Care coordination covers a multitude of activities and requires a coherent collaborative effort among policy makers, payers, community agencies, healthcare providers, and families.
Care coordination features an essential set of services, particularly for patients with conditions that are complex and long-term, a recent article in JAMA Pediatrics says.
To deliver effective care coordination, healthcare providers and community partners should have key shared assumptions such as comprehensive assessments of patient needs, a written care plan, and coordination between clinicians and community service professionals.
"Despite the centrality of care coordination to healthcare reform, practice redesign, and chronic care management, there remain multiple definitions, expectations, and approaches to its provision. This variability reflects the different purposes for which care coordination is intended, such as improved quality, reduced healthcare use and costs, more comprehensive care, meaningful response to social determinants of health, and planning care over the life course," the JAMA article's author wrote.
This week, the author told HealthLeaders that establishing shared assumptions about care coordination is crucial to extending the concept to include the personal and social circumstances of patients and their families.
"In the past, care coordination focused on coordinating among medical care providers and, sometimes, other healthcare providers. Today, the need to address the patient's social needs such as housing, nutrition, social support, and education to achieve good health outcomes is appreciated and some health plans and payers, including Medicare and Medicaid, are beginning to pay for such services as legitimate health expenses," said Edward Schor, MD, of the Lucile Packard Foundation for Children's Health in Palo Alto, California.
Schor's article highlights 10 pivotal shared assumptions for care coordination.
1. Teamwork emphasized
Care coordination should be family-centered and team-based with clearly established goals, frameworks, and obligations.
2. Assessment conducted
Services should be crafted and deployed based on a comprehensive assessment that gauges the health and psychosocial needs of the patient.
3. Plan promulgated
Care coordination services should be documented in a written care plan designed by the patient, family, and healthcare providers. "It is generally not possible to have coordination in the absence of a plan. Otherwise, service providers are merely reacting," Schor said.
4. Care plan monitored
The plan for care coordination services should be supervised on a regular basis and revised as needed.
5. Communication expanded
Electronic communication should supplement face-to-face communication between the patient, family, and healthcare providers to strengthen the working relationships between clinicians and others involved in the patient's care.
6. Information shared
The patient and the family should be given information and supports that can help them manage the patient's care.
7. Community professionals included
Healthcare providers should coordinate their efforts with community-based professionals who offer services and support to the patient and family.
8. Care coordinator assigned
Patients should have an assigned care coordinator who has regular contact with the family and primary clinician.
9. Information shared electronically
An electronic medical record should be used to share the patient's health information with family members and all healthcare providers.
10. Transitions of care managed
Any patient transitions between settings should be managed to ensure continuous access to care. "Care coordination for transition, whether between settings or from pediatrics to adult care, is hazardous, especially for patients with chronic or complex health conditions. I consider transition services to be a subcomponent of care coordination," Schor said.
Healthcare organizations are being urged to help patients address cardiovascular disease risk factors such as hypertension and smoking.
A national effort to reduce cardiovascular disease (CVD) events such as heart attack and stroke has made progress but is at risk of stalling, a recent article in the Journal of the American Medical Association says.
The Million Hearts initiative, which is a joint endeavor of the Centers for Disease Control and Prevention along with the Centers for Medicare & Medicaid Services, is designed to prevent CVD events including heart attack, stroke, heart failure, and related conditions.
CVD events are costly, deadly, and often preventable. In 2016, CVD events accounted for about 2.2 million hospitalizations and 415,480 deaths, according to the JAMA article. If the 2016 trends continue through 2021, there will be an estimated 2.2 million preventable deaths and 11.8 million hospitalizations with costs of about $170 billion.
Million Hearts was launched in 2012 with a goal of preventing 1 million CVD events over five years by focusing on the ABCS risk factors: aspirin when appropriate, blood pressure control, cholesterol management, and smoking cessation. "Projections using 2012-2014 data suggest that an estimated 500,000 events may have been prevented by 2016, although improvement in risk factors was slow," the JAMA article's authors wrote.
A recent CDC report detailed the limited success in addressing the ABCS risk factors.
"Appropriate aspirin use decreased between 2011-2012 and 2013-2014. From 2011-2012 to 2015-2016, small but statistically significant reductions were observed in combustible tobacco use and physical inactivity. No significant improvements were observed for hypertension control or statin use among eligible persons; sodium consumption remained high," the JAMA article's authors wrote.
Healthcare leaders have a key role to play in reducing CVD events, the lead author of the JAMA article told HealthLeaders this week. "Leaders are critical to achieving high performance by setting an expectation of excellence; establishing an aim, target, and timeline; and resourcing their teams to make and report progress," said Janet Wright, MD, executive director of Million Hearts.
Leaders can have a significant impact in addressing CVD risk factors, she said. "Healthcare leaders can make a difference in the population's health—for their employees, patients and families, and community—by creating the conditions for excellence in the ABCS."
Wright and her coauthors identified four efforts that healthcare organizations can embrace to prevent CVD events.
1. Run a quality improvement cycle
"We recommend starting by prioritizing a cardiovascular condition such as hypertension, abnormal cholesterol, or smoking; pulling together a small team led by a passionate champion; analyzing current performance and setting a target and timeline for improvement; and implementing one or more strategies that move the needle," Wright said.
This approach can be applied by a variety of organizations, she said. "We have seen systems large and small use this highly replicable quality improvement cycle to achieve excellence—and to build on success in one area like blood pressure control then tackle a challenge like in-clinic smoking cessation."
2. Capitalize on MIPS measures
Addressing the ABCS risk factors can be done in conjunction with the cardiology, general and family medicine, and obstetrics and gynecology specialty measure sets of the CMS Merit-based Incentive Payment System (MIPS). For example, high blood pressure control is a high priority MIPS measure.
3. Gain from real-time insights
Tools are available to help healthcare providers track risk-factor performance, Wright and her coauthors wrote.
"Population health management tools are widely available, permitting real-time insights into performance on the ABCS. Million Hearts partners and others have developed tools to identify patients with undiagnosed hypertension who are 'hiding in plain sight.' This approach can be adapted for other risk factors."
4. Adopt and adapt proven strategies
To prevent CVD events, there is no need to start from scratch, the JAMA article's authors wrote.
"A common strategy is a clinician-led, team-executed treatment protocol that incorporates the practice's preferred counseling language and medications, facilitates identification of patients who need customized attention, and enables more patients to be optimally treated."
In less than 5 minutes, the Shock Index assessment can gauge the severity of a patient's condition.
Stroke is a deadly and expensive-to-treat condition that kills about 140,000 Americans each year, with annual costs for healthcare services and medications estimated at $34 billion, according to the Centers for Disease Control and Prevention.
But what can clinical leaders do to mitigate deaths and healthcare costs due to stroke?
For stroke patients prior to hospital admission, a simple and inexpensive assessment can guide treatment decisions and predict a range of outcomes, recent research shows.
A Shock Index (SI) calculated as heart rate divided by systolic blood pressure can quickly and inexpensively assess stroke patients, researchers wrote recently in Journal of the American Heart Association.
"Our study shows that SI is a significant predictor of important patient-related acute stroke outcomes including mortality, acute hospital length of stay, discharge destination, ambulatory status at the time of discharge, and poststroke disability," they wrote.
The researchers collected data from more than 425,000 patients. Most of the patients (89.7%) had experienced ischemic stroke.
Here are three reasons to use the Shock Index assessment on your stroke patients.
1. It's a good predictor of outcomes
The lead author of the research says the SI is a powerful predictive tool.
"SI appears to be a very good predictor of several stroke outcomes immediately after stroke—not just mortality but also for dependency and discharge destination other than home," Phyo Kyaw Myint, MD, of the Institute of Applied Health Sciences at University of Aberdeen's School of Medicine in the United Kingdom, told HealthLeaders.
