To manage the health of a customer group with incentives that align for the system and customer today, the Wisconsin health system has been aggressively marketing a broad-based portfolio of health services to area employers.
This article includes exclusive excerpts from HealthLeaders Media's FirstLook broadcast "Bellin Health: Build Your Direct-to-Employer Business," a behind-the-scenes video case study that will be broadcast Oct. 20.
The most effective play in football history may be the Green Bay Packers' "power sweep," Vince Lombardi's simple running play that relied on guts and repeated execution instead of misdirection.
Bellin Health, a 167-bed community health system a few miles from Wisconsin's Lambeau Field, has a health strategy power sweep of its own: Go directly to the employers.
"We are not waiting for payers to come to us, and not waiting for some literal act of Congress to change the payment system, but instead we are going out and working hard on managing the health of populations," says Bellin Health CEO George Kerwin.
Even now, the industry's drive to population health has a strategic hole in it; how to better manage the health of a customer group with incentives that align for the system and customer right now, and not at some aspirational future date.
The evolution started with its own employees, where over a decade Bellin has been able to bend its own health spend by more than $25 million, including a 1% cost premium cut last year.
Bellin's board members, many of whom run area companies, took notice and asked for the same services, which include plan design, wellness incentives, health coaching, and a variety of access points, including on-site clinics.
The strategy also hurdled another population health obstacle: losing volume.
Done properly, a health system should see a decline in inpatient and acute volume, which usually correlates to lost market share. But by partnering with area employers, Bellin has been able to balance the volume shift while also growing market share.
Market and Revenue Growth
Bellin's overall market growth has been at 4%. Annual revenue growth from employer partnerships is posting gains of more than 10% in recent years, while also improving the payer mix, says Randy Van Straten, Vice President, Business and Community Health. From a base of zero, Bellin now has more than 2,500 employer relationships for services, 125 with direct onsite services and 20 as high-level strategic partners.
Bellin had, and sold, its own health plan a decade ago, but now is able to work directly with employers to customize a health plan carve-out, Van Straten says.
"Basically what employers are buying are service levels configured to their needs," Van Straten says. "So it may be health risk appraisals, or health and wellness programs. We are now building compete on-site primary care clinics right on site at the employer to not only manage their prevention but to manage their chronic conditions and acute care services."
Bellin isn't reliant on any one tool to improve access.
A manufacturer with a blue collar workforce can offer on-site occupational therapy before the first shift.
At a school district, a physician's assistant may be available before and after classes.
A service company with many locations can provide virtual consults and centrally located fast care clinics.
"Especially when you are working with a population that has set hours, if they can't get off work to go see you, they are not going to get healthcare," says Brad Wozney, MD, medical director, Bellin Health. "So you need to make sure they can access care any time they need it."
The overall goal is to cut premium increases for each customer by half the national average, which in many cases Bellin has been able to match and exceed, Van Straten says, because Bellin is able to influence care before it gets to the hospital.
"It's about the navigation platform to get people at the right care at the right time at the right price," Van Straten says. "Really, it is about removing barriers of care to make it easy for employees and family members to get the care when they need it."
Valarie Wunderlich, director of benefits and compensation for 700-employee Northeast Wisconsin Technical College, says her school had three goals when it put out its health plan for RFP five years ago:
"One was cost containment. We had to see how our plan design was affecting our overall health costs,"
"Second was we wanted to build an overall culture of health and wellness."
"Our third pillar was education. Bellin has really helped us to educate our employees on receiving the right level of care at the right time."
To meet the goals, Bellin placed an on-site "Campus Care," clinic with a physician's assistant who handles preventative and acute care. NWTC had a high spend on musculoskeletal issues, so an on-site physical therapist was added. An on- site personal trainer works with employees and managers to build wellness into the daily routine, Wunderlich says.
Premium Cost is Key
On site, [a] PA looks at preventive as well as acute care. We also have physical therapy. Musculoskeletal is a high claim area for us so we wanted PT to bring down those costs. We also brought in a personal trainer to look at it from a preventive standpoint."
Through the program, NWTC has seen increases in important wellness metrics, including 40% participation in reasonable alternative standards compared to a national average in the single digits, she says.
Of course, the primary metric is premium cost.
"Our health plan has seen a total increase in premium of 5.9% in six years with some plan design changes which is significantly beating trend of 6.5%/year," Wunderlich says. "We attribute these savings due to on-site services, increase in overall health of our population and plan design that encourages consumer behaviors."
Kerwin says Bellin's team embraces results like NWTC's, even if it may mean fewer dollars coming into the hospital side.
"If this is really effective, you are going to drive down volume in the emergency room. You are going to drive down illness, and surgeries, and all the other acute things that are profitable in our industry," Kerwin says.
"We understand that. We know that it is happening. We feel it is our responsibility to adjust accordingly."
Leaders at Sharp HealthCare have developed a pod-and-huddle system built for speed, quality, and communication.
This article appears in the November 2015 issue of HealthLeaders magazine.
If you were to design an emergency department team that could be versatile, facilitate effective teamwork, and dismantle the barriers of traditional ED clogs, what would that look like?
Many modern EDs are designed in a linear flow, attaching nurses or physicians to particular patients and specific tasks. The problem is that linear workflows are vulnerable to uneven staff flow, waiting patients, and a backflow out of the ED to discharge. An ED team built for the purpose of flexibility and even workflow might look something like a pod, or so the leaders at Sharp Memorial have believed for most of the past decade.
The pod, simply, is a unit within a unit. In a Sharp ED, the pod consists of a single physician, a lead nurse also known as the pod leader, one clerk, one bedside tech, and three or four registered nurses. Each pod is accountable for eight to 10 beds per 12-hour shift. In theory, the pod structure is meant to enhance the ability of the ED team to work together more effectively.
"So that really changed the dynamic of the team," says Christopher Walker, MS, RN, NP, CNS, director of emergency services at Sharp Memorial Hospital in San Diego. "It introduces the concept that they're all responsible for all the patients within that pod, not just the three that you're assigned to. So one nurse doesn't put up their blinders and just take care of the patient in front of them. They have some peripheral vision to see what's going on with the patients to their side. That's the only way we'll ensure the highest level of safety and quality for our patients."
In a typical case, the patient is greeted by the triage nurse and assigned an emergency severity index level from 1 (resuscitation) to 5 (nonurgent), which will indicate whether the patient goes back to the ED pod beds or goes to the Sharp ED's quick care unit. Once the patient is in a bed, a pod nurse and usually the physician do the first bedside consult. The ED nursing flow is set up as a primary nurse model (defined as a therapeutic relationship between a single registered nurse and an individual patient), but with some specific alterations that give the nurses flexibility to move from patient to patient as the need arises. Any of the nurses will perform tests and basic procedures and provide education.
"One nurse can get caught up if there's one procedure that takes some time," says Charlene Anderson Dean, RN, clinical nurse for emergency services at Sharp Memorial Hospital. One example is a patient requiring a splint and crutches. Properly placing the splint can take 15 minutes or more, and showing the patient how to use crutches can take another 15 minutes.
"To a layperson, that doesn't sound like a long time," Dean says, "but if you're taking care of three patients and you've got another patient who's in pain that the doctor has ordered medication for, and you're stuck trying to place a splint, then you are taking away from that other patient."
In the pod model, "the expectation is that everyone is in charge of everyone. The other members actively search out other orders that need to be completed," Dean says.
A huge benefit of that model is in staff satisfaction, Walker says. "There's nothing worse than someone having a nice quiet day, thinking over what their patient population is, and the person adjacent to them is drowning."
From a physician's perspective, the pod makes communication more about the patient than trying to remember which nurse was supposed to perform which order.
Tim Watt, MD
"It brings a more cohesive team," says Tim Watt, MD, medical director for emergency care at Sharp Memorial Hospital. "For the big chunk of your shift, you're working with the same nurses. There's better communication because that team tends to be together for most of the day. And so people know each other's work styles. I think there's more continuity among the patients. There's fewer hand-offs. I think that's the root of the success."
Overall patient flow is overseen by the pod leader, who monitors the board to see if there are any gaps in care or orders that have not been filled quickly enough. A key component of team communication are the hourly huddles, where the pod team comes together to update status of patients and address any changes that would keep patients in the ED who don't need to be.
While the concept of the huddle is elegantly simple, actually having the hourly huddle consistently is a challenge, Dean says.
"It is difficult to do because nurses are always busy," Dean says. "It is like herding kittens: you get one and bring it in, and then you go get the other one and the first one leaves. So then an hour goes by quickly in the ED and you look up and says, 'Oh gosh, it's been two hours since our last huddle.' That's one reason why the huddles sometimes were being dropped."
Part of the solution was to reinforce the accountability of the pod nurse leader to be responsible for the consistency of huddles. Getting the team together to communicate about patient care is a skill like any other, Dean says.
"We revived the huddles by redoing the competency, and to re-evaluate the huddle leaders that we had, because it is a certified role," Dean says. "You do need to have a competency in the role. If you're not able to manage that time, get your team together, and take control of the pod, then we may not update your competency in that role."
Leaders at Memorial Hermann have developed an accountable care organization that combines care coordination and physician alignment to drive savings.
This article appears in the October 2015 issue of HealthLeaders magazine.
Back around 2007, Memorial Hermann Health System had only a distant promise when the Houston-based organization began to talk with area physicians about the concept of clinical integration. Terms like accountable care organization were still mostly left to theory. As Keith Fernandez, MD, recalls, the selling point that he and other leaders of the MHMD Memorial Hermann Physician Network had to offer was a more manageable life for physicians.
Keith Fernandez, MD
"We had a great advantage over many other groups," says Fernandez, now also chief medical officer of the Memorial Hermann Accountable Care Organization. "We had a group of doctors in very small practices [averaging 1.8 per practice] that had no collective vision of how they might move successfully into an uncertain future. The doctors were ready to do things differently and were intrigued by models of clinical integration."
The concept that attracted the doctors was simple—do the right things to care for patients, be measured in quality and cost, and prove to the community and themselves that they were the highest quality and most cost-efficient.
Recalls Michael Shabot, MD, executive vice president and chief clinical officer of Memorial Hermann Health System, and founding chairman (now past chairman) of the Memorial Hermann ACO: "In a way, our secret was starting early, before we knew what the actual goal or plan was going to be. We had a more generic goal of taking better care and more efficient care of our patients."
Michael Shabot, MD
That promise of the future rang true, and success has followed. In the first full year of the Medicare Shared Savings Program in 2013, the Memorial Hermann ACO led all MSSP ACOs with savings of nearly $58 million, almost $20 million more than the next highest ACO. From a ground of zero at-risk lives in July 2012, Memorial Hermann now has almost 240,000 in risk arrangements.
But building the physician alignment strategy for successful clinical integration took some learning.
"We sold doctors on the concept of being able to manage their future practice by defining what quality is, improving it, and measuring performance," Fernandez says. "In other words, not relying on other people to decide what good quality is, relying on them to report it accurately, and then using that to determine what defines a good doctor. I was really hoping for 500 physicians on the first pass, but we had 1,200 physicians sign up, which was a surprise to me."
The number of physicians in the network swelled to almost 3,000 after the success of the shared savings program, and this created a problem. "When we looked at our quality metrics at that time, we saw a deterioration in performance. And so we implemented more stringent criteria to both enter and stay in the clinical integration program that would protect the quality and cost-efficiency of the network."
The result was a more specific business agreement that the physicians now sign to join the ACO. It requires physicians to supply EMR data for 90 days, be on a preferred EMR, and agree with and abide by the MHMD compact, Fernandez says. Other requirements include appropriate policies and procedures that govern patient safety.
Aligning hundreds of independent physicians meant addressing some initial cultural and governance barriers. Many held true to a spirit of physician autonomy in the state, where historically physician groups had been relatively small and deeply competitive.
To create a physician-driven structure that could propel clinical improvement, the physician organization created clinical program committees in each specialty, which focus on evidence-based best practices, Shabot says. While there were just a handful of core committees in the program's first year, that number has since increased to 50.
"Years and years and years of effort went into this to create quality protocols, safety protocols, and efficiency protocols developed by the physician committees," Shabot says. "And then to make them active in the hospitals, we had developed a mechanism for getting them through each of our currently 11 medical executive committees. Getting 11 MECs to agree on the same thing—that wasn't easy either. And we put literally scores of quality and safety measures through the MECs in that way over the past seven or eight years."
Christopher Lloyd
Each of those 500-plus measures sent through the clinical program committees and then to the hospitals started with some basic agreements, says Christopher Lloyd, CEO of the Memorial Hermann Accountable Care Organization.
"There has to be some focus," Lloyd says. "There has to be some reason why certain things are done, and usually that's guided by clinical data and input from a whole bunch of other different team members. Even beyond what clinical condition you identify, you have to ask, what's the point in doing it? What driver are we looking to drive? Do we all have agreement on that before we even step into it? Do we all agree that we're managing a cost metric or we're managing a clinical metric? It just depends from measure to measure, but I think that there's a lot of discussion around making sure that our goals and our roles are in the same direction."
Early success and shared incentives have also helped usher in "a gigantic cultural change," Fernandez says. "I rarely have any trouble with engaging physicians now. In fact, I have to sometimes restrain them. We have 50 clinical practice committees—not because I'm looking for more committees, but because the doctors are demanding them. I have doctors coming to me now saying, 'I've got to get this problem fixed.' "
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HealthLeaders Media LIVE from Memorial Hermann: A Care Management ACO,will be broadcast on Wednesday, November 11, 2015, from 11:00 to 2:00 p.m. ET. Memorial Hermann reveals its multi-pronged approach for their successful Accountable Care Organization. How physician alignment, patient engagement methodologies, and a focus on community health has propelled them to the top.
Leaders at Baylor Scott & White Health have developed a program to lower costs, improve quality, and reduce readmissions.
This article appears in the July/August 2015 issue of HealthLeaders magazine.
It wasn't that long ago that the healthcare payment system was structured against palliative care, recalls Robert Fine, MD, FACP, FAAHPM, clinical director of the Office of Clinical Ethics and Palliative Care at Baylor Scott & White Health. An effective family meeting or "goals of care discussion"—where the physician sits down with the patient and his or her family and discusses patient pain and family needs—takes at least 90 minutes, more than six times the norm of the typical office or hospital 15-minute physician visit.
"Well, there's not even a code for family meeting, right?" Fine says. "I used to kid our administrators. I showed them some of our data on reduced readmissions and shorter length of stay. I said, 'If you're getting paid for every one of those days, I'm your enemy because I'm shortening length of stay.' So you had to have this shift in how healthcare's reimbursed for hospital administrators to go, 'Oh, I get it.' "
Changes in reimbursement through healthcare reform, as well as the general marketplace mandate for more efficient and cost-effective care, have finally altered that equation. So has the view of palliative care from the administrative side, says Fine.
"If it's a value-based payment mechanism, I'm your friend. If you're getting penalized for readmissions or length of stay, then suddenly the time it takes to do the better care planning, or the extra staff it takes to work with the children, or the better pain management we do in the clinic, now we fit that value equation. That's what Baylor Scott & White leadership has really understood."
As the payment system has evolved, so too has the palliative care team at Baylor. From serving 119 patients in the first nine months of the program in 2004, the supportive and palliative care team (SPC) provided 4,192 new inpatient consults, 11,098 hospital follow-up visits, and 748 outpatient office visits in fiscal year 2014. From a part-time team on a single campus, the Baylor Scott & White SPC team now has eight physicians, 10 advanced practice nurses, one registered nurse, six social workers, five certified child life specialists, and five spiritual care providers spread across north and central Texas, and the team will grow by six members in the coming years.
The team has grown because results have supported its value to the system, says Martha Philastre, MS, MBA, FACHE, administrative director of palliative care, who works with Fine in dyad leadership for the program. "One metric that we are definitely showing a reduction in is readmissions," Philastre says. "We have demonstrated a 17% reduction if a patient is seen by palliative care as opposed to a matched patient that didn't get palliative care."
The greatest cost savings come when the SPC team is engaged early in the hospital stay, Philastre says. Baylor's healthcare economist conducted a study in 2013 that tracked 2,405 SPC consults over a 42-month period and compared them with a control group. In that study, the SPC team demonstrated cost savings of $9,128 per patient for the first five days of hospital stay and $9,699 from days 6 to 10 for patients who died. For patients who were discharged, the savings were $2,667 for the first five days of a hospital stay and $2,743 for days 6–10.
"If we see a patient within the first 10 days of them being in the hospital," Philastre says, "we will show significant cost savings as opposed to a patient that has been in the hospital for over two weeks because typically, by that time, so much cost has gone into the patient that may or may not have needed to happen, that it's sort of done by that point."
Fine is quick to point out that only one in five of patients seen by the SPC team die in the hospital, which means the other four go home or are discharged to skilled nursing or hospice. Along with the shift in the payment model, there has been a change in the perception that palliative care is only for patients who are in the last stages of dying, Fine says. One of his best examples of the value of palliative care came from a Baylor staff nurse named Amy who was battling colon cancer.
"Amy gets admitted by her oncologist after she's already had surgery and treatment. She is in horrible pain. I happen to be on call the evening she's admitted. I go to meet her. It was very apparent that she was afraid that she was dying, and that I was from hospice. And I said, 'Let me just reassure you, I'm not from hospice. I'm from the supportive and palliative care team, and my job, first off, is to palliate. That means to comfort you, to make your pain go away. And my second job is to support you and your family. I want to make you feel better so that you don't have to be in the hospital, so you can get up out of bed and continue to take your treatment.'
"She was so relieved. The next day, her pain was so much better and she was emotionally relieved. She said more people need to know about this. She asked, 'Why wasn't I referred to you six months ago? Why have I kind of mucked around in pain for all these months?' "
Fine says there are three reasons for consults: care planning, pain, and other symptom management. "Many patients need help with all three, but care planning is the single most common reason we get called, and that is also why we need more time to work with patient and family."
Cancer patients make up 32% of patients, followed by cardiac at 15% and neurology at 13%. Fine says the focus on using pain management in palliative care is for serious illness. "We get a lot of consults for pain. We emphasize to people that we don't do chronic pain management, like chronic back pain. We don't do routine postop pain management, but for a cancer patient with pain, we get called all the time."
The SPC team set a system goal of having at least 80% of its patients report that their pain was better after SPC pain management stepped in. In the two years studied, the number of patients reporting better pain management was consistently above 85%; some months it climbed to above 90%.
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This article appears in the July/August 2015 issue of HealthLeaders magazine.
Leaders at Catholic Health Initiatives have committed resources to eliminating variation by standardizing care, aligning physician compensation, and building the efficient service line.
At any health system, reducing variation is always the second step. First, of course, are the deceptively tricky questions of agreeing on the key metrics and their definitions. In March 2013, Colorado-based Catholic Health Initiatives, with 105 hospitals in 19 states, created the Analytics Center of Excellence, part of the Enterprise Intelligence team, to answer these questions. Developing common data standards across a clinical enterprise as large as CHI required a lot of education, collaboration, and communication to build consensus, says Jim Reichert, MD, PhD, vice president of enterprise intelligence for CHI.
"In order to reduce variation, you need to identify a best practice," Reichert says. "And in order to do that, you need to have a national reporting standard across the enterprise. That allows for risk-adjusted data to be used in an apples-to-apples comparison."
CHI began by identifying a "single source of truth" for each metric that would be used in its standard reporting solution. The data source for length of stay, mortality, and complications is Premier Quality Advisor, but for healthcare-acquired infections, CHI uses the CDC"s National Healthcare Safety Network. Patient experience data comes from HealthStream, Reichert says.
Leaders at Intermountain Healthcare have committed resources in analytics, care management, and clinic models to reduce high utilization.
This article first appeared in the May 2015 issue of HealthLeaders magazine.
Theorists in healthcare have tried over the years to apply some version of the Pareto principle to the health of a population. While Pareto's theory was that 80% of the land in Italy was controlled by 20% of its population, healthcare leaders believe that when applying the principle to population health, the real number of patients who use a disproportionate share of resources is less than 5%.
The term hot-spotters was popularized in a 2011 New Yorker article by Atul Gawande, MD, who profiled the work of Jeffrey Brenner, MD, a family physician in Camden, New Jersey, who found that just 1% of patients in the community accounted for 30% of healthcare costs. Scott Pingree, director of strategic planning at Salt Lake City–based Intermountain Healthcare, and other leaders at the integrated delivery system wondered whether their patient population was any different.
Intermountain Healthcare found that between 2008 and 2012, its top 5% of high-cost, high-utilizing patients consumed 51% of healthcare costs. Even more telling, the top 1%—the true hot-spotters—accounted for a starkly disproportionate share: 24% of all healthcare costs.
Leaders from Baylor Scott & White Health developed a merger partnership built on cultural fit, clinical alignment, and market growth.
This article first appeared in the July/August 2014 issue of HealthLeaders magazine.
In 2011, Baylor Health Care System was hemmed in. For an organization that already had 30 hospitals, 180 physician clinics, and $4 billion in total operating revenue, having its growth limited was not an acceptable state of affairs. A merger with another Dallas market giant, Texas Health Resources, had run off track with regulatory hurdles a decade ago, and any similar mergers with local players would likely meet the same result.
Baylor faced a thornier problem: scale. Many health systems across the country have looked to mergers, acquisitions, and other partnerships to grow scale so they can manage a population of patients, whether under contracted agreements with commercial payers or by creating their own payer organization. With scale, or so the thought goes, comes efficiency that can provide higher-quality care at a lower cost. Even as large as Baylor was, it still lacked the clinical and operational scale it needed to meet that bar.
"We were growing. The [Dallas area] metroplex was growing, but so was everybody else," says Baylor Scott & White Health CEO Joel Allison, who at the time was CEO of Baylor Health Care System. "At the same time, we knew that if we really wanted to become a statewide presence that we needed another partner to move forward. We looked at how to improve the footprint to get to population health management. Our ultimate vision was to be able to manage the total care of the population."
A two-hour drive away in Temple, Texas, Scott & White Healthcare had 12 hospitals and a national reputation for clinical excellence. Its multi-specialty group practice model was well-positioned for healthcare reform. But it was also on an island in Central Texas, says Bob Pryor, MD, who was serving as Scott & White's CEO at that time. He is now president, chief operating officer, and chief medical officer of Baylor Scott & White Health.
"As a $2.5 billion organization, we could not grow anymore, because we'd grown organically in the region all we could," Pryor says. "We could not acquire anybody. We couldn't build anymore. We didn't have enough population to really make population health work. We knew that if we really wanted to lower costs and improve quality, we had to figure out how we could work together in a way that was uninhibited. We needed to be able to push forward care plans and compare costs across a large geography, and then contract over that large geography for population health."
The timing was on Scott & White's side.
"We didn't really have to make that leap three years ago," Pryor says, "but we knew if we were going to take that next leap, there was only one partner in all the state of Texas that we would have partnered with. That was Baylor. There wasn't a No. 2 choice."
There were several factors that made a proposed merger between Baylor and Scott & White a logical fit. One was that the two health systems were not in the same market, and together would form a larger regional player that would not face as many antitrust concerns as two systems in the same market would.
"It would be really challenging to go into some of these markets without a partner," Allison says. "For us, there was no better partner than Scott & White. It was just so logical. As Bob and I were talking about it, it just made so much sense that we made good partners because we had almost identical mission, vision, and values."
No merger is a perfect fit between two organizations, and this one was no different. Baylor had been built for rapid physician growth, with a large number of independent physicians aligned to the health system and a growing employed physician group with HealthTexas Provider Network. (Texas law restricts the direct employment of physicians and the corporate practice of medicine, but the so-called 501(a) model, named for a section of state law, provides for a physician-governed group practice to essentially function as a hospital-employed group, thereby avoiding the state's ban on the corporate practice of medicine model.) Scott & White was a highly integrated multispecialty group with an emphasis on physician leadership.
Beyond the physician model structures, there were other significant differences: The two health systems had different electronic health record system vendors. The nursing practice models were different. And both brands had such a long local history that each unique brand identity would have to be maintained.
What kills many mergers before they finish, however, is culture. Allison and Pryor say they felt the cultures of their two organizations were a great fit, but with so much at stake, their respective boards asked them to hire a consultant just to make certain. As part of the due diligence, McKinsey & Company conducted a cultural audit that found the two systems are "much more alike than they are different," Allison says.
"It gave us a comfort level that we're moving in the right direction," Allison says. "There have been a lot of past relationships among our teams, so when we sat down to do the mission, vision, and values for the new organization, it took us about five minutes. Basically we just blended the two because they were so much alike. We maybe changed one or two words here or there, but otherwise it was right on."
Beyond the culture question was a leadership one: Who would helm the combined health system? The merger was announced in December 2012 and finalized 10 months later. One fiduciary board was created, with advisory boards in the two local markets. Allison retained his title as CEO of the combined system, while Pryor was named president, COO, and CMO of the newly branded Baylor Scott & White Health. Combining the operating and clinical sides of the system under Pryor was intentional.
"It's not like I wanted another title," Pryor says. "For the first 24 months, I thought it was important that both the clinical enterprise and the operational enterprise report to me. I have cross-membership of both the clinical and operational committees. I think that sends a strong message that we're still a clinical-operational dyad that moves forward."
The merger is now in what Allison describes as the "budgeting and strategy phase" but is quickly moving ahead on four strategies:
Continue with overall system integration
Develop the clinically integrated network built around the the Baylor Scott & White Quality Alliance (since renamed the Quality Alliance)
Develop systems for population health management
Continue to seek strategic growth
Allison and Pryor say the integration has gone smoothly so far, but there is no timeline for completion.
"The timeline of the integration is basically as soon as possible, and it's realistically another year to a year-and-a-half out," Allison says. "This time next year we'll probably still have about six months of work to do to get everything fully to what we would consider integration, but it's a journey."
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This article appears in the July/August 2014 issue of HealthLeaders magazine.
Leaders from UNC Health Care are driving outcomes and patient engagement through a multidisciplinary model.
This article appears in the July/August 2014 issue of HealthLeaders magazine.
The National Cancer Institute designates 41 U.S. hospitals as comprehensive cancer centers, with each required to demonstrate excellence in laboratory, clinical, behavioral, and population-based research, and to set high standards for outreach and education. This puts the University of North Carolina Lineberger Comprehensive Cancer Center in the same category as the Mayo Clinic, M.D. Anderson, and other leading cancer centers.
What makes the UNC Lineberger Comprehensive Cancer Center stand out is its mission to provide cancer care across the state, from rural areas to the thriving Raleigh/Durham/Chapel Hill metropolitan area. The flagship N.C. Cancer Hospital treats patients from every county in the state, with more than 135,000 patient visits a year. UNC physicians treat all cancers and participate in more than 225 cancer clinical trials.
HealthLeaders Media LIVE From UNC Health Care: Transforming Cancer Care Date:September 4 11:00-2:00pm ET—Join the leadership team from UNC Lineberger Comprehensive Cancer Center as they reveal the strategies behind their successful, multidisciplinary cancer treatment program, including proven methods to integrate oncology specialties and mental health for better clinical outcomes. >>>Register
Like many health systems looking to grow their footprint following healthcare reform, UNC Health Care has merged with or acquired other hospitals in the state, including High Point Regional Health System in 2013. UNC Health Care has everything from a state-of-the-art academic cancer hospital to a critical access hospital. Cancer care across different UNC Health Care facilities is delivered by a mix of faculty physicians, employed physicians, and independent oncologists. Even with this range of facilities and expertise, the goal is the same, says Ian Buchanan, MD, vice president for cancer and children's services for UNC Health Care.
"We are really spending a lot of time thinking about and planning how to link together our oncology services to provide seamless cancer care for people across the UNC Health Care system," Buchanan says. "Our goal in the next few years is to be able to say with confidence that if somebody goes to one of our affiliated hospitals that's 150 miles from here, they're going to get 'UNC cancer care' even if they're in a different location."
Cancer care, by definition, should be multidisciplinary, as many treatment plans involve more than one specialty, including surgery, radiation oncology, and medical oncology. Beyond physicians, cancer treatment brings in a host of other professionals—nurses, care managers, pharmacists, therapists, nutritionists, and technicians—who all need to communicate and collaborate. Buchanan says even as the health system has expanded its cancer footprint, there has been a lot of focus on reinforcing teamwork.
"One of the things that we've been successful at, particularly in the last couple of years, has been in having less of a culture of 'us and them,' where it's the doctors versus the hospital staff," Buchanan says. "It is really getting to the point where we're all in this together."
A major step that facilitated more team interaction this year was a systemwide implementation of an Epic-based electronic health record, which brought together the cancer center's physicians, nurses, pharmacists, and other team members to work on care pathways and implementation programs.
"One of the unanticipated benefits of our implementation of Epic is that it put all of our clinical folks—nurses, doctors, pharmacists—all into the same boat, and they all had to paddle together to get ready to go live with Epic," Buchanan says. "That exercise has been very positive at building a culture where we are a cancer team and everybody is doing their part for the patient and the organization."
Lisa Carey, MD, physician-in-chief of the N.C. Cancer Hospital, medical director of the UNC Breast Center, and associate director of clinical science for UNC Lineberger Comprehensive Cancer Center, says the cancer program is "a technically and operationally multidisciplinary model." At the flagship N.C. Cancer Hospital, the collaboration is enhanced by proximity, she says.
"We are all in the cancer hospital together," Carey says. "We view our cases together—surgery, radiation, oncology, medical oncology, genetics, pathology, and radiology are all in the same room at the same time for a couple of hours every week. So when we have issues that relate to the best approach for the patient,
we can have those conversations as a group, which facilitates decision-making tremendously."
Carey says that unlike some programs, where certain days are scheduled as disease-specific clinic days, at UNC "we're there all five days of the week. So even oncologists that have strong research programs also have a strong presence in the clinic. And that's true of the surgeon or the radiologist. So every day is at least theoretically a multidisciplinary care day, and it's not infrequent that I will walk a patient over to the surgeon or he will walk a patient over to me for a consultation."
That multidisciplinary approach extends to cancer physicians outside Chapel Hill, with at least 15 disease-specific tumor boards a week, Buchanan says. Physicians across the state are able to join via videoconference.
"Any doctor in the state who wants to can get a camera from us and join in," Buchanan says. "On one end of the spectrum, if they want to just listen to the discussion, they can do that. And at the other end of the spectrum, if they want to have their patients' pathology and images sent here, we can include their patients on our tumor board list and have our specialists give input on the patient. That gives the patients the opportunity to be treated in their home communities because we have a lot of very good community oncologists in North Carolina."
The collaboration extends to the nursing leadership as well. Meghan McCann, RN, MSN, director of oncology for UNC Hospitals, says it's helpful that the nursing leaders on both the inpatient and outpatient sides report to her.
"I think that gives us an opportunity to ensure continuity of care," McCann says. "Cancer is a chronic illness. Patients have various touch points throughout their care continuum, both inpatient and outpatient. By all working together and being one team of leaders, we ensure that quality of care and that continuity is consistent across office visits, inpatient stays, or outpatient. So, for example, when we take care of a central line, we're doing that the same way whether the patient comes into one of our clinics or whether they are being cared for as an inpatient."
A key member of that team is the nurse navigator, who is the connection point to the clinical team for those patients with more complex cancers, McCann says. "If the patient is identified as complex, it is very possible that they'll have surgery, have a medical oncologist, and have a radiation oncologist. So the navigator is that touch point for them throughout that process."
The nurse navigators specialize in disease groups and are connected to patients as soon as they are brought into the system, McCann says. The navigators usually are with the patient and physicians during the clinic visit to answer any questions and complete patient education. The navigator is also the one who funnels information from the patient to the care team, and serves a triage role in case the patient has further symptoms and needs more help, McCann says.
Overseeing the teamwork is a leadership structure that reinforces communication and accountability. "Our physicians and our nurse leaders have been in consistent communication," McCann says. "We have a weekly leadership meeting that includes physician, nursing, and hospital leadership. We discuss what's going well, what our needs are, how we can improve the operations, meet patient needs, and discuss strategic plans for the service line. It is not always perfect, but open dialogue and formal standing opportunities to have those discussions with our leaders are keys to the success we have had."
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This article appears in the July/August 2014 issue of HealthLeaders magazine.
Carolinas HealthCare System leaders have developed a team-based approach to effectively address patient experience through shared decision-making.
This article appears in the June 2014 issue of HealthLeaders magazine.
The term patient-centered care has had an unfortunate misinterpretation for many in healthcare. Some providers end up building teams and processes around the patient at the expense of those who work with the patient. The team at Carolinas Medical Center-Mercy understood the relationship between doctor and patient historically has been paternalistic, with the physician as expert directing care based on his or her view of what is best for the patient. Providers have generally moved past that model, but few have embraced a true collaborative model in which the physician and patient each bring their knowledge, says Hazel Tapp, PhD, associate director of research for the Department of Family Medicine at Carolinas Medical Center-Mercy.
"Shared decision-making is a meeting of two experts," Tapp says. "The patient is the 100% expert on what's important to them and their preferences. And the provider brings expertise around disease knowledge and psychosocial situations."
Dael Waxman, MD, interim chair of the Department of Family Medicine at Carolinas Medical Center-Mercy, says this approach is really about helping the patient make decisions about what is best for him or her.
"Shared decision-making says the physician is the expert on the disease and about what needs to happen to treat the disease," Waxman says. "The patient is the expert [on] what they're willing to do, what they can afford to do, what makes them happy, what's distasteful to them. In the middle, we're going to have a conversation about what the patient is going to do. The physician may have some suggestions, but the patient is the one that's going to walk away with it."
The team at CMC-Mercy decided to test the hypothesis that shared decision-making could result in better outcomes using an evidence-based toolkit, Tapp was awarded a $2 million, three-year grant from the Patient-Centered Outcomes Research Institute to test a shared decision-making toolkit for asthma care in the primary care setting. The sample size is 30 practices statewide, randomized to three arms of 10 practices per arm. The project started in August 2013 and will finish August 2016.
The first set of patients who were identified for intervention were asthmatics who had ended up in the emergency department or inpatient admission following an attack. Those patients were invited to come to the primary care office for a "specialized asthma visit," which started with the nurse taking vital signs and performing a spirometry test to measure pulmonary flow. Then the patient met with a designated asthma health coach, who "can be anyone in the practice," Tapp says. "It can be a PharmD or an educator or a nurse or someone who has a little passion around asthma." The health coach worked through a script that first explained the shared decision-making approach, and then asked a series of pointed questions about the patient's understanding of his or her asthma and medications. The goal was to come up with a treatment plan that worked with the patient's life, Tapp says.
"For example, we had a 16-year-old boy who was really struggling and coughing every day," Tapp says. "His mom was real worried about him. He was supposed to take his medication twice a day, morning and night. So we worked through the profile with him and he just said, 'I hate taking it at night.' We said, 'That's fine. You can take a higher dose in the morning. Forget the nighttime.' They came back and everyone was really crying. He was feeling so much better. The mother was feeling so much better. He just needed to be listened to and to be able to do it his way."
This approach to shared decision-making includes discussion that guides patients beyond just stating what their problem is, but what their goals are.
"Our patients all have barriers. We serve an underserved population. But when we can get a patient to state a goal, they do so much better than equivalent patients with the same number of barriers," Tapp says. "From a motivational standpoint, you're much more likely to do it by stating a goal rather than if you are just listening passively to paternalistic advice. So I repeat that to physicians all the time. Try to get them to state a goal. Trick them into stating a goal if you have to, because it's very effective."
The approach works well beyond asthma, and Waxman says he has used the shared decision-making model for patients with other chronic issues.
"I just used this yesterday with a patient who has pretty bad peripheral vascular disease, and he's smoking, which is really bad," Waxman says. "He had said it was his goal to quit smoking. We had a whole conversation about what the different options were. He had tried several of them before that didn't work. I put the options out there that other patients have told me worked for them. He selected one of those, and then we had a conversation about when he would be ready to start."
In the former physician model, says Waxman, he may have "ordered" the patient to start immediately, but instead suggested he start in a couple of months. The patient said he could start in two weeks.
"And then he was there. So it wasn't me saying, 'I think you need to do this two weeks from now.' It was him saying, 'I think two weeks is about when I'm going to be ready.' So he actually set a date and he set a plan for how he's going to do that. And the research would say that he's more likely to actually do that and more likely to reduce or stop smoking than if I had said, 'You need to stop smoking.' "
The asthma study continues, but preliminary findings showed that patients in the study saw their ED visits drop from 14.4% to 9.1%, and inpatient hospitalizations dropped from 4% to 1.7%. Use of oral steroids also dropped, from 27% to 20%.
The primary care physicians have seen the data that supports shared decision-making, and now they are seeing firsthand how much better their patients are doing, says Tapp.
"ED visits are dropping. Patients are adhering to their medication. Providers already kind of sensed that anecdotally. They just weren't seeing the same patients popping up again and again. So that really was hitting home for them."
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HealthLeaders Media LIVE From Carolinas HealthCare System: Patient Experience, will be held on Thusday, July 29, 2014, from 12:00 to 3:00 p.m. ET. Participants will discover how a shared decision-making toolkit for asthma care can significantly reduce ED visits and inpatient hospitalizations among other helpful tips.
This article appears in the June 2014 issue of HealthLeaders magazine.
Intermountain Healthcare leaders have developed a team-based approach to address patients' mental health issues.
This article appears in the May 2014 issue of HealthLeaders magazine.
Long before patient-centered medical homes or accountable care organizations were buzzwords, Salt Lake City–based Intermountain Healthcare was looking at all of the points of care that could improve the health of patients in its system. It did not take long to identify mental health as a problem.
All too often a patient would come to one of Intermountain's 185 primary care clinics with multiple comorbidities that were exacerbated by mental health issues such as depression or dementia. So the primary care physician would refer the patient to a mental health specialist, but the next available appointment could be weeks away.
"The other problem with that is the doctors would send them and then the patients would fall into a black hole. The doctors would never hear anything back. There was no linkage," says Brenda Reiss-Brennan, PhD, APRN, director of mental health integration for Intermountain Healthcare. "So what we did, basically, is said mental health is not just provided by a mental health provider. There's a whole spectrum of mental health issues and concerns that could be addressed by the whole team."
Shifting the underlying view of mental health away from being a specialty referral to a routine medical condition that could be treated by the primary care team necessitated new roles for some, and additional expertise for the primary care clinic. "It became more of a consult, and everybody on the team did their part," Reiss-Brennan says.
A first step was to shift primary care physicians into taking a more holistic view of mental health, essentially empowering them with tools to identify patients who need mental health treatment, and enabling the PCP to provide that treatment for certain more common conditions, including mild to moderate depression.
For many of the PCPs, treating mental illness themselves was a transition they had already made, Reiss-Brennan says. "They felt forced to take care of the depression because there was lack of support and nobody else," Reiss-Brennan says. Especially in rural areas where mental health specialists were particularly rare, the primary care physicians "felt like they were being forced to become psychiatrists."
Linda Leckman, MD, CEO of Intermountain Medical Group, says an early part of any mental health integration plan is reeducating the primary care physicians, because most of them have little more than their residency training to fall back upon.
"Once you've been out in practice, you lose some of that. So there is intensive education in regard to those conditions that are appropriate to deal with in a primary care practice," says Leckman. "And what we have found is that about two-thirds of the behavioral health issues that present in a primary care practice can be dealt with by that primary care doctor. And it's been really interesting, because physicians have found that to be empowering."
Often the physicians already know which of their patients may have a mental health issue, but for others there are screening tools now in place that the PCP or other team members can use for diagnosis and assessment, starting with a patient health questionnaire, such as the PHQ-9, a series of questions about the patient's recent mood and behaviors.
Intermountain recognized that improving mental health integration in primary care required more than just asking the PCP to "try harder." Inevitably, addressing the access problem required adding mental health professionals at locations where they could do the most good: the practices themselves.
Simply adding mental health staff on site, so-called "colocation," was not the complete solution. Intermountain looked at what the team makeup for mental health should be and added a variety of mental health professionals of various titles and responsibilities.
They ranged all the way from psychiatrists to handle the most medically complex cases; to psychologists and psychiatric advanced practice registered nurses for screening and coordination; to RN care managers, social workers, and peer mentors from the National Alliance on Mental Illness to provide patient support, education, and a link to the entire MHI team. The key, however, is not in the staff, but in the integration.
MHI practitioners are assigned in blocks of hours based on the complexity of the patient population at a particular clinic, Reiss-Brennan says. Practitioners often rotate through several primary care clinics, so a clinic with a high number of complex mental health patients with critical needs may have a rotating psychiatrist in for a day a week, whereas other patients with a need for talk therapy can be seen by a clinical psychologist, she says.
Jeremy Hernandez, regional assistant operations officer for the North Salt Lake region of Intermountain Medical Group, says a key distinction is that the mental health resources are "supports to the existing patient population of our primary care physicians. The intention is not to colocate a mental health provider at a location and have patients coming there specifically for mental health. Instead the intention is to integrate the mental health provider into the primary care team where patients can have their medical and mental health needs met at the same location."
The role of the MHI professional is not to form a permanent therapeutic relationship with the patient, says Laurie Younger, RN, regional nurse consultant for Intermountain Medical Group. Instead, he or she assesses the patient and coordinates with the PCP to develop a treatment plan. In certain cases, however, the MHI provider, in coordination with the care manager, can act as a bridge to keep patients stabilized while the referrals to long-term mental healthcare are in progress, Younger says.
"In one of the cases, the wait time to start long-term therapy was eight weeks," Younger says. "This patient would have deteriorated further if we had to wait eight weeks to have them see a provider. So the mental health provider in the clinic saw that patient for eight weeks, weekly, until they could get [the patient] into a long-term facility."
The leadership team assesses need at each clinic regularly to make sure clinics get enough MHI resources to fit their patients' needs, Younger says.
"We add resources very slowly," Younger says. "For instance, at one of our sites, which we brought up at the beginning of last year, we added four [MHI] hours once a week. It didn't take long to where that provider is busy [for] all four hours, so we incrementally add an hour, and then another hour. One of the ways to mitigate that cost risk is to implement slowly to make sure that you're filling up those provider hours that you've allocated there."
Intermountain also makes sure that the responsibility for mental health integration goes beyond therapists, Hernandez says. The front desk receptionist in the clinic is often the "go-to person" for insurance prior authorizations or checking on coverage. RN care managers who may be assisting patients with diabetes or other conditions will also make sure the MHI referrals are happening, and may even make referrals themselves if they notice an issue with a patient, Hernandez says.
Regardless of which team members are involved, the integration plan is still based in primary care, with the PCP at the center of a "consultative model," says Wayne Cannon, MD, primary care clinical program medical director for Intermountain Medical Group.
"The primary care physician retains responsibility and stewardship, but not in a control sense," Cannon says. "The mental health providers help a lot to reduce the burden because they can do a lot of things that the primary care physician can't do as far as therapy, support, and diagnosis. But when it comes down to keeping the treatment going or making treatment decisions or just who the patient calls [for] a medication refill, that is still based with the primary care physician. So it's a consultative and collaborative approach."
The integration work has taken a lot of the burden off of the PCP, Cannon says. "It helps the physician to have the whole team involved, so it's not just you. This is the most critical factor for success. The receptionist knows what to do, your medical assistant knows what to do. So just from the very beginning, the process is easier. The evaluation is a lot easier. Before, everyone would have their own little approach to doing this, and I know the one I used wasn't as time-efficient and helpful. Once we have a diagnosis, I have people besides myself that can help."
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This article appears in the May 2014 issue of HealthLeaders magazine.