Split Decisions

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Fragmentation is one of healthcare's central and most challenging problems. While bundled payments, denials for readmissions, and other reforms aim to encourage coordination, linking the care continuum will happen at the service line level. But first providers will have to change their relationships, and how they think about care delivery.

Before joint replacement patients set foot in an operating room at the Agnesian Center for Bone and Joint Health, they start in a multidisciplinary presurgical education session. A nurse answers frequently asked questions about the surgical process, a pharmacist talks about anticoagulation and pain medication, a rehab representative explores home modifications and other postsurgery issues, and a discharge planner lays the groundwork for the postsurgery transition. By surgery time, not only does the patient have a better idea of what to expect from the process, but so do the providers.

When the U.S. healthcare system is at its best, patients hardly notice the transitions along the care continuum. Their health information travels with them across settings, and each step in the care process builds on previous work. The end result is efficient and high-value healthcare.

Unfortunately, it doesn't often work that way. The three big healthcare problems being debated by reformers—rising costs, poor quality, and limited access—stem at least in part from a central, fatal flaw: Healthcare is highly fragmented.

Costs are rising because physicians don't communicate well about tests and procedures, and repeat them. Quality is measured in bits and pieces, and a patient may receive excellent care in one setting and poor care in another when being treated for a single condition. Even for those with insurance, access is tiered and limited by the long waits and shortages that plague a system designed to reward quantity over quality.

Care is delivered through a multitude of disparate services: inpatient care, outpatient care, rehab care, diagnostic services, and so on. But patients only want a single service: healthcare. Or to be more specific, care for their arthritic joints, or management of their diabetes, or treatment of whatever episode currently threatens their well-being.

Linking the care continuum to make many different healthcare services function as one is a central challenge facing hospitals, physicians, and other providers. The federal government knows this and has its eyes on bundled payments, incentives to prevent hospital readmissions, and other reimbursement changes designed to encourage provider cooperation.

However, these structural realignments are a long way off and, even if enacted, will only provide the framework for change. New care models will have to come from providers, and this will likely happen at the service line level. That's where episodes of care happen, and it's why Medicare's Acute Care Episode demonstration project, which is experimenting with bundled payments for inpatient care, is based on specific cardiovascular and orthopedic services.

There's a case for linking the care continuum now to prepare for the future and gear up for a new reimbursement system. But there's an even better short-term reason: It provides a competitive advantage. Patient satisfaction levels are near 100% for Agnesian's joint replacement program because patient expectations are managed from the beginning, says Zach Pitz, director of musculoskeletal and rehabilitation services for Agnesian HealthCare, a two-hospital integrated delivery system located 60 miles north of Milwaukee. Improved coordination has cut length of stay from 4.3 days to 3.5, which means fewer staffing expenses and easier planning. Agnesian is growing its orthopedics market share and plans to adapt a similar service line model for cardiovascular and oncology services.

Truly comprehensive and patient-centered service lines may be the key to defragmenting delivery and solving some of healthcare's big problems. But it isn't always easy. Every provider along the care continuum must be involved, so hospitals, physicians, and even patients will have to change how they think about healthcare.

Engaging patients before care
Although the majority of care is provided in hospitals and physician offices, the care continuum begins and ends at the patient's home. Patient education efforts are often considered a marketing function, a way to build and reinforce brand recognition. But service line leaders are increasingly realizing the quality benefits of engaging patients before they actually need care.

Stroke offers one of the best examples. Administering the clot-busting drug IV tPA can significantly increase the survival chances for a stroke victim, but there is a short initial window of about three hours after the onset of the stroke to act. Other treatment methods have similar timeframes of three to eight hours, creating a very direct link between timeliness and quality.

But there is only so much that a hospital can do to improve its reaction time. On average tPA administration rates can range from 0% to 20%, in part because patients simply show up at the hospital too late for the treatment. Educating patients to recognize the signs of a stroke and get to a hospital can shave valuable minutes off the treatment time, says Susan Catto, MD, codirector of the stroke program at William Beaumont Hospital, a 1,061-licensed-bed community hospital in Royal Oak, MI. And that, ultimately, improves the quality of the program.

That's why The Joint Commission has included patient and community education as one of the requirements for stroke center certification. It's that important. Catto considers the patient the initial stakeholder in the vertical integration of the William Beaumont stroke program. From a leadership perspective, the patient is part of the team.

After holding community forums and even running television ads to raise awareness about stroke symptoms, the percent of patients arriving within two hours of the onset of symptoms increased from 11% to 20% in a year, says Catto.

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