A projected increase in emergency department volume within the next three years means hospitals need to get to work now to implement better patient flow schemes. The need is urgent because how patients move through the ED has significant financial implications throughout the rest of the hospital.
This article appears in the May issue of HealthLeaders magazine.
These days, hospitals are trying to make things quick, quicker, and quickest for beleaguered emergency departments and their patients, who often face delays in treatment after they enter the hospital's automated doors. By establishing streamlined throughput systems, hospitals hope to prevent frustrated patients from walking out, bolting without getting care.
Leaders are improving triage areas, redesigning facilities, rotating physician staff, separating patients for urgent or nonurgent care, and implementing improved technology for greater efficiencies to eke out cost savings.
These multipronged approaches are born from hospital leaders' awareness that quality of care is affected when ED patients are placed in holding patterns, or boarded. Overcrowding contributes to poor care, frustrated patients, increased costs, potential harm, and stress for both patients and staff.
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And the worst may be yet to come: Healthcare leaders overwhelmingly expect an increase in ED volume within the next three years—with 36% forecasting a major increase and 50% a minor increase, according to the May HealthLeaders Media Intelligence Report.
Overcoming delays is important for hospitals because patient satisfaction also can be impacted, which carries monetary consequences when poor scores are reported to the federal government.
But when patients, information, and materials flow efficiently through the ED, all aspects of care there can improve significantly. Hospitals are working to implement various flow schemes—such as split flow, bed counting, and fast tracking—all in an effort to move patients more efficiently through the ED. They are also improving workflow management and using technology programs to reduce extensive
patient waits.
At Pittsburgh-based UPMC, a 20-plus hospital system, when nursing staff and physicians meet every morning, part of their focus is on the ED, a big-picture view looking at big-screen projections showing the expected daily census, how many discharges, and how many patients they can add to each unit in each hospital.
"We predict the demand for the day," says Deborah Kaczynski, MS, who is senior administrative director for UPMC Mercy, which has 462 licensed beds, and works for the UPMC system's patient flow initiatives. She also is a faculty member for the Institute for Healthcare Improvement, an independent nonprofit organization based in Cambridge, Mass.
Kathleen Mikos, chief nursing officer and vice president for patient care services for the 275-staffed-bed Ingalls Memorial Hospital in Harvey, Ill., attends meetings with the organizationwide steering committee to focus on patient flow. She and her staff examine the ED demands, monitoring its impact on the rest of the hospital. Mikos oversees patient flow of the ED, which includes a fast-track component for patients with less serious conditions.
Mikos and Kaczynski are emphatic that improvements to the ED patient flow can only be mastered by addressing the needs of other hospital units—from surgery to housekeeping—that are impacted by what happens in the emergency department.
"You are never going to make headway toward improving the ED unless you realize it's a system issue," Mikos says. "We don't want long wait times, so we have to be in a constant state
of readiness."
Achieving that state of readiness often comes at a price: many failed attempts, Kaczynski says.
"We had tried many of the traditional approaches in the past to improve patient flow and were very frustrated. Nothing was working," Kaczynski recalls. "Ultimately, we learned that you couldn't attack patient flow in a silo, as a single entity. You had to find a certain platform that would manage flow at the entire hospital level."
Improving ED patient flow has significant financial implications through the rest of the hospital, says Andy Daniels. He is chief operating officer of Avita Health System, which runs Bucyrus and Galion community hospitals, each with 25 staffed beds, in Ohio.
"The ED is the gateway for 70% to 80% of the admissions into our facilities," says Daniels. "As a team, the ED is a critical component of the inpatient program. An ED department with a good flow is essential to a successful inpatient program, period."
"Healthcare facilities should be paying close attention," Daniels adds. "The trains need to run efficiently, effectively, and be considerate of the patient experience. Without that in your ED department, you're sunk."
Many hospitals have used technological changes to improve ED throughput. The 509-bed Albert Einstein Medical Center in Philadelphia uses a workflow management tracking tool to keep pace with ED flow. For an urban facility, the benefit of such a system was important to reduce waiting times and improve movement of patients through the ED, says Carl Chudnofsky, MD, chairman of the department of emergency medicine at Albert Einstein Medical Center.
"We put in automatic tracking with different types of tracking hardware," says Chudnofsky. Despite successes, the process isn't always smooth. Over time, the hospital has had to overcome technical challenges, such as the fact that tracking and electronic medical record software were not "talking to each other." The facility shut down the tracking for a while to fix that issue, he says.
The 371-bed George Washington University Medical Center in Washington, D.C., also uses a computer-based fast-track system. While technological systems are important, proper coordination and communication among physicians, nurses, and other staff is essential to improve ED patient flow, says Robert Shesser, MD, chief of emergency medicine at GWU Medical Center. "We've managed to make improvements by making little changes and measuring the effect of those changes," Shesser says.
Coordinating care may be the most important element, says Daniels of Avita Health System. "We are doing fast-track and process reengineering and doing the triage up front, a combination of things. We're working on improving with quick registration and bedside registration." Although the hospital has electronic medical records, the ED "is still paper-based, and we're still able to accomplish improvements," he says.
Team coordination is extremely important to improve ED operations, according to Daniels. "It takes a strong ED leader, a good working relationship with your ED physician group, and a willingness on the part of the support departments like lab and x-ray to play along. Improving ED flow is a team sport," he notes.
Success key No. 1: The process
When the 374-staffed-bed St. Mary Medical Center in Langhorne, Pa., began looking into process improvements for its hospital several years ago, leadership believed it had no choice. The throughput in the ED was sluggish. An ED designed for 50,000 visits a year was hosting nearly 70,000 patients. Perhaps predictably, patient satisfaction was low.
"For many years, the ED carried a significant portion of the hospital burden, and volumes were steadily increasing," says Gary Zimmer, MD, chairman of the department of emergency medicine at St. Mary Medical Center and senior vice president for TeamHealth, a Knoxville, Tenn.–based company that provides hospital-based services including ED management.
It was "part demographics, partly an aging population around the hospital," Zimmer adds.
The hospital made two changes—one in brick and mortar, the other in clinical processes. Both were lengthy, tedious, and, ultimately, worthwhile, he says. With the ED nearly 50% over capacity, in 2011 the hospital began adding 18 new beds in the emergency department as part of a $22 million expansion scheduled for completion the first quarter of this year, for an overall 70-bed treatment area, including 11 pediatric beds.
In the meantime, St. Mary initiated a split-flow model designed to have patients seen by a provider as quickly as possible. Under this model, patients are seen first by a nurse as soon as they enter the ED, says Sharon Brown, vice president of patient care and chief nursing officer. "Nurses are specially trained [that] when the patient comes in through the door, the assessment process begins. We figure out what's going on and how we can meet the needs of a patient in an efficient manner."
The nurse then makes an initial evaluation and directs patients to the appropriate specialized unit, whether that is prompt, urgent, or rapid assessment care, or pediatric care. Prompt care is for minor injuries, such as a sprained ankle. Urgent care is for severe illnesses that could result in hospital admission. Rapid assessment is what the hospital calls a "resource-intensive process" in which studies and tests are done, and then a patient is moved to a private area for treatment decisions.
Patients also are moving quicker through the ED, says Zimmer. Since 2005, the door-to-doc time decreased from about 45–50 minutes to 20–25 minutes in 2013, he says. In the meantime, he says "length of stay dropped 40 minutes" from 344 minutes to 304 minutes, based on Hospital Compare data.
According to Hospital Compare, the average time a patient spent in the ED before they were seen by a healthcare professional at St. Mary was 28 minutes in 2012, while the state average was 31 minutes and the national average was 30 minutes.
Just getting to the point of initiating the split-flow model was complicated, Zimmer says.
The hospital embarked on a six-month plan that focused on workflow process redesign, which involved 30 employees, including staff interacting with the ED, lab, floor nurses, physician assistants, and leadership, Zimmer adds.
St. Mary initiated the changes after reviews by hospital leadership and staff. It was an exhausting and
sometimes aggravating cultural shift, he says. In a two-day Lean workflow analysis, hospital officials whittled down what had been a lengthy process—68 steps from when a patient arrived until care was completed—to about 48 steps, he says.
"During those two days, we retooled people's jobs," Zimmer adds. "Some people were unhappy, but we listened to their concerns. There were some sleepless nights. But the process wasn't designed in a vacuum; it involved staff, and that was the key. There was an attitude, 'We can do this,' and we all pushed each other. We also had many site visits in ancillary departments that were impacted."
Zimmer says the hospital worked to "adopt a really different way of thinking. We really hardwired the process and didn't allow people to deviate from it." Eventually, the champions of change—including nurses and physicians who were "process owners of the change"—narrowed down the pool of ideas to those that could be implemented, he says.
"The basic concept of sorting out the middle-acuity patients was the key to our success," Zimmer says. "We committed ourselves to continue to evolve the process."
Success key No. 2: Bed control
Keeping tabs on hospital bed usage—how many patients are on the floor, who is ready to be discharged, what kind of patients are arriving—helps hospital personnel efficiently process patients from the ED to other areas of the healthcare facility.
Several years ago, Ingalls Memorial Hospital "didn't have a strong process in place for bed control," says Mikos, the CNO who oversees the ED and projects designed to increase hospital efficiencies. "It might have taken three hours to find a bed."
Implementing an electronic bed request system has significantly improved the hospital's ability to coordinate care for patients, especially those transferred as inpatients from the ED. A computer system monitors the beds and determines which ones are open, filled, or need to be cleaned. "Having an electronic bed management system has drastically improved the hospital's ability to find a range of beds and coordinate care," Mikos says.
Bed control. Central transportation. Housekeeping. "It all ties together; all three are important," she says.
The hospital receives about 49,000 visits a year to its 26-bed ED, an increase of 7,000 from five years ago. During that period, the hospital reduced its ED length of stay from 335 minutes to about 200 minutes. Mikos attributes the results to what she termed improved efficiencies in the hospital's ED throughput, especially its bed request or "tele-tracking" system.
With the bed request model, Mikos identifies another benefit: It reduces the need to build more bed space for the ED.
For many hospitals, "I think the instinct is you need more beds," she says, "but that's not the case to improve patient flow in the emergency departments."
To improve bed control, Kaczynski, the patient flow coordinator at UPMC, also keeps her eye on the numbers. The hospitalwide bed meeting is attended by the chief nursing officer, medical director of care management, nursing and clinical leaders, and directors of ancillary support departments. In a presentation before the Institute for Healthcare Improvement, Kaczynski said the "ED and inpatient must partner for success."
Using a real-time demand/capacity management program, the staff works to predict capacity each day. It begins with a "unit-based huddle" where nurses evaluate who will be discharged, what rooms are available, and who might be admitted. It is determined whether procedures such as MRIs are needed and if transportation must be arranged.