2. It does not require expensive equipment
The SI is particularly valuable for healthcare facilities that struggle to fund expensive assessment technology or to train staff on the National Institutes of Health Stroke Scale (NIHSS), he said.
"SI is calculated based on the heart rate and blood pressure, and these measurements are usually done by trained clinical staff. It doesn't require any special equipment or computer system to calculate SI. It is easy to perform and takes less than 5 minutes. Therefore, SI as an alternative tool to assess the prognosis of stroke patients at the time of assessment is extremely useful in low-resource settings such as rural hospitals and low-income settings," Myint said.
3. It can be used in clinical settings now
Although Myint and his research coauthors are calling for more research on the SI, he says the assessment tool is appropriate for use in clinical settings now.
"As this is a physiological index, it can be applied in clinical practice immediately. We stated more research is needed in the sense that, to make change in practice, large numbers of studies are required before we can start to see changes. Therefore, our findings should be replicated in different populations as well as in different healthcare settings to demonstrate the external validity of the findings to convince clinicians of the robustness of the SI as a useful prognostic assessment," Myint says.
As more studies are conducted, patients can benefit from clinicians using the SI, he says.
"In the interim, we would recommend that stroke patients with high SI should be carefully monitored and clinicians should be made aware of their likely poor diagnosis to ensure appropriate management strategies can be implemented and realistic expectations of the outcome can be communicated with the patient's relatives," Myint said.
SI by the numbers
Myint and his coauthors divided the patients in their study into three SI cohorts: patients with SI values greater than 0.7, patients with SI values between 0.5 and 0.7, and patients with SI values less than 0.5.
Patients with SI values greater than 0.7 were at higher risk for poor outcomes and comorbidities, the researchers found.
For example, compared to patients with lower SI values, patients with high SI values were prone to have peripheral vascular disease and heart failure. "They had significantly higher heart rate and lower systolic BP on admission and were associated with significantly higher rates of poor outcomes for all outcomes examined," the researchers wrote.
The researchers found SI greater than 0.7 was associated with several poor outcomes.
There was high mortality relative to other stroke patients. In-hospital mortality was 11.0% for patients with SI greater than 0.7 compared to 5.9% for other stroke patients.
For patients with high SI values, 55.7% were not able to ambulate independently, compared to 48.0% of other stroke patients.
Other poor outcomes for patients with high SI values included longer hospital length of stay and higher likelihood of disability.
The SI provides clinicians with a powerful stroke assessment tool at low cost, the researchers wrote.
"This information may be useful in clinical practice for managing stroke patients, to identify those with high risk of poor outcomes from the point of contact, particularly if NIHSS is not available, and to better inform patients and their significant others about the prognosis of these important outcomes," they wrote.
The Clinical Frailty Scale assessment can be performed in less than a minute and indicates likelihood of post-surgical mortality and loss of independence.
Prior to vascular surgery, an easy nine-point frailty test can predict non-home discharge as well as long- and short-term mortality risk, recent research shows.
Vascular surgery, such as abdominal aortic aneurysm repair, often involves high-risk procedures, particularly for frail patients. Tools that can predict surgical outcomes can help vascular surgery practices enhance transitions of care, inform patient decision-making, and set patient expectations.
The researchers used the Clinical Frailty Scale (CFS), which can assess frailty in less than a minute, to predict loss of independence after major vascular procedures.
"The CFS is a practical tool for assessing preoperative frailty among patients undergoing elective major vascular surgery and can be used to predict likelihood of requiring discharge to a nursing facility or death after surgery. The identification of frail patients before major surgery can help manage postoperative expectations and optimize transitions of care," the research wrote this month in the Journal of Vascular Surgery.
The CFS rates frailty on a scale of 1 to 9. In the study, patients with CFS scores greater than or equal to 5 were considered frail.
The study featured 134 independent patients who were assessed with the CFS before undergoing seven vascular surgery procedures, including open abdominal aortic aneurysm repair, endovascular aneurysm repair, and carