread Promising Practices

The key challenge, however, is spreading these promising practices throughout the health care system. There is a vast body of literature on the “diffusion of innovations” in health care, much of it informed by the landmark work of the late sociologist, Everett Rogers, and put into practice by organizations such as the Institute for Healthcare Improvement. Unfortunately, health care has historically been notoriously slow in adopting innovations. It may therefore be worthwhile to examine some of diffusion theory’s more salient lessons, especially as they relate to the DSRIP “promising practices.”

One of the most important factors driving the widespread adoption of an innovation relates to attributes of the innovation itself—whether the proposed changes produce benefits; the degree to which the changes are compatible with existing values; how simple or complex they are; how easy the innovation is to trial; and how readily observable are the results. When it comes to the promising practices, we can focus on practical things like simplifying the innovation when feasible, paying attention to the culture of organizations while rolling out changes (especially if provider buy-in is necessary), and ensuring that the benefits are meaningful and highlighted for all to see.

Focusing on the Adopters and the Environment

The second important factor in the spread of innovation relates to the adopters themselves. In the context of the DSRIP promising practices, we could create an environment where influential early adopters can easily interact with the innovators—as well as showcase and share their experiences with the remaining early and late majorities who will need to change.  

Which is a good segue to the final factor that can accelerate adoption: the broader environment or context. In the DSRIP promising practices example, this may mean an additional investment of resources for the innovators and early adopters, as well as explicitly creating the expectation of wider adoption of the practices. It will also be important to ensure that there is an adequate workforce and a payment environment that is ultimately supportive of the innovations.  

If this all seems expensive and complex, it is—just like that last mile problem. But given New York’s goal of spreading the promising practices from DSRIP, the additional funds and time requested may be a sound and smart investment.

Reprinted from Blueprint, Fall 2019.

Nov. 25, 2019
Focus Area
Quality and EfficiencyClinical-Community Partnerships