Lahey Health Reexamines the Appropriate Care Model

This nonprofit, three-hospital health system in eastern Massachusetts has prioritized directing care to the most appropriate setting, which often means admitting patients to the community hospitals closest to their homes.

Community hospital leaders often express anxiety about the loss of independence and control that comes when their hospital is acquired by a larger health system. In many health systems the smaller hospitals are used as feeders to ship patients to the flagship hospitals.

That's not the way they do business at Burlington, MA-based Lahey Health. For the past two years the nonprofit, three-hospital health system has prioritized directing care to the most appropriate setting, which often means admitting patients to the community hospitals closest to their homes.

The arrangement appears to be working. Richard W. Nesto, MD, chief medical officer of Lahey Hospital & Medical Center, says Lahey Health, which will soon include the 229-bed Winchester Hospital, has thrived with its emphasis on appropriate care settings. Inpatient volumes are up at Lahey Hospital & Medical Center, Beverly Hospital, and Addison Gilbert Hospital, even though inpatient admissions are down in the rest of the Bay State.

The medical center is seeing fewer low-acuity patients because they've been redirected toward Beverly and Addison Gilbert, which can provide care at a lower cost and with greater convenience for the patients being treated closer to home.

At the same time, with fewer low-acuity patients, Lahey has freed beds to treat more complex patients who historically would have headed 20 miles south to get their care at Boston's prestigious academic teaching hospitals.

Nesto spoke with me recently about Lahey Health's appropriate care model. The following is an edited transcript.

HLM: Why the emphasis on appropriate care settings?

Nesto: We have deployed our specialists in as many as 10 community hospital settings as far away as 60 miles from here in an effort to delivery Lahey quality and expertise locally in community hospital settings. We've been doing this for 15 years or so in a number of specialties, always by invitation and never with the interest in stealing or absorbing patients back into Lahey. We want them treated in the appropriate location and returned to the appropriate primary care doctors in those settings.

Because we have two community hospitals locally and a third one to come on line, Winchester Hospital, we now have hospital partners and we can be much more nimble.

Some examples: We have patients now who come to our emergency department at the tertiary medical center in Burlington who reside in communities where our other partner hospitals are located. If those patients have a condition that can be treated just as well in a community hospital setting, we actually transfer them back to the community hospital.

This is a very novel idea because most academic teaching hospitals want to take on as many patients as they can to fill their beds. What we are doing is reversing the transfer process and patients are getting great care within our system at a lower cost to the plans and the patients and the Commonwealth of Massachusetts.

We are also actively telling our primary care practices surrounding the tertiary medical center to use local consultants and specialists who are on the medical staffs of our system community hospitals to keep care local. Before, we would encourage those primary care doctors to send their patients to the mother ship because we didn't have partner community hospitals.

HLM: How can you tell if your efforts are successful?

Nesto: The end result is that our community hospitals have the highest censuses they've had in years because of this redirection of care.

Community hospitals, particularly in a highly competitive market like eastern Massachusetts, unless they keep their census up are going to wither. That is counter-productive because then more and more care will go to Boston, where it is much more expensive.

I worked 25 years at Boston and Harvard teaching hospitals and at any one time probably 30% of the patients have conditions that can be treated just as well in a community hospital setting and the patient can stay close to the home.

We are introducing more specialists in Lahey community hospitals so patients don't have to migrate to Boston. They are getting procedures done in their community hospitals that they may not have been able to get before because we have sprinkled these hospitals with Lahey specialists. We really think our system is more than aspirational. In fact, it is working and we have the data to prove it.

HLM: How to you determine the appropriate care setting?

Nesto: Our community hospitals now are redirecting all of their transfers to us as opposed to Boston teaching hospitals. Because we are in constant dialogue with these hospitals, they have a better idea of what should be transferred and what should be held locally. And with the access to Lahey specialists and physicians on site they can retain more of these patients who formally where directed to tertiary care, which was a great inconvenience to the patients' families and a greater expense to the healthcare system.

There has been a 22% increase in the number of patients from Lahey primary care doctors who are admitted to Beverly Hospital who formerly would have gone to Burlington prior to the merger. That is a pretty robust increase in a community hospital census as a consequence of this merger.

The other evidence that this is working, the (Case Mix Index) of severity of illness is going up at our community hospitals, which means that sicker and sicker patients are being treated more and more locally and as long as the quality is good, which we measure through a variety of score cards, then that also means the system is working.

HLM: How do you determine what service lines you'll carry?

Nesto: The big ones we are concentrating on are neurosciences and neurosurgery, cardiovascular disease, cancer, and primary care. Now you can get a neurosurgical operation at Beverly Hospital where there was no neurosurgery before.

We are doing a lot of spine surgery that had to be shipped out before, but now patients are having it done there because we have a Lahey neurosurgeon there. We are doing a lot of cardiovascular implants at local hospitals, like defibrillators, and some cardiology testing that couldn't be done formerly without Lahey physicians and expertise.

HLM: What effect has this push for care settings had on inpatient volumes?

Nesto: For the first quarter of this fiscal year compared to last year, overall in the state of Massachusetts the inpatient census is down 6%. Outside of the top 10 hospitals, most hospitals are in double-digit declines. That is huge for a hospital year over year.

Our community hospitals have increased their censuses but it is not at the expense of Lahey because we are getting their tertiary work that they had formerly sent to four or five hospitals. Our census is about 94% and our CMI tops 1.9 for the past two months.

We have the highest case mix index in the state. So, we are caring for sicker and sicker patients and we have more and more patients in our beds. Beverly is caring for more and more patients, and frankly their CMI has gone up too.

It is really a shift in market share. We are full and Beverly is full because we are doing a better job of retaining patients and keeping them within the system, and somebody else has fewer patients. There is no question about that. The population is not expanding. Our marketing and communications plans are all focused on community-based care.

HLM: How do you burnish the Lahey brand with healthcare customers?

Nesto: There is pretty intense loyalty to community hospitals in this area. Both Beverly and Lahey have been in place for more than 100 years so they have a strong community identity. We have added to that. We haven't diluted it. We haven't changed the names of these hospitals. They are members of Lahey Health. They are marketing that they can do even more for their communities now since the Lahey merger. That has been our message.

You get some momentum in the community and the word travels fast that the hospitals are healthy. Most hospitals are announcing layoffs right now. When the public hears that a hospital is closing beds and laying people off, that doesn't serve people's confidence. We have not done that. We are busy. We are hiring people. That also is a positive statement to patients.

HLM: Where do you see Lahey in five years?

Nesto: We don't know where we are going to be next week with the movement of the players in this market. But our goal is to have four or five community hospitals within 50 miles of Lahey so that we can expand our current modus operandi. We also plan to develop a much bigger primary care base outside of the networks of those hospitals.

That may require us to go into southern New Hampshire or other places. Ultimately, the goal is to be big enough to have our own insurance product. When you have all of the resources in-house you can reinvest what you've made from giving better care. You can take whatever revenue you generate and you are responsible for your own bottom line. You can reinvest it in the system.