By 8:30 each morning, they evaluate capacity and whether demand could exceed that. If so, transfers may need to be arranged or special units may be contacted for extra bed capacity. Then evaluations are made during a "housewide bed meeting" attended by nurses representing each unit who review data on a large screen.
In addition, while many hospitals attempt to have discharges by noon, Kaczynski does not subscribe to that philosophy. "We want to make sure we have a bed when we need a bed, whether it's 10 a.m. or 5 p.m."
Started at its Shadyside campus, a 512-licensed-bed tertiary care hospital, the real-time demand/capacity management program has been replicated on other campuses.
Carrying out the patient flow philosophy ensured successful reductions in the hospital's ED length of stay, Kaczynski says.
Rick Wadas, MD, chief of community emergency medicine for UPMC, says six years ago, the Shadyside campus, which sees a high-acuity population, had ED lengths of stay that hovered "in the 400-minute" range. By 2013, the ED length of stay generally decreased "down to 230 or 240 minutes," he adds. Wadas says a key reason for the improvement was the real-time demand/capacity management program. "That's why there was a lot of success," Wadas says. "We also have gotten buy-in from the entire hospital knowing that this is not just an emergency department problem, but one involving the whole facility."
Success key No. 3: Physicians First
While having patients wait in the ED is aggravating to just about everyone involved, the 340-bed Roseville (Calif.) Kaiser Permanente Hospital decided to take a bold step to improve patient flow: It got rid of the waiting areas and began a Physicians First program.
Within the past year, the hospital increased the size of its ED, a 60-bed unit equipped for 70,000 patients annually. "Instead of having patients in a waiting room, we put them into the ED itself," says Pankaj Patel, MD, an emergency medicine specialist. "We didn't need a large waiting room."
If patients have to wait, they do so in an ED bed or sitting area within the department, where there are increased diagnostic tools and emergency cardiac catheterization equipment readily available, he says. The increased size has not only led to improved and swift care, but has given a psychological lift to patients who usually wait long periods for ED beds.
"With this new system, the physician is right there and will determine if you should be taken care of," Patel says. "When a patient comes in, instead of being in a waiting area, a nurse or physician will see him in the ED itself, as the Physicians First name implies," he adds. "We've eliminated our triage area in the front where most of the patients would be and instead added rooms," Patel says. "It makes it a much more efficient process."
The overall door-to-doc waiting time has been reduced to 5–15 minutes as opposed to the 45 minutes it was previously, he says. The hospital ensures that three physicians are "up front in the ED and try to assess the patient within 5 minutes of arrival," he adds. At that point, the ED uses a triage system, depending on the care that a patient needs. "If you stubbed your toe, we give you a treatment and discharge you from the front [of the ED]," he says. "If you have chest pain, we can get an EKG or lab workup, so we can get that process started up front right away, as well."
Success key No. 4: Patient satisfaction
One of the major goals for hospitals working to improve the patient flow is to achieve patient satisfaction. It's no easy task. The ED is often a chaotic place, with disruptions and people suffering from various degrees of illness or injury. Waiting times might prompt patients to leave before being seen because they perceive that the hospital is taking too long.
"We live in the real world," says Zimmer of St. Mary. "Some patients are upset with us." While the Centers for Medicare & Medicaid Services has not released national statistics about how many patients leave hospitals without being seen, an Annals of Emergency Medicine study published in 2011 found a median percentage of 2.6%, based on 9 million ED visits to California hospitals. However, the range varied widely from lower than 1% to 20.3%.
Of the hospitals profiled in this story, rates for patients leaving without being seen ranged from 0%–2%.
Wadas says the organization's hospitals "have rates of 0% to 0.1%, depending on the month; it's actually that low. If you think about it, if that number is high, you are not meeting people's needs and so you are not providing service. That was a big goal of ours to make sure that number was low. That number is partially dependent on the rest of the process. If all your beds are clogged up and people are there for hours and hours, you can't get people in the waiting room into beds, get them seen and taken care of."
Ingalls' rate for patients leaving without being seen is 2%, but was high as 10% a few years ago, says Mikos.
Paul Zielske, director of patient care and emergency and surgical services for Ingalls, attributes the reductions to "the changes that we've put in place, and shows what can happen with an effort: You can decrease those times."
At the same time, he notes, the hospital's ED volume increased from 42,000 to 49,000, but efficiency enabled the hospital to "have better responsiveness."
When patients leave without being seen, they are, in their own way, expressing deep dissatisfaction with a hospital. By decreasing the number of those patients who leave, satisfaction scores can improve, Zimmer of St. Mary says.
At St. Mary, patient satisfaction registered 95th percentile in 2012, after the hospital expanded its ED and made split-flow changes. Zimmer says that was an improvement over several years and that patient satisfaction with the entire hospital is linked to improvements in the ED.
Patients spread the word when there are long wait times. They even compare notes: "How long did it take for a physician to see you?" Zimmer says. "If you have a poorly run ED, it's very difficult to have inpatient satisfaction. From a business perspective, Medicare dollars are at risk based on HCAHPS scores. If you have ED docs that do not do well, you have a direct risk of losing Medicare dollars because of poor outcomes," he explains.
At George Washington University Hospital, 2% of nearly 38,000 people were reported to have left without being seen. Several years ago, that rate was at least 5%, says Shesser, chairman of GWU Hospital's ED.
"Over the years, we've managed to decrease our 'left without being seen' rate and improve throughput by making little changes and measuring the effect of those changes," Shesser says. "We are certainly paying closer attention to that in the new world of pay-for-value."
At Avita Health System's small Bucyrus and Galion community hospitals, both had to deal with high rates of patients leaving without being seen, at 3% several years ago. "We focused our interdepartmental groups on reducing time lags," says Daniels. As a result, the health system has reduced the 'left without being seen' rate to 0.41% at Bucyrus and to 0.18% at Galion as of January 2013.
"The biggest problem that remains to be overcome is always maintaining the success that you already have," Daniels says. "The more successful we become in our community and as word spreads, we will be the ED of choice. As our volume grows, it will be important that we do not slip and that we continue to meet customer expectations for service."
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This article appears in the May issue of HealthLeaders magazine.
Sarasota Memorial Healthcare System's focus on care transitions for its elderly and heart failure patient population has continually resulted in good readmission scores. Other hospital leaders could do the same, but the process has taken years and attention to detail.
In some ways, the Sarasota (FL) Memorial Healthcare System is already at the point where many of America's hospitals want to be. It has distinguished itself by caring for a significant elderly population for years, serving patients in a county that has the fourth-oldest residents in the country.
As more hospitals struggle to lower readmissions, Sarasota Memorial has been there, done that, despite caring for a challenging group of patients. Its 804-bed safety-net health care system's inpatient population is 50% Medicare, and it provides about 85% of local Medicaid hospital services. Yet the hospital achieved a 30-day readmission rate for heart attacks of 16.9% last year, compared a national rate of 20%, according to CMS data.
Getting there involved a "long and winding road" to improving quality, safety, and outcomes, says Fred D. Jung, RN, PhD, CPHQ, executive director of quality and patient safety.
One of the most significant and successful aspects of care for Sarasota Memorial has been its heart failure clinic. "If you look at it, we're comprehensively doing everything that everyone identifies as being significant [to improve care]," Jung says. Sarasota has been tracking its outcomes, costs, and efficiencies for years. "It wasn't 'wow, value-based purchasing is coming and there are going to be penalties for readmission rates.' We did this before people really thought about readmission rates," he says. Heart failure care has been a centerpiece and a focus for over a decade.
Sarasota Memorial got a head start years ago by putting structures in place to improve patient care transitions, Jung says. He characterizes his hospital's traditionally lower readmission rates as the result of a "combined, synergistic effect" from the success of multiple strategies built into the system over time.
"It's a given throughout healthcare—and physicians know this particularly well—that putting patients first is the way to go," Jung says. But how exactly is that done? Jung highlights managing care transitions after patient discharge, focusing on readmissions, and yes, keeping an eye out for regulations and penalties.
As Sarasota Memorial embarked on its path to better quality, establishing a strong electronic medical records system was a major area of need at the outset. Making this commitment allowed hospital workers to reach out to aging patients who were sometimes alone and uncertain about what prescription they should take next.
A heart failure nurse meets with patient and caregiver for intensive bedside counseling. Patient educational programs include an RN case manager, social worker, dietitian, pharmacist, and heart failure program coordinator. Patients also receive an informational letter each week for four weeks to reinforce their discharge education.
"You want to make sure medication reconciliation is done effectively," Jung says. "We have pharmacists do that in the community; we have bedside medication delivery." Sarasota Memorial maintains a partnership with Walgreens that enables the pharmacy to provide bedside pharmaceutical deliveries, and then follows up with patients in their homes. Under the arrangement, Walgreens manages a WellTransitions program with the hospital to provide pharmacy care for heart failure and other contracted health plan patients, both before and after discharge. There is no cost to the patient but the hospital pays a fee to Walgreens for the heart failure patients.
The arrangement with Walgreens was motivated by the need for care for patients after they leave the hospital. "If you don't have an onsite retail pharmacy, it makes it a lot harder for patients to get their medications," Jung says. Sarasota Memorial physicians must ensure they are complying with the medication reconciliation programs "or they can't discharge a patient."
Coordinating care for elderly patients is especially important, and that's why Sarasota is forging relationships with nursing homes, too. "That's where one-third of our readmissions come from," Jung says. Over the last two years, Sarasota has improved its bonds with local nursing homes. There are some aspects of patient care, such as improving diet, that can only be successful if different health facilities agree on the plan to achieve it. With some nursing homes, "we've talked openly about the fact they've got salt and pepper shakers on the table. A few of the nursing homes follow through and give their patients salt-restricted diets," he says.
Those conversations with nursing homes, as Jung sees it, are "baby steps toward clinical integration."
Case management of patients after they leave the hospital is also becoming more important, he adds. The hospital has begun a pilot "transition case manager program" to help monitor patients, which includes home visits. Many of Sarasota Memorial's patients are discharged to an empty home, or to one with an elderly care giver. "They've got baking soda, fried food, and soup with a lot of sodium. And in the refrigerator there's a six-pack or two of beer. If you are going to knock down the readmissions, somebody needs to do a home visit and see what's going on at the home," Jung says.
To implement these programs, Jung says coordination with primary care physicians is paramount, but has yet to be fully realized. It's an ongoing process, the focus of constant discussions. "We need to talk with them and coordinate with them—that this patient is going to be discharged," he says.
While Sarasota Memorial has case managers on staff, Jung says that leaders realize the importance of case managers also working out of the primary care physician offices. Still, there are kinks to work out, particularly related to fiscal incentives for physician groups. Case managers "probably need to be in primary care offices, but we need the incentive between the two, to work together to make it worthwhile," Jung says. That means diving a bit "into the weeds," as they discuss revenue codes and fiscal returns, he notes.
Once a patient is discharged from the hospital, "we need to talk with [the physicians] and coordinate with them," Jung says. "That promotes the clinical integration piece that payers are going to look for as well. Everyone needs to be around the table and discuss information about people who are discharged."
Keeping an eye on quality measures is a constant. "Our readmissions rate is pretty stable and we're focusing on it," Jung says. "We remain competitive, and we are starting to push this transition case manager program."
The general feeling at Sarasota is, "let's do this—we're good at it, and let's see if we can remain good at this."
(To learn more, tune into a HealthLeaders Media webcast, "Patient-Centered Care Transitions for Better Quality, Costs and Readmission," on Wednesday, May 29, 2013, with speakers Fred D. Jung, RN, PhD, CPHQ, executive director of quality and patient safety for the Sarasota Memorial Health Care System and Kathleen M. Martin, RN, BSN, CCM, CPC-H, VP of Patient Safety and Care Improvement for Griffin Hospital, in Derby, CT.)
A Michigan healthcare system tells physicians: Be part of a multidisciplinary team or go away. Though many physicians are not collaborative by nature, a team-based approach is the only way to ensure success, says Spectrum Health.
For physicians at Spectrum Health System in Grand Rapids, MI, the multidisciplinary concept is taken seriously. The cardiology team is blunt when it evaluates doctors who are part of the group: you must be totally immersed in the team concept, or you will be asked to leave the group. Sorry.
Within Spectrum's cardiothoracic critical care unit at the Frederik Meijer Heart & Vascular Institute, for instance, the group has "tried to create an atmosphere that selfish behavior is not tolerated," says Michael Dickinson, MD, medical director of the heart failure and transplantation center for Spectrum Health. "We would say only certain physicians are allowed to be 'citizens' of the unit."
The multidisciplinary concept in healthcare is touted, encouraged, and practiced, to improve patient care in a coordinated approach. The Institute for Healthcare Improvement (IHI), for instance, encourages the multidisciplinary rounding concept, which it describes simply as "several key members of the team caring for patients to come together and offer expertise in patient care."
But as the IHI reported in 2011, "too frequently physicians alone prescribe care for patients" without the input of other providers such as nurses, pharmacists, respiratory therapists, nutritionists, physical therapists, occupational therapists, and social workers.
One incarnation of Spectrum Health's multidisciplinary teams is the cardiothoracic critical care unit. These patients have "persistent, disabling symptoms" and they "may keep coming in and out of the hospital," says Dickinson. The clinic provides a range of services including heart transplants, mechanical circulatory support, and an acute heart failure program. It also includes a multidisciplinary "shock team" to rapidly assess patient conditions.
The cardiac team is critical to Spectrum Health's success, and its multidisciplinary approach is essential to make the unit work, Dickinson says. (Cardiac care's significance and its role as a growing margin contributor is reflected in the March 2013 HealthLeaders Media Intelligence Report.)
To become a member of the Spectrum cardiothoracic team, physicians must "exhibit behaviors that show they can do multidisciplinary care," Dickinson says. The unit comprises eight physician members, nurses, social workers, and other staff. A quality common to each doctor within the unit is that they have a "healthy disrespect for themselves and realize they need all of us to get involved," Dickinson says. By "healthy disrespect," he means that these physicians express confidence in their individual abilities while acknowledging that each of their voices isn't the only one, and doesn't always have to be the loudest in the room. The team seeks uniformity of purpose. Some physicians "have come in and have left over the years, based on their personality and willingness to work," Dickinson says. (He would not reveal how many physicians have been asked to leave the unit.)
"We are captains of the ship, coordinating care with other specialties to make it work," Dickinson says.
The shock team employs an immediate, team-based response. "The focus is on patients not responding well to therapy, and these patients have a high risk for readmissions. It takes a multidisciplinary team to take care of these patients," Dickinson says. "In some ways, the system has not worked for them. These are complicated patients."
Running a smooth multidisciplinary team is no easy task. "It's really hard to do," Dickinson says of the team-based concept. "It's not something that comes naturally [for physicians]," he says. "Most physicians would migrate off and make decisions on their own. Most physicians develop passive-aggressive personalities, and are not good at being collaborative."
In some cases, it's clear that the physicians don't embrace the team concept and won't ever be a fit. Sometimes, however, there are doctors who just need some guidance to become part of a multidisciplinary group.
Dickinson describes a situation in which a physician leader worked with a specialist who "nobody liked" because that person did not adhere to the multidisciplinary style. The doctor in question "would implement plans and put in orders and go in the opposite direction of what we were doing," Dickinson says. It became clear that the other doctors did not want this physician rounding in the ICU.
The clinical team did not give up on the problematic team member. The physician leader approached the doctor and asked if they could round together for a week. The leader spent at least an hour each day with the physician. "They would walk side by side through the unit, seeing patients together," Dickinson recalls.
The physician eventually gained a stronger sense of what the multidisciplinary team was about. Once the concept clicked, he found the multidisciplinary team approach appealing. Now, the physician "looks at issues and comes up with lists, saying, 'Let's see what this patient needs. Let's talk through this.' And it has completely changed the way in which we think about this doc."
"This physician needed a model, a mentor who could help them see another approach. And the goal was achieved."
The extra effort of Dickinson's team paid off, demonstrating a high level of commitment to both the physician and the team itself, and improving patient care.
Physician groups say the time is finally right for lawmakers to overhaul the disdained sustainable growth-rate formula. But no one in Congress is embracing a specific plan, and the funding possibilities are uncertain.
The much-maligned sustainable growth rate formula is caught in the vise of what's known on Capitol Hill as "issue fatigue," an American Medical Association official in Washington D.C. told me recently. And that's a good thing.
Essentially, SGR is an issue that gets an airing in Congress every year, but members shout it down before anything gets accomplished. When this keeps happening, year after year, fatigue sets in among lawmakers. Eventually they conclude that something (anything?) must be done; otherwise it just will keep coming back.
Over the last several years, Congress has imposed the "doc fix" to ward off potential cuts in the SGR, which is scheduled to lower Medicare rates by 24.4% in 2014. The SGR sets Medicare physician payment rates through an economic rate formula set in 1997. Proposed cuts have prompted Congress to delay the cuts since 2002, but have essentially increased the price tag of yearly fixes.
"There is this issue fatigue on the Hill," said the AMA official, who did not want to be identified. "It's getting as bad for (Congress) as it is for all of us. Coming up with money for these short-term fixes is getting harder and harder. In the end, you fix this for a year and have the same problem the next year."
Issue fatigue may be surfacing as a major factor on the doc fix, but there's something even bigger that may drive Congress to get rid of the SGR for good: a fiscal bargain.
That "bargain" refers to Congressional Budget Office (CBO) projections. Under the new Medicare spending plans, CBO estimates that keeping Medicare physician payments at their current level over a 10-year period would cost $138 billion. That's a significant reduction from the $243 billion CBO estimate for the same policy a year ago.
Although uncertainty has haunted the SGR debate for years, an element of optimism has crept into the debate this year because "it's a good deal right now," Frank G. Opelka, MD, FACS, vice chair of the National Quality Forum's consensus standards approval committee, told me the other day.
Healthcare advocates say it's time to strike: get rid of the SGR and put a new plan in its place. When I asked for his view, Jeremy Lazarus, MD, president of the American Medical Association, sent me a statement indicating that there is a definite economic incentive for Congress to act now to repeal the SGR, noting the CBO cost projections.
"The CBO estimates that the cost to repeal the SGR is now less than half the cost projected at this time last year. Congress should act now, before this sale price ends," Lazarus says. "At a time when members of the baby-boom generation are aging into Medicare at an average rate of 10,000 each day, we cannot afford to wait any longer."
Rep. Kevin Brady, (R-TX) chairman of the House Ways and Means health subcommittee, also said in a statement before a hearing Tuesday on the SGR that he was hoping to take advantage of the "good CBO cost estimate."
"While funding the money to pay for an SGR replacement policy remains a challenge, the most recent Congressional Budget Office SGR repeal estimate surely helps," he adds.
Brady pointed out, specifically, how physicians are upset over the continued failed attempts to deal with the SGR and the repeated "doc fix."
"Physicians are understandably frustrated," Brady said. He added, "The current broken system is forcing doctors to rethink their future with Medicare, consider closing their private practices or joining up with a hospital. Who can blame them? The SGR is a major contributor to an unhealthy system—and it needs to change this year."
Over the last several months, House Republicans have proposed various payment models based on what they term "quality metrics, performance, and clinical improvement," which has drawn bipartisan support. Providers are also trying to get Congress moving by providing more details of plans, such as proposing to incorporate clinical data registries to evaluate quality of care.
"Aligning clinical data with improvements to claims data is the most robust path toward true quality improvement," David Hoyt, MD, FACS, executive director of the American College of Surgeons, said in testimony before the health subcommittee.
While Congress is examining specific bills and probably a five-year value-based transition plan from the SGR, no one is embracing a specific plan, and the funding possibilities are uncertain.
"My hope is that we can put the days of kicking the SGR can down the road behind us," Brady said, using the most-favored cliché for this slow-burner of an issue.
Not even the determined Ways and Means subcommittee was able to move the issue forward. It held three hearings on improving the Medicare physician payment system last year, trying to provide a framework for change. Anders Gilberg, senior vice president of MGMA-ACMPE, (Medical Group Management Association-American College of Medical Practice Executives) told me that, indeed, the subcommittee "has seized upon the reduction, and there is an impetus to try to do something this year, replacing the SGR."
But, Gilberg asks: "With what?"
One of the things MGMA-ACMPE has been working on is what Gilberg calls a "glide path" from the SGR formula, which Gilberg also believes may take five years to test. "This isn't one size fits all," he says. "Primary care physicians aren't going to like bundling payments like a surgeon. We need to repeal the SGR, leave our options open, and get physicians into quality models."
Opelka of the National Quality Forum, told me that a political consensus appears to be emerging for approval of an alternative payment model over a period of years.
"SGR grew up in the volume-based world, and we tied targets for payment to available dollars. Those available dollars were tied to overall utilization of service demand," Opelka told me in an interview after testifying Tuesday.
"As time moved on, the SGR was not an adequate way of addressing the problem, so we're now doing this healthcare transformation, moving us from a volume proposition to value."
"We need targets somehow aligned so we don't have competing economic forces driving the delivery system," Opelka says. "It's still unclear in everyone's mind how do we actually do that."
For now, all eyes are on Washington to see how this will play out for physicians, and the Medicare patients who rely on them.
This article appears in the April 2013 issue of HealthLeaders magazine.
Years ago, doctors would make rounds to supervise care for dozens of hospitalized patients. Now physicians often want to orchestrate care from their office, so they'll make fewer trips to the hospital—or none at all. Many especially don't want to be called at 3 a.m. to report to the hospital for one of their patients, or even get involved in certain procedures beyond their specialties.
Increasingly, hospitalists are gaining more responsibilities in areas such as monitoring patients day to day, ordering tests, performing surgeries, handling specialized care, or taking on leadership roles. Their specializations are many—from laborists who handle OB-GYN cases to surgicalists who specialize in trauma care and neurohospitalists who handle brain cases, as well as nocturnalists, who work strictly on the overnight shift.
Hospitalists are among healthcare's fastest growing specialties, with at least 60% of hospitals now employing these professionals. Since 2003, when there were an estimated 8,000 hospitalists, the specialty has grown to about 30,000, according to the Society of
Hospital Medicine.
Those urging expansion of hospitalist programs see them as a way to reduce length of stay while improving patient satisfaction. In addition, some hospitalists are specializing in acute care transitions for uninsured patients who have no primary care physicians, and for elderly patients who are cared for in hospitals then nursing homes.
"The whole field has exploded in the last 10 years or so. It's been born out of logistical need," says Louis J. Lux, MD, chief of hospital medicine at the 156-bed St. David's Round Rock (Texas) Medical Center. "Doctors used to follow patients into the hospital when they got sick. Now, the overwhelming majority is choosing to stay in the office. It's hard to be in two places at once," says Lux, also cofounder of Central Texas Hospitalists in Round Rock, a hospitalist physician group.
Philip Vaidyan, MD, FACP, director of hospital medicine in the department of internal medicine at the 525-bed SSM St. Mary's Health Center in St. Louis, says some hospitals see hospitalists as "quarterbacks" who enhance relationships with primary care physicians, coordinate care with multidisciplinary teams, and overcome the fragmentation of care. These specialists are playing an increasingly important role in keeping tabs on patients after they are discharged from hospitals to help prevent 30-day readmissions, he says. "We're seeing a majority of patients in the hospital," says Vaidyan, referring to the gamut of patients cared for by hospitalists.
Vaidyan himself is an example of how hospitalists are playing more of a leadership role in hospitals, especially those who are contracted from outside hospitalist groups. In addition to his role at St. Mary's, Vaidyan also is practice group leader of a team from IPC The Hospitalist Company, a North Hollywood, Calif.–based hospitalist physician provider group.
Shifting roles
The diminishing amount of time doctors are spending at hospital bedsides is reflected in national surveys. The average physician devotes only 12% of his or her time to hospital consultations with patients, according to the Society of Hospitalist Medicine. Hospitalists are becoming more central to coordinating care. St. David's Round Rock Medical Center and St. Mary's are among the hospitals that are increasing their general and specialized hospitalists on staff and the number of patients those doctors see.
"What's driving the growth of hospitalists these days is that patients who are in the hospital with very complex conditions … need to be seen multiple times a day, so someone is needed right there," Vaidyan says. "Hospitalists also are essential for providing patient safety and quality, and they play a major role in residency education. You need to have folks dedicated to the hospital with all the multidisciplinary team members, the nursing staff, the case managers, the social work consultants." In 2005, St. Mary's started its hospitalist program with four physicians and by early 2013, it had 13 hospitalists and four nurse practitioners working with them. The team increased care from 30 patients per day to at least 140, he adds.
At the same time, hospitalists are filling gaps in specialized care. St. David's Round Rock Medical Center, for instance, employs 11 hospitalists compared to three a few years ago, and it also has specialists, including three surgical specialists for trauma cases and a neurologist.
Hospitals use employed hospitalists, but also contract with local or national physician groups that provide such services. Some have exclusive contracts with individual hospitals and provide full coverage. Occasionally, though, hospitals have had to overcome turf issues among various hospitalist groups. That's why the 1,423-bed Lee Memorial Health System in Fort Myers, Fla., reduced the number of contracted hospitalist groups working for it to improve efficiency and consolidation, says Scott Nygaard, MD, MBA, chief medical officer for physician services at Lee Memorial Health System.
From their perspective, hospitals are seeing more synergistic opportunities, and they have "crossed the divide for better outcomes and quality measures," insists John Donahue, president and CEO of the Brentwood, Tenn.–based Cogent HMG, a hospitalist group. For such companies, "it's a great growth opportunity to be in the market. The pitch to hospitals to hire more hospitalists is: 'If you are underperforming, we can take you to the next level,'" Donahue explains.
E. Allen Joslyn, MD, is hospitalist director of inpatient specialists for Cornerstone Health Care, a multispecialty group practice with more than 300 physicians and midlevel providers in High Point, N.C., and a hospitalist at the 335-bed High Point Regional Hospital. He says when he became a hospitalist seven years ago, he was uncertain about the field's potential. Over time, he has seen the opportunity for improved coordination and quality of care. Now Joslyn says he is riding a wave of "explosive growth of hospitalists, which really has not outpaced the hospital demand.
"Hospitalists are definitely sought, and hospitals are moving toward value-based care, what the C-suite is hungry for," he says.
Success key No. 1: Revamping the program
In 2011, Lee Memorial Health System had many hospitalist groups—at least six—but they were in disarray, often competing against each other and not coordinating care throughout the system, which includes four hospitals. What's more, the patients were unhappy. As a result, the health system changed its contracting procedures, imposed monitoring programs, and contracted with one major hospitalist group instead of different groups, says Nygaard.
"We were traditionally, and maybe excessively, competitive," Nygaard says, referring to the use of multiple hospitalist groups. At first, the hospital decided that having many different hospitalist groups seemed to be the best fit for its different campuses. The hospitalists had overseen at least 50% of the hospital admissions.
Initially, "while there were standards for hospitalist medicine approved by the medical staff, in terms of desired outcomes and communication, in my opinion, none of it was being managed well," Nygaard says. "We had to bring some order to what we were doing."
Not only did the health system internally find problems with coordination and care offered by the hospitalists, but patients responding to surveys showed they were highly dissatisfied, Nygaard says. Indeed, an annual medical survey ranked hospitalists as "very low in performance," he adds.
"We had a lot of patient complaints on a routine basis because of a lack of coordination and lack of understanding what the hospitalists are and how they were supposed to really work effectively. There was no measurable benefit to what they had. And when you look at quality metrics, core measures, and HCAHPS, we were going to lose a lot of money. It wasn't that the hospitalists were solely accountable for that, but they were part of it."
At the outset, the hospital took steps to revamp its relationship with hospitalists. "We developed a mutually agreed-upon scorecard to measure quality enhancement and put measurable targets in there," Nygaard recalls. A joint operating committee was appointed for each campus, which included administrative leadership and a hospital medical group executive committee, to examine the hospitalist structure. "The board and the medical executive committee of the hospital approved a resolution to allow Lee Memorial Health System to contract with hospitalist groups directly," Nygaard adds. "We put some expectations in the service agreement that allow us to manage the hospitalists' program better."
Next, Lee Memorial Health System formed a relationship with a new physician group—Inpatient Specialists of Southwest Florida—to manage and provide hospitalist services across the four-hospital health system. This Fort Myers, Fla.–based group of 35 hospitalists oversees hospitalist care at each of the hospitals. ISSF was formed through a partnership of hospitalist affiliates of Cogent and Hospitalist Group of Southwest Florida.
As for patient satisfaction, Nygaard says, Lee Memorial Health System is working toward improvements. In Hospital Compare data, when asked if doctors were "always" ready to help out, Lee Memorial Health System scored 73%; lower than Florida, 77%, and the rest of the nation, 81%. However, when rated for always excellent care, Lee Memorial Health System received 20%; higher than Florida, 17%, and the rest of the nation, 15%.
"We're not there yet but, our figures are showing that patients are becoming satisfied," Nygaard says. The latest internal patient satisfaction poll shows patient satisfaction with hospitalists at 100%, he adds.
In Mesa, Ariz., the 342-bed Banner Baywood Medical Center also reduced the number of hospitalist groups working for the hospital, says Larry Spratling, MD, chief medical officer. There was much infighting, competition, and ultimately uncertainty in delivery of care, he adds.
"Several years ago, there was basically a chaotic situation: entrepreneuring physicians and competing hospitalist groups working for their market share," he says. "The competition was pretty intense, and we weren't getting the service in terms of hospital needs."
In addition, the hospitalists at Banner Baywood "were trying to increase the patient volume by claiming a larger share of patients admitted without a previously established attending physician," Spratling recalls. "We chose, for unassigned patient care, to contract with the best performing group. The other groups, without a contract, experienced a decline in patient volume and were noncompetitive," he says.
Success key No. 2: Transition to acute care
To improve care coordination and reduce readmissions, particularly among patients discharged to skilled nursing or rehab centers, hospitals are tasking hospitalists with coordinating care, especially for patients without primary care physicians. "We are increasingly seeing patients who don't have primary care physicians, who don't have insurance, who have low health literacy," says Vaidyan of St. Mary's. The hospital implemented Project BOOST (Better Outcomes for Older adults through Safe Transitions), a program to help prevent discharge medication errors and reduce readmissions. Project BOOST is sponsored by the Society of Hospital Medicine and aimed at improving transitions of care.
Because of concerns about readmissions, healthcare facilities are also contracting with hospitalist companies, such as IPC and Cogent, both of which provide hospitalist services to dozens of hospitals. For the most part, hospitals are working to incorporate hospitalists into postacute care to reduce the "revolving door" of readmissions, says Jerome Wilborn, MD, FCCP, a national medical director of postacute care for IPC.
Donahue, the Cogent CEO, says the discharge strategy for patients is becoming increasingly important to prevent readmissions. "We put a discharge plan in place and coordinate with primary care, home health agencies, visiting nurses, and family members."
Hospitalist groups are tapping into electronic health records to enable smooth transition of care and to ensure that laboratory results are finalized following a patient discharge, Donahue and Wilborn say. In addition, once patients are discharged, follow-up information is sent to primary care physicians. If a patient doesn't have a PCP, hospitalists work as the primary care physician to oversee follow-up care, or connect with other physicians if the patient needs additional observation or care in a nursing home. Vaidyan says St. Mary's has worked closely with community programs and nursing homes to improve handoff of patients following hospital discharge.
Some hospitals are also looking to expand the role of hospitalists who do double duty, working in clinics and in hospitals. These hospitalists are known as extensivists. In a 2011 study of patients treated by extensivists in California, the Agency for Healthcare Research and Quality found a length of stay of 4.5 days compared to the average 5.6 in Medicare patients.
The University of Chicago Medical Center has initiated a study of 2,000 patients in a program known as Comprehensive Care, says David Meltzer, MD, PhD, chief of the section of hospital medicine at the University of Chicago. The project is focusing on patients with chronic conditions who are likely to need frequent hospital care. "Many people think that the doctor-patient relationship is the key to better health," he says. "If that is true, patients who are often in the hospital might get better care if they could see the same doctor in clinic and in the hospital," Meltzer says.
Success key No. 3: Unit scheduling
A few years ago, at St. Mary's Health Center, the hospitalists were in the building, but they were scattered all over, "having patients in 13 different units," Vaidyan recalls. Indeed, hospitalists were often assigned patients on different floors and in different units, wasting time and resources, as hospital officials saw it. "It wasn't productive," says Vaidyan.
"We redesigned our program in which a hospitalist would have 80% of their patients in one unit," Vaidyan says. "The idea is that the hospitalist can stay in that unit for an extended time to build a relationship with the nursing staff and multidisciplinary team members. The process has led to improved patient satisfaction."
At St. Mary's, an internal report compared patient satisfaction in hospitalist cases to nonhospitalist ones. The use of hospitalists increased patient satisfaction from 41% in 2008 to 55% in 2010 under a HCAHPS survey, according to St. Mary's. During that same period, a nonhospitalist unit improved only from 41% to 49%.
The hospital is continuing to strive for improvement in patient satisfaction scores, Vaidyan says. Overall, the hospital received 81% patient satisfaction scores, similar to scores in the rest of Missouri as well as the rest of the United States, according to Hospital Compare.
Although the dilemma seemed simple, the location of the hospitalists had a cascading impact from efficiency to patient satisfaction. Moving the hospitalists to be nearer the patients had a psychological advantage: Suddenly patients saw the hospitalists as physicians who were right there, caregivers who would be mindful of their needs. To resolve the problem, St. Mary's assigned hospitalists to a specific unit, including a special 20-bed area specifically reserved for them and RNs.
Banner Baywood also uses a so-called "unit-based assignment model, says Spratling, who praises the model. "Instead of rounding on patients scattered throughout the hospital in multiple units, the hospitalist is assigned to round on all the patients in a convenient 26-bed unit. The new model creates a new rounding priority that enables the hospitalist to discharge patients earlier in the day, resulting in improved patient flow," he adds.
"There was a basic dysfunction that was overcome," Spratling says. "Patients were waiting to go home, and they'd wait and wait, and before you knew it, it was 4 p.m. Often, it was then too late to arrange for home healthcare if they needed it or to get them to a skilled nursing facility if needed. We made the changes so the patients could be discharged in the morning, and we didn't have 'rush hour' discharges at the hospital at 5 p.m."
With its revised scheduling, the hospital was able to receive an average of 40 more patients for inpatient procedures. The hospital did not merely set the stage for efficiency but it also improved relationships among the case managers, social workers, "as well as face-to-face time, having a true interdisciplinary team working with the family and patient," Spratling says.
At Banner Baywood, patient satisfaction scores for the unit are 99%, about 15 percentage points higher than the 84% for the rest of the facility, according to the hospital. Both St. Mary's and Banner Baywood Medical Center credited the rounding changes to improved patient satisfaction scores.
Success key No. 4: Team-based approach
Hospitalists are becoming pivotal players in carrying out team-based care. They are involved in admissions and discharges of patients, especially when patients don't have a primary care physician. In some cases, hospitals are characterizing hospitalists as "captains" of teams to coordinate care as they take leadership positions.
Having hospitalists in leadership roles helps to ensure proper coordination, as well as coordinating patient safety data and core measures, says Lux, the chief of hospital medicine at St. David's Round Rock Medical Center. At his facility, hospitalists have "a place at the table" in hospital governance, he says. Hospitalists are assigned roles on the medical executive committee, which represents all major departments in the hospital.
"We're having a permanent seat, and it's rotated after two years," Lux says of the medical executive committee. "We have become the universal admitters to hospitals, and we're admitting patients and assigning them to other specialists. It's important there is regular interface with other medical disciplines."
Hospitalists are on other major committees like quality and pharmaceutical. They are also on the hospital's cancer committee because of the increasing role that palliative care plays, he adds. "This is one area that can touch many patients," Lux says, noting that half of Americans die in hospitals. "That whole dynamic falls within the role of hospital medicine. It's a critical relationship and taking on more importance, especially as hospitals are becoming more concerned about readmissions for illnesses such as congestive heart failure," Lux notes.
Such collaboration is important because of hospitalists' workload, say officials at various hospitals. In an early 2013 Johns Hopkins University study, four in 10 hospitalists reported their workloads exceeded safe levels at least once a month. In a research letter published in JAMA Internal Medicine, Henry J. Hichtalik, MD, and Peter Pronovost, MD, and others said that 36% of 506 hospitalist respondents reported workload assignments exceeding safe levels at least once a week.
Nygaard at Lee Memorial Health System says workloads have been a consistent issue for hospitalists, but he and other organizations are working to resolve the problems through scheduling changes. "We're trying to have our hospitalists have 18 to 20 patients, but any more is a lot for an individual physician," he says. "We had one physician who had 30 to 40 patients, and that was too much. The acuity of these patients is high."
In Arizona, Banner Baywood Medical Center also is embracing the team-based model to improve coordination with hospitalists, but CMO Spratling says the process isn't easy.
"It was very hard for the older docs to get used to working as a member of a team of physicians. We determined that a team of unit-based physicians could improve not only patient flow but also patient and staff satisfaction, as well as physician efficiency. With all the patients in one location, travel and communication delays were removed. That was what we wanted."
Reprint HLR0413-7
This article appears in the April 2013 issue of HealthLeaders magazine.
For physicians, it might seem like the ultimate revenge fantasy—suing for malpractice the malpractice attorneys who represented them, but not to their satisfaction.
For Berton Forman, MD, it's a vivid reality that may be a cautionary tale for other physicians.
Forman, a Nassau County, N.Y. anesthesiologist, has no fear of the legal arena, even though malpractice litigation has already cost him $1 million from his insurance coverage. That ultimately derailed his career. And in a rare twist, the 60-year-old doctor is looking to litigate—this time, to save his reputation. Forman has been waiting five years for his day in court.
In 2008, Forman filed a breach of contract lawsuit against his original malpractice attorneys, Martin Clearwater & Bell, LLP. Opening arguments in the New York Supreme Court lawsuit are scheduled to begin this week.
It's an unfolding case that should be watched by other physicians concerned about malpractice litigation impacts. Such a case is extremely unusual, says Henry J. Miller, an attorney representing Martin Clearwater & Bell. "You've got a legal malpractice case underlying a medical malpractice case," Miller told me. "I haven't seen one like it."
In 2006, Forman was one of the defendants in a malpractice case settlement that he says led, in part, to his eventually quitting medicine after practicing for 30 years.
Forman was part of a group that included several physicians, the insurer and hospital, who paid out $1.3 million stemming from a complicated and problematic delivery of a baby at Mercy Hospital in Nassau County, NY. The baby survived, but lawyers for Martin Clearwater & Bell said the baby was severely brain damaged.
In his lawsuit, Forman says he's seeking unspecific damages for breach of contract, misrepresentation, and conflict of interest because he was told he was at most 15% to 20% responsible for the malpractice award.
When it was finally paid out, he was left to pay a majority—$1 million out of his insurance policy—of the $1.3 million settlement. Mercy paid $300,000, he said.
That $1 million payment eventually "triggered an investigation by the New York State Office of Professional Medical Conduct," and made it difficult for him to gain employment after he left Mercy, Forman said in a statement. Forman says he eventually retired for health reasons.
A review of Forman's complaint and an interview with him suggests the trial may raise questions about loyalty, agreements among physicians, hospitals and insurers, and proper recordkeeping and clinical decisions. The case also shows mistakes Forman says he made in agreeing to a settlement, without looking at all the details, which he says should be a lesson to other physicians. He says the lawyers asked him to be a "team player" prior to the settlement years ago, but he considers that concession a mistake.
"I took the blame for the case because I was the idiot who was willing to play ball and signed off on the consent," he says. "Another lesson—when you sign off on a consent and your attorney tells you, 'This is going to be $100,000,' make sure he puts that down in writing. Do not believe what your attorney tells you unless he puts it in writing. I would never do that again."
"It's a case of man bites dog," Forman calls it. "It's imperative to be proactive in this process. You can't be passive."
"I was told I would be responsible for 15 to 20% of the payout. Instead I paid out 81%, so I paid for all of the defendants," he says. "This is the essence of the case. My own attorneys were representing the interests of the insurance company [and] hospital, before defending my interests."
In his suit against his malpractice attorney, Forman charges that Martin Clearwater & Bell used "undue influence to pressure" him into agreeing to a settlement that effectively benefited the hospital where he worked, Mercy Hospital, and an insurer, Medical Mutual Liability Insurance Company. The firm represented the insurers and hospital in the case as well.
Two Martin Clearwater & Bell lawyers who were cited by Forman have denied the physician's claims, according to court papers filed by attorney Robert Frisenda of White Plains, NY. The lawyers deny "each and every allegation," but admitted that "defendant Martin Clearwater & Bell agreed to and did provide to plaintiff appropriate legal counsel in connection with the defense of the malpractice action."
The papers add: "Dr. Forman executed an unconditional consent to settle the underlying malpractice action." Frisenda did not comment further.
Miller, who is co-counsel defending Martin Clearwater & Bell, says "there's very little we agree with in the plaintiff's case." As for the malpractice settlement, Forman may have been hit with "many millions of (dollars) in damages, way beyond his insurance coverage," Miller said.
As far as Forman is concerned, one of the problems that impacts physicians in malpractice cases is when the same insurance company represents the doctor and hospital. "Someone is going to get the short end of the stick, especially if one defendant signs off on the consent and the others don't," Forman says.
There was another thing that he didn't do that certainly might have helped his cause, and should be in a physician's playbook to avoid malpractice litigation, and that's to keep tabs on hospital records, he says.
Before agreeing to the settlement, the anesthesiologist was told that he "needed to be a team player for the hospital that had been good to him," Forman recalls. He says an internal hospital review essentially exonerated him and he had good employment records. But Forman says in his suit that his employment records were mistakenly shredded by the hospital after he left.
"It was a nightmare, but something you put in your rearview mirror," Forman says. "I want to shed light on this situation because lawyers and the insurance industry have to become more transparent."
No medical device dominates the news as much as the multi-armed robot, particularly the da Vinci, which is at once fiercely loved and incredibly despised.
Some doctors tell me it's the greatest tool they've got to improve efficiencies in the operating room. Others say it's a disaster waiting to happen. In some instances, they believe it already has. While some hospitals are counting on the robot for higher ROI, a growing number of lawsuits is taking center stage over allegations of improper procedures.
In the meantime, the federal Food and Drug Administration has launched a survey to evaluate the robot, focusing on physicians' opinions about the device.
Indeed, the controversy isn't just about the mechanics of the device itself. Often, the robot problems are associated with physician training. Questions about training involving the manufacturer have been raised and there have been allegations of physicians mishandling the device.
The FDA acknowledges there have been increasing reports of adverse events related to the da Vinci, and agency officials want to talk to surgeons about the reasons behind the complaints. Are physicians to blame? Are the robots to blame?
Federal officials have begun a survey of physicians "after we observed an increase in the number of (adverse events) we received about the da Vinci surgical system," FDA spokeswoman Synim Rivers told me.
While the FDA isn't revealing numbers, Rivers emphasized that the "increases in reporting can be due to a number of factors, including an increase in the number of devices being used—as well as an increase in awareness of how to report device issues to the FDA."
To get a better sense of how to interpret the da Vinci reports, the FDA is surveying a "small sample of surgeons" who use the da Vinci system. "Since it is difficult to know why the reports have increased, FDA has elected to talk with surgeons to better understand the factors that may be contributing to the rise in report numbers," Rivers says.
The surveys are considered a "routine part of surveillance" and one of several postmarket tools that the FDA uses to help evaluate device performance and use and to "further understand the risk-benefit profile for devices."
"Increased publicity resulting from product recalls, media coverage, litigation, and other influences can also increase the number of reports, but this doesn't necessarily indicate a true rise in event occurrence," Rivers explains.
And because reports submitted to the FDA can contain "incomplete, inaccurate, duplicative, and unverified information, an upward trend of adverse event reports is not by itself directly indicative of a faulty or defective medical device," she says.
As part of the survey, the FDA is interested in questioning surgeons who use the da Vinci device for "a variety of procedures." The agency sent a letter to surgeons at hospitals that participate in the FDA's center for devices and radiological health's Medical Product Safety Network, known as MedSun.
In the letter, the FDA says it wants to "better understand users' perspectives on the different challenges raised when using the da Vinci surgical system interface for performing surgery versus conventional surgical procedures." Among the questions to surgeons:
How many surgeries and what types of surgeries have you performed using the da Vinci surgical system over the last three years?
What procedures do you believe are most suited, or least suited for the da Vinci;
Do you prefer the da Vinci system to conventional systems?
What are the "problems or challenges" of the da Vinci?
What "kind of complications" are you seeing?
How is training usually conducted and how often does it occur?
The FDA says the survey "is intended to help us better understand [users'] perspectives on the different challenges raised when using the da Vinci system interface for performing surgery versus using conventional surgical procedures." The survey also could assess current and future trends in the robotic surgery. The survey results would be "qualitative in nature, not quantitative."
For now, the FDA is holding back on its view about the da Vinci – or even how physicians are using the robot until it gets more facts.
But the agency shouldn't wait too long, since many patient outcomes and huge dollars are hanging in the balance.
The issue of physician training is spotlighted in a case that is playing out in Washington state, where a jury will decide whether Intuitive Surgical, the maker of da Vinci, properly trained a physician who, in his first unassisted surgery using the company's da Vinci surgical system, removed the prostate gland of a patient who later died, according to Bloomberg News.
"Surgeons and patients around the world have found da Vinci surgery to be safe and effective minimally invasive treatment option for a range of complex conditions," Intuitive has stated. "In fact, roughly 3,000 peer-reviewed studies have been published demonstrating the clinical effectiveness of da Vinci surgery."
The Massachusetts Board of Registration in Medicine issued an advisory to physicians last month after finding increasing complications in robot-assisted surgeries. The board outlined steps that should be used to properly use the robot, including proper quality, safety and credentialing measures.
"As with any new technology, care should be taken that protocols are in place to ensure appropriate patient selection, and the full explanation of risks and benefits for all surgical options," it adds. Board officials did not respond for interview requests.
A significant concern involves lack of adequate training of physicians in handling of the robot. "How does the procedure present itself? The robot plays a supporting role in that," Thomas Skorup, FACHE, VP for the ECRI Institute, a non-profit that researches safety, quality and cost-effectiveness of patient care, told me in a recent conversation about the issue.
"How many 'at bats' are these surgeons getting to keep up their proficiency level at the appropriate level?" Skorup asks, referring to training of physicians in the use of the robot. "The safety issue is a key," he says. "There's a strong correlation, in my mind, to the proficiency and training of physicians."
Care for chronically ill and very sick patients is historically costly and sometimes inexorably linked to unnecessary procedures. Physicians of ten struggle over the question of how much care is appropriate under the circumstances: Should there be another test done? Should there be another surgery?
It's never easy, and of course, it's wrapped around a series of complex issues, among them the wishes of the patients and family and the ethical decision for each case.
Through it all, physicians want to help patients, who are often seeking "a mix of cure and comfort," in the words of Brad Stuart, MD, CMO, Sutter Care at Home, the homecare and hospice provider based in Northern California near San Francisco.
That task may be difficult, at best. Inevitably, healthcare executives often rely on implementing palliative and hospice care to improve quality of life for chronically ill patients, or those nearing death. More hospitals are developing such programs, and the need may be greater in the years ahead, considering the growth of the U.S.'s aging population. By 2030, the number of people in this country over the age of 85, for instance, is expected to double to 8.5 million.
Palliative care is growing in popularity with its multidisciplinary teams who work to care for patients in efforts to relieve suffering, pain, and even the depression and stress that often accompany chronic illness.
And although palliative care is growing, experts in the field are still struggling to define precisely what it is. They are dealing with what they call "image" or "branding" problems, especially as it relates to hospice for patients who are very sick or dying.
Providers, patients and families are all grappling to understand what this varying level of care is all about.
"Palliative care leaders are trying to distance themselves from hospice because they feel hospice has a branding problem," since it is associated with dying or end-of-life care, says Stuart. Hospice officials believe they have "painted themselves into a bit of a corner in this branding and are trying to move upstream in the care continuum," says Michael Nisco, MD, MBA, medical director of the Saint Agnes Medical Center Hospital and Hospice and Palliative Care Services in Fresno, CA.
Enormous complexities confront health professionals charged with treating complicated illness, and providing end-of-life care.
"We haven't been able to deal with the issues of death and dying very effectively in our culture," says Kathleen Potempa, dean of the University of Michigan School of Nursing. "When you have a very seriously ill person, a physician is trained to do everything to save a life, and the family may be [hoping] that one more thing will be the magic bullet, but that isn't the reality."
Helping patients and their families deal with the stark realities of severe illness and impending death is a growing concern among physicians in general, and the issue is taking center stage within palliative and hospice care communities.
Stuart and Nisco see palliative care as a way for healthcare facilities to broaden services for chronically ill people, while also serving as an important link to hospice care. Palliative care has extended outside the hospital setting to ambulatory and home-based services, Stuart says. Having an integrated program that involves hospitals, medical homes and community-based services helps patients and their families to deal more effectively with late-stage chronic illness, he adds.
That's why Sutter has included its palliative care program under the umbrella of the Advanced Illness Management Program that Stuart created for what he terms a "vulnerable and growing population." While palliative care is often focused on the "relief of symptoms and suffering," Stuart says, "our focus is much more positive."
Multidisciplinary teams include physicians, nurses, social workers, psychologists and nutritionists. Various elements focus on the specific needs, of course—and wants—of patients. While physicians often outline the medication needs for patients, the Advanced Illness Management Program always considers "what does the patient want?" Stuart says. It's the "little things" that matter, too often lost in traditional medical care.
Ultimately, it's personal connections that make palliative care work, Nisco says. "We need to sit down and get to know the person as a person, what are their likes and dislikes," Nisco adds. "It is important "to follow the patient's wishes, and easing their transition of care."
Essentially, "we're helping people live the lives they want, and in so doing we are shifting the focus of care out of the hospital into the home and community," Stuart adds. "And I think what's happening we're developing a much wider and deeper footprint for the healthcare system out in the community."
"We are taking more seriously those little things that a patient wants or needs," Stuart says. "It's like the patient walking to the dinner table with their family, seeing a granddaughter graduate from high school. We make those personal goals the priority and then design care plans to match those," Stuart adds. "That causes a very interesting shift in priorities, not only for the care team but people."
Important clinical procedures, such as patient adherence to a medication regime, "gets a lot easier to accomplish when a person who is ill sees us as the team helps them accomplish what they want to in their lives," Stuart says. "It shifts away from 'here's what the doc wants you to do,' to 'here's what we can do together what you want in your life."
To develop its Advanced Illness Management Program, Sutter received $13 million from the Centers for Medicare and Medicaid Services under a three-year grant for palliative care and advanced care planning for patients with late stage chronic illness. The money came after Sutter's Sacramento region showed positive outcomes from its AIM program, such as reduced hospitalizations and improved care transitions.
From 2009 to 2011, Sutter reports show a 54% reduction in readmissions, an 80% reduction in ICU (intensive care unit) days, and a 26% reduction in hospital length of stays. In addition, there were reduced visits to physician offices, and home health care, Stuart adds. He cites cost savings of more than $500,000.
Sutter has been demonstrating success in its palliative care program for years. Seven years ago, in an extensive study, the Sutter Health Institute for Research and Education, part of Sutter Health in San Francisco, found that palliative care programs at 798-bed California Pacific Medical Center in that city resulted in an estimated annual savings of $2.2 million, with daily costs for palliative care patients estimated at 14.5% lower compared to usual care patients.
The Saint Agnes Medical Center also has found success in reducing costs and in palliative and hospice programs, says Nisco of the Saint Agnes Medical Center Hospital and Hospice and Palliative Care Services. The hospital has saved at least $1,800 per patient in its palliative care versus other programs.
For a hospital system, putting together a palliative care program may become invaluable as the healthcare moves from fee for service to value based systems, Nisco adds. "When you net out all the cost savings, with what you can achieve with a program like this, it's kind of cost neutral: it doesn't wind up costing a lot of money."
Nisco acknowledges that hospital financial chiefs may still be reluctant to embrace palliative care. "It may not immediately result in reduced costs to excite your CFO because everybody is looking for the kind of dollars [in savings] that makes your eyes sparkle," Nisco says.
"But a forward-thinking CFO is going to see this as an important thing to emphasize as the priorities of healthcare change. It is being a little ahead of the curve, having an integrative palliative care program in your healthcare system."
For many, it's simply a matter of "raising their palliative care IQ," Nisco says.
(A HealthLeaders Media Webcast, Develop an Innovative and Integrated Palliative Care Program is slated for Tuesday, April 23, 2013, with Brad Stuart, MD, chief medical officer of Sutter Care at Home in Emeryville, CA and Michael Nisco, MD, MBA, medical director for Saint Agnes Medical Center Hospice and Palliative Care Services, in Fresno, CA.)
This article appears in the April 2013 issue of HealthLeaders magazine.
They come into the emergency department as if it's their second home; indeed, they often are on a first-name basis with the medical personn el who are there to greet and treat them. On this particular Sunday night in a suburban Washington, D.C., hospital, a patient is in the ED, smiling but with a bloodied face. A nurse whispers in the hallway: "Mary's alcohol level is high again." Just as the bartenders at the local taverns do, the ED nurses know Mary. She is a regular. Scenes like this one are being played out regularly across America, like well-worn reruns.
Theodore I. Benzer, MD, PhD, FACEP, is chairman of ED quality and safety and director of clinical operations for the department of emergency medicine at Boston's 907-licensed-bed Massachusetts General Hospital. He sees and treats many of the patients who return to the ED time and again—at least five to 12 times a year or more. "They are so near and dear to us," Benzer says. "This is our group of patients we feel we know."
These are the so-called frequent fliers, a broad term that covers patients with varying needs. Some of these rebounders are challenged by alcohol or drug abuse issues or they need mental healthcare. Others choose the ED because they have no health insurance or primary care physician. Some are driven by fear and suffering associated with chronic pain but are reluctant to make an appointment to see their primary doctor—or their doctor is reluctant to see them yet again.
"We have very much longed for the opportunity to see new ways of taking care of these patients … to meet their needs, but in less and less costly ways," says Ted Townsend, president and CEO of the 250–300-staffed-bed St. Luke's Hospital in Cedar Rapids, Iowa, which has been working to reduce frequent fliers' usage of the ED. "We need to intervene with these patients in a different way."
The urgency of grounding frequent fliers has prompted hospitals, healthcare systems, and academics to initiate strategies to curtail what many believe will become more of an acute problem. Insurers are working with hospitals to implement programs for mentally ill patients and others with chronic conditions in an attempt to divert the patients into hospital-sponsored coordinated care plans that connect with government and community organization–provided services. Case managers closely monitor frequent fliers by following up after ED visits to prevent recurring hospital stays. Hospitals are installing electronic medical record programs that may flag frequent fliers for primary care physicians and community organizations.
Hospitals are assigning nurses and social workers to pore over records to identify patients who come to the hospital too often and actually are alerting the patients themselves that they may need primary or psychological medical care, not another trip to the ED.
"Each month, we review the frequent fliers, and some who are even very frequent fliers, the patients who come five or six times a month," says Benzer. Whether the patients use the ED five times a year or five times a month, he says, "Over the years, we've found what other hospitals are finding: A lot of these patients have drug, alcohol, or substance concerns, and there are some who are homeless."
Also, there are patients who repeatedly use the ED who have "very severe and complex medical problems," Benzer says. "It's very complicated. The sad part in all of this is that, in medicine, in terms of treatment, it's not easy. It's not like giving penicillin for strep throat; there's no 100% cure." Patients "may be drunk, but drunk people have heart attacks and skull fractures. When they get drunk they can't tell you how they are feeling."
Because of the complexities involved with ED frequent fliers, MGH has been coordinating programs with city and state social service organizations with a simple goal: "We can get them into a program rather than the ED," Benzer says.
For hospitals, frequent fliers are a strain not only because of the high cost of running the ED, but because repeat users add to overcrowding and wait times that impact patients with emergent care needs. Better treatment of this population has never been more urgent for hospitals, what with reimbursement changes away from fee-for-service and upcoming 30-day readmission penalties from the federal government. As more elements of the Patient Protection and Affordable Care Act get implemented, emergency medicine physicians expect the use of EDs to increase when as many as 40 million previously uninsured people flow into the system.
Throughout the country, frequent fliers are impacting hospital EDs in varying degrees. As reported in a series of studies in 2012 for the Annals of Emergency Medicine, frequent fliers at hospital EDs sought emergency care at least four times a year and sometimes as often as 21 or more. Individual patients can account for one or two dozen visits, sometimes more. In 2010, the Department of Emergency Medicine at Mount Sinai School of Medicine in New York reported that frequent users comprised 4.5%–8% of ED patients, but accounted for 21%–25% of all hospital visits. A 2010 Rand Corp. study reported healthcare spending of $4.4 billion on people using the ED for routine, nonurgent care.
"There is a small population driving costs in the system, which given its fragmentation has not been well designed to meet the complexity of their needs," says Allison Hamblin, MSPH, vice president for strategic planning at the Center for Health Care Strategies, a nonprofit health policy resource center based in Hamilton, N.J. "But the pendulum is swinging. We are starting to see more organized care and more integrated programs for these patients with complex needs."
Case manager plan
The frequent flier issue was exemplified at St. Luke's, where a Cedar Rapids woman took the bus—almost as a commuter would, with no sense of urgency—to make 12 visits to the ED in 2011, says Sallie Selfridge, a case manager in the hospital's ED, which logged 55,079 emergency visits that year. Although the patient had congestive heart failure—a chronic condition—there was nothing urgent about the elderly woman's visits.
Hospital executives started to evaluate the process after a social worker and nurse practitioner began comparing notes, saying, "Did you see Fred was back in the ED again today?" Townsend recalls. "The fact they could actually know who these people were on a first-name basis seemed incongruous to the emergency department," he says.
St. Luke's Hospital began a consistent care program to identify frequent fliers who returned to the ED for at least 12 visits in 12 months. The solution is giving these patients assistance in locating alternative care. The effort has been successful in reducing patient trips to the ED. In 2011, 103 patients who were designated frequent fliers made 1,679 visits to the ED. But after involving the patients in coordinated care planning, within a year the same group made only 537 visits.
At St. Luke's, they found that many of the patients use the ED because they don't have a family doctor, and others have difficulty keeping appointments because they lack transportation, have work schedules that make it tough to visit a doctor during office hours, or have financial or insurance issues.
"We wanted to identify these frequent fliers and put together a plan of care for each of these individuals to see if we can find a way to reduce their utilization of the ED—not just to avoid the ED but to get them to more appropriate levels of care, and that's exactly what happened," says Townsend, the CEO.
As hospital officials examined the frequent flier situation, they focused on the financing, and it "came out as a wash," he says. By eliminating the income to the ED with the decrease in frequent fliers, the hospital estimated that it lost about $500,000 in one year related to patients who were diverted to other care.
At the same time, the hospital estimated it saved about half a million dollars by not having to provide additional care and testing for such patients, Townsend adds. "In reality, because of the payer mix of folks coming through the ED, that was roughly a break-even proposition for St. Luke's," he adds. "Yes, we would have generated $500,000 in fees, but we probably were incurring $500,000 in costs; it was a zero-sum game," he adds. "It's the right thing to do for the community and works reasonably well for St. Luke's."
Creating a direct relationship
As Benzer points out, even in Massachusetts, where health insurance is universal, frequent fliers are prevalent at hospital EDs. "Almost all of these patients have been identified as having primary care physicians, and they had insurance, so that wasn't the issue," says Dawn Williamson, RN, MSN, PMHNS-BC, an addiction specialist in the ED at MGH.
Staff physicians and nurses at MGH reviewed their records and formed a team to coordinate various programs for the frequent fliers, or, as they dub them, MVPs or multivisit patients.
"Such patients are often the focus of conversation among the hospital's quality committee personnel and staff, says Williamson. "We always ask: 'Are we missing something? Did we fail the patient the first time around?' There were a whole bunch of psychological, social, and economic issues involved.
"These patients weren't connecting with their care, and coordination was lacking," Williamson adds. "And sometimes the patient may have a goal, but doesn't have the executive function to follow through on those goals, [such as] making the next appointment or getting to the next step in care. We are always the safety net."
MGH leadership committees explore data that identifies the frequent ED users. Once it's established who they are, the hospital reaches out to these patients and makes appointments with primary care physicians or other specialists such as psychiatrists, if necessary, Benzer says. "In that way, a direct relationship is established between the hospital and the patient."
A care manager presents individual plans to the patient's primary care provider or finds a primary care physician if the patient doesn't have one. The care manager also informs the patient's provider about the frequency of the patient's ED visits and the treatment the patient received each time. At MGH, letters are sent to primary care physicians to make them aware that their patients have used the ED frequently and should be involved in a program to reduce the trend. At St. Luke's, similar letters are sent to patients, many of whom agree to pursue specific care plans with their physician once they are helped to negotiate the healthcare system.
Case management programs can be cost-effective. Reduction in hospital costs exceeded the cost of the case management team, according to a July 2011 report from the Annals of Emergency Medicine. That research shows a median cost reduction per patient of $2,406. For all hospital services, potential cost savings were estimated at $10 million per year for 157 patients enrolled in a two-year program.
"Our systematic review suggests that interventions targeting frequent users of hospital EDs may be effective at reducing ED use," the report states. "Case management, the most described intervention, could reduce ED costs and may also improve social and some clinical outcomes."
Following the care plan
At St. Luke's, 12 is the magic number for dealing with frequent fliers. After a dozen visits, patients receive notification in the mail of their inclusion in the consistent care program. The letter includes an introduction to the program, a copy of their care plan, and a release of information that they are asked to sign so their medical information can be shared with other care providers.
After the patient is enrolled in the program, the case manager reviews the patient's discharge instructions from the last ED visit and makes sure the patient understands those instructions and that the treatment plan is being followed.
The hospital works to see that the patients follow through with physician recommendations, take medications as prescribed, and take appropriate preventive measures, such as diet and exercise.
Often frequent fliers are stunned to realize what they have done. "It's eye-opening for them. For some, it is shocking that they have come to the emergency department so many times," says Selfridge, the St. Luke's case manager. For those who only had a slight injury or a cold, they are told they could have waited a day and didn't need to come to the ED.
Technology and diabetes
One academic report focusing on the ED of a county hospital noted an "excessive number of visits for diabetes complications, a high rate of hospital admissions from the ER, and the high cost of ER use."
That report was written in 1985. But the commentary is still relevant almost 30 years later, dramatically illustrating how long hospital officials have been grappling with the issue of ED use, particularly by diabetes patients, and especially those with lower income or limited access to primary care. In 2010, a study in Southern California showed that of 1,309 patients in two hospitals, about 11% were diabetic.
Healthcare systems increasingly rely on electronic medical records as a crucial step to keep these patients from going back into the ED, encouraging them to instead seek care elsewhere, such as with their primary care physicians.
Working with community organizations, the 681-licensed-bed Unity Health System in Rochester, N.Y., which is affiliated with the University of Rochester School of Medicine and Dentistry, established the Community Diabetes Collaborative to identify all of Unity's diabetic patients and their caretakers. The collaborative connects diabetics to providers through an interoperable platform that can accommodate all types of EMRs. The accumulated data enables physicians to keep a current record of diabetic patients' needs, says Margaret Donahue, MD, who recently retired as Unity's chief medical information officer.
To eliminate gaps in care for diabetic patients, Donahue says, the hospital uses electronic records to identify patients in need of care. While the hospital had tried for years to reduce dangerously high levels of hemoglobin-related blood sugar counts among patients, it recently improved its care in this area, she says.
"They were not getting the care they needed," she says bluntly of diabetic patients. For instance, some patients hadn't checked their hemoglobin levels in six months, says Donahue. In the ED, patients wouldn't know the medications they were on. "We saw an opportunity to identify these patients, get their hemoglobin tested, record their medications, and analyze this information." Continuity from the patients' electronic records coupled with improved care management enabled the hospital to convince patients how important it is to check their hemoglobin levels and maintain improvements in their care.
With dbMotion interoperability software, the hospital has been able to maintain a "master patient index to identify patients between the different EMR systems and consolidate and semantically map the data from across the systems," Donahue says. "We have the data from both hospital and office EMR systems to identify those gaps." Donahue says the hospital's "access to the patient's medication history is greatly improved with access to the [software] and to external medication history through e-prescribing."
Behavioral care and insurers
In Pittsburgh, the proximity of a number of hospitals to each other means that sometimes patients decide that they can take their pick of emergency departments.
A Pennsylvania medical assistance program is seeking to integrate physician and behavioral health services for adults with serious mental illness and physical health comorbidities, directing its efforts at patients who frequent the ED and are often readmitted to the hospitals. Pittsburgh-based UPMC—a $9 billion global health enterprise with 21 hospitals, 400 doctors' offices and outpatient sites, and a health insurance division—is involved in this effort.
Behavioral and physical care systems often lack coordination, which can result in negative impact on individuals, according to James Schuster, MD, MBA, chief medical officer for community care at UPMC's insurance services division.
The program, Connected Care, involves UPMC's Medicaid managed care plan, UPMC for You. From July 2008 through April 2011, the program enlisted more than 2,500 of 8,600 Medicare members in a pilot study. UPMC for You and Community Care Behavioral Health, based in Pittsburgh, launched the test for the Pennsylvania Department of Public Welfare to integrate behavioral and physical healthcare Medicaid services for people with serious mental illness. The organizations worked with other stakeholders, such as behavioral health and physical health systems in Allegheny County, which includes Pittsburgh. By coordinating care and using electronic medical record reviews and case manager follow-up, officials of the UPMC Health Plan say Connected Care has significantly reduced mental health readmissions to hospitals and has shown promise to reduce ED use.
The Connected Care plan involves a multidisciplinary team that holds clinical case reviews for patients with "complex needs." The team, which meets twice a month, includes the health plan's medical directors, care or case managers, clinical supervisors, and UPMC pharmacists. Then UPMC care managers educate the patients on how to manage their physical condition, prevent unnecessary ED visits, and follow up within 24 or 48 hours of a hospital readmission or ED visit.
"The effort required some IT and clinical process development work. This is now complete and the incremental cost for expanding this program to additional regions is expected to be nominal," Schuster says.
The all-cause readmission hospital rate dropped from more than 43% to nearly 39% for the study group from 2007 to 2011, Mathematica Policy Research found. Its report stated that Connected Care "holds promise for improving ED and mental health hospitalization rates." Too often, there are not enough programs to assist patients who simply use the ED as a "kind of urgent care center," says John Lovelace, MS, MSIS, president of government programs and Individual Advantage for the UPMC Health Plan. "Some people don't take advantage of psychiatric care. There is a proportion of people who do not go see a primary care doctor. They don't do anything."
Coordination is impacted by what may seem like the simplest of flaws, Lovelace says. "A lot of times, the ambulatory provider or behavioral health person doesn't know someone was in the ED because the patient doesn't tell them, or they may not see them very often," Lovelace says.
Changing behavior
With a focus on individuals and families as well as population health management, CareOregon also is working with healthcare systems to improve coordination and reduce emergency department visits. The Portland, Ore.–based nonprofit health plan is involved in delivering care to Medicaid patients through five different coordinated care organizations in Oregon and includes 8,000 primary care providers and specialists, 43 hospitals, and 34 public health departments.
Last year, CareOregon mapped patients with high healthcare needs to identify key commonalities among patients. "We did a lot of multidisciplinary team building in order to find the behavioral drivers of high utilization," says Rebecca Ramsay, BSN, MPH, director of community care for CareOregon.
"We needed a pretty wide net, with primary care teams spending 60% to 70% of their time making home visits," she says. "It's boots on the street." At least four outreach workers supported 46 patients, and within six months reduced the patients' ED visits by 31%. "Our community outreach workers have told us that when they engage with a patient, they are essentially acting as an extension of the primary care team that goes into the community," Ramsay says. "The patients gain so much support from this approach that they often don't need to come into the office for care as frequently."
Changing behaviors is essential. Revamped care coordination has shown good results for the 349-licensed-bed Good Samaritan Hospital in San Jose, Calif, according to Hospital Compare. At Good Samaritan, the average patient wait time to be seen by an ED professional staffer was 20 minutes in the first quarter of 2012, far below the national average of 30 minutes and the California average of 33 minutes.
Still, the Good Samaritan ED isn't perfect: The average time a patient spends in the ED before being sent home is 168 minutes, 5 minutes fewer than the California average, but greater than the national average of 140 minutes.
One of the biggest problems for the hospital is an aspect of the frequent flier that Good Samaritan sees often: patients who are looking for certain prescription drugs, and they drop in to get them. "It's a pretty significant problem," says Ellis Weeker, MD, vice president of CEP (California Emergency Physicians) America in Emoryville, and an ED physician at Good Samaritan.
Many of the patients who frequent the EDs for this reason have pain issues, and some already have been prescribed medication from their doctors. To help resolve those issues, Good Samaritan has developed a quality assurance process to create a care plan and coordinate it with patients' primary care physicians to thwart potential medication abuse, Weeker says.
No cure yet
As Townsend, the CEO of St. Luke's, sees the issue of frequent fliers, he has hope, but also concerns. While the hospital has drastically reduced repeated use of the ED by a select group of frequent flier patients, it has only scratched the surface, he says.
"The volume in the ED went up last year, even though we found a better way to take care of these frequent fliers. The story is very much the same around the country; it's an issue that will stay," he says. "It will be an issue for years to come."
While St. Luke's has successfully steered more than 100 frequent flier patients away from the ED toward alternative care, the hospital estimates that hundreds more may be eligible to become frequent fliers within the next year or so.
"We're starting to put the hospital and physicians in a position to coordinate care whenever that care may need to occur," Townsend says.
Dealing directly with the patient and discussing the need for change can produce results. A 50-year-old St. Luke's patient who frequented the ED admitted he had limited options for a primary care physician because he caused such a fuss in his physician's office that he was no longer welcome. The hospital worked to connect the patient with a new primary care physician.
"Several months passed. The patient had not returned to the ED, and one day he called me to 'check in'," recalls Selfridge, the social worker at St. Luke's. "He let me know he had found a physician in town that accepted him as a patient and he wanted to let me know that he was keeping our conversations in mind and things were going well."
Joe Cantlupe is senior editor for physicians and service lines for HealthLeaders Media. He may be contacted at jcantlupe@healthleadersmedia.com.
Reprint HLR0413-2
This article appears in the April 2013 issue of HealthLeaders magazine.
Although physicians and hospitals continue to push for more collaborative care with multidisciplinary teams, they have a number of hurdles to overcome before realizin g the holy grail of full-blown cooperation.
One of the root problems starts with the lack of integration between academic and clinical settings.
In January, the Josiah Macy Jr. Foundation, an organization that focuses on healthcare education, convened a meeting among educators and healthcare providers to discuss the need for "interprofessional education" with a focus for both sides on understanding each other's needs, perspectives, attitudes, and strategies to deliver better care.
In a recent follow-up report, the Macy Foundation concluded that academics aren't communicating properly with practicing clinicians, and it's a serious problem. The result, the report says, is disjointed oversight of care that too often bypasses team-based care and too often fails to elevate the needs of patients and families—which is sorely needed to improve healthcare delivery models.
The blame extends beyond academicians and physicians; it also rests upon onerous regulatory requirements. As it now exists, healthcare education and healthcare delivery have "developed and functioned separately with little recognition that the two are inextricably linked," the Macy Foundation report states.
To make needed changes, the report indicates that healthcare professionals and academics must coordinate their goals and evaluate accreditation standards, data and clinical care focus. "Achieving this goal will require changing expectations for health professional competencies," the report states.
"Educational planning and care delivery planning need to be done together," George Thibault, MD, president of the Macy Foundation, told me. "A lot of positive things are happening in education and care delivery. But in most places, the educational change and discussion is happening in one place, and the care delivery discussions are occurring in the other. We need to integrate education and delivery. That's really the fundamental concept we are trying to get across. Up to this point, each group has been very focused on its own issues, but they need to understand the issues of the other group as well."
In a world beset by "silos," nowhere is that more apparent than in the academic and clinical settings, a division that must be overcome, Thibault says.
"Education is focused on the immediate product—the knowledge and skills of people they are training and sometimes it's a little divorced from what some would say is the real world, what's going on out there," Thibault adds.
"The people who are most focused on trying to get an efficient delivery system say, 'Well, education is going to slow us down, let us just focus on delivery of care.' That is a shortsighted view. They need to have the same set of unified goals and not be too separate," he explains.
While there is so much team-based care sought, it is sorely lacking in today's healthcare delivery system, the Macy Foundation report states. Healthcare delivery systems "must incorporate practice redesigns if we are to achieve enduring transformation," according to the report.
"People tend to focus on what they know best and what they are familiar with," Thibault says. "A bit of a cultural change is needed. Leaders of organizations will have to want this to happen. We need to really have one and the same set of unified goals, not separate."
Specifically, educators and healthcare providers should develop coordinated metrics to evaluate the impact of care models used in academic and clinical settings to improve population health management and reduce costs, the Macy report suggests.
Proper protocols need to be developed to advance the Triple Aim goals: better care, better health, and lower costs. The report further notes that there is now a "paucity of rigorous measures to evaluate the impact of linking interprofessional education and collaborative practice."
In addition, the report states that accreditation and certifications themselves pose barriers to efficient and effective team-based care. They attribute that, in part, to regulatory policies that generally "lag behind advances in healthcare education and clinical quality improvements."
While the report's language advocating change is strong, Thibault concedes that change will not come easily, in part, because education programs and clinical programs are now so entrenched.
"A whole lot of things need to change," he says. "We hear from some of the leaders of the integrated healthcare systems that are further along with delivery and they say 'trainees aren't prepared to work in these models, we have to retrain them.'"
Thibault proposes a solution: "My feeling is, 'Get them there in the first place, do their initial training in these care models, with their education."
As for the Macy Foundation, it suggests convening a national group to identify effective methods for patient and community engagement, beginning with a public-private partnership of federal agencies, and a private foundation.
Organizations that may be involved could include the Institute for Patients and Family Centered Care, the Institute for Healthcare Improvement, the Patient Centered Outcomes Research Institute, along with local and national healthcare systems. Others could be the National Center for Interprofessional Practice and Education, and the Robert Wood Johnson Foundation.
The foundation notes, of course, that healthcare scholarship and teamwork should include other fields, such as business. The Centers for Medicare and Medicaid Services, the National Institutes of Health and other organizations "should all share an interest in supporting this work in partnership with private foundations," the Macy Foundation states.
As it outlined the communication problems of academics and clinicians, the Macy Foundation acknowledged that a bridge to solutions would not be built overnight. "We do not underestimate the magnitude of the change in culture that will be required to accomplish all of these recommendations," the report concedes.
Still, there's no time like now to begin the process, says Thibault.
"I think we've got a moment in time in which change is around us. Almost no one can defend the status quo," he says. "Change is inevitable and we better figure out how to do it. If we miss this opportunity, some things may be imposed on us by the government and that won't be as good as what we do ourselves."