CHI's Hospitalist Program Standardizes Care, Lowers Costs

Why hospitalists are essential to population health management, how to get physician leaders on board with shared clinical protocols, and how data can rein in patient complications, mortality, and length of stay.

By standardizing clinical protocols across all hospitals and care sites, health systems seek to produce reliable patient outcomes, reduce the overutilization of expensive resources, and decrease the overall cost of care.

But it's much easier said than done to align clinical staff around these goals.

Catholic Health Initiatives, the 105-hospital, not-for-profit healthcare giant based in Englewood, CO, has found success in gaining these kinds of efficiencies through its hospitalist program, in which its roughly 900 hospital-based physicians assume the traditional care coordination duties of primary care doctors.

At CHI, which operates hospitals in 18 states, more than 75% of all hospitalized patients are cared for by one of its hospitalists, accounting for about $1.5 billion in annual net patient-service revenues. 

Hospitalists are key for population health

Before CHI connected its hospitalist programs across the system to share best practices and help define standards, the outcomes from hospitalist teams at different locations varied greatly.

Now, better and more consistent outcomes are being achieved at a lower cost through a coordinated effort, says Manoj Pawar, MD, CHI's vice president of clinical operations and physician leadership development.

Providing efficient and effective care is critical to success as the healthcare industry moves toward value-based reimbursements, he says. "You can't be successful in a population health environment without having a progressive and robust hospitalist program. We want to leverage our hospitalists to take advantage of these new payment schemes by focusing not on the location of care but by looking at the stratum of patient complexity and acuity."

For example, Pawar says, hospitalists have been the linchpin of success for CHI's bundled payment structure in its orthopedic service line.

"We are able to achieve some of the best outcomes at the lowest cost by integrating the work of our hospitalists. They are doing pre-op assessments and understanding the complexity of the patient to avoid additional complications or a greater length of stay. We couldn't be successful in managing that bundle without the hospitalists."

Amanda Trask, national vice president for CHI's hospital medicine service line, agrees that hospitalists are an important component to the system's long-term population health strategies and believes they will take on an even bigger role over time.

"Hospitalists have the responsibility for caring for the sickest of the sick in our populations and our ministries. These are also some of the highest-cost patients. … Hospitalists are working in partnership with primary care physicians and ED physicians in a triad model for high-acuity patients. They are working with subspecialties like cardiology and surgery to identify how the hospitalist can play a key role in assuring a smooth transition from the hospital to a post-acute site," Trask says.

"We see our hospitalists expanding their reach and caring for high-acuity patients beyond the four walls of the hospital to meet some unmet needs. They are looking to provide the same type of services in the outpatient, post-acute setting for higher-complexity patients and to provide gap care for patients who don't have a primary care physician and need to find one."

Building a Culture of Cooperative Physician Leaders

In order to create a successful, system-wide hospitalist program, CHI first invested time in developing a culture where physician leaders are willing to work together, Pawar says. Once physicians from across the system understood they were all facing the same challenges and working toward the same goals, it became easier for them to develop standard protocols for the hospitalist program.

"One thing we did that was very intentional was we spent a lot of time on culture-building and alignment. We spent a few years bringing program leaders together, building a sense of community, and finding that the key drivers and issues they were dealing with were very similar. They started to realize they should not all be operating separate programs," he says.

Having a high level of cooperation among physician leaders is the only way to achieve the desired results, Trask adds.

"To get to the financial gains, process improvements, and population health strategies, we have to have the right leaders in place and they have to be connected with other leaders. It comes back to making sure that we are able to remove any barriers. It's a highly collaborative environment," she says.

Data for clinical decision-making and benchmarking

CHI has been able to advance the conversation among physicians to improve care and lower costs, Trask says, by providing trustworthy, actionable data to guide clinical decision-making.

The data has spurred deeper analysis of clinical protocols and is also encouraging better alignment with quality teams.

"Hospitalist groups and their physician leaders are now going to their quality leaders and asking for more information to drive care for patients. The questions that are being asked and the research that is being done now is something that wasn't present in the past. We believe, as a result, that our hospitalists are more attuned to making the right decisions for patients," Trask says.

"This is about quality improvement and financial improvement. … Our work has been to tie the two together so we are not functioning in a silo environment. We are really trying to demonstrate with the data how all of it is interconnected."

To that end, CHI uses benchmarking data to compare its hospitals to each other and to hospitals outside of its network with regard to metrics such as patient complications, mortality, and length of stay.

"We really wanted to understand those three measures across all of our hospitals. When we looked at it less than a year ago, for example, we had tens of thousands of excess patient days beyond what we would have expected based on patient presentation or illness," Trask says.

Armed with the data, CHI's hospitalists are working with quality teams to make improvements, and the results so far have been substantial. In under one year, the organization's excess patient days have been cut by about 60%, Trask says, adding that this will equate to $2 million in savings in fiscal year 2015.

A Boon to the Bottom Line

Brad Ludford, CHI's vice president, operational finance, says he expects the organization to reap even bigger savings this year thanks to the hospitalist program.

"A consistent approach to hospital care led by our CHI hospitalist physicians ensures we're appropriately utilizing our hospitals. By managing more consistently and intentionally, we are on pace during the current fiscal year to save approximately $4 million of avoided direct costs," he says.

Additionally, CHI is experiencing indirect "positive financial outcomes through these efforts," Ludford says. "Other financial improvements not easily quantified include additional hospital capacity, which enables us to serve more patients than we could before, and fewer hospital-acquired conditions emanating from unnecessary and excess hospital patient days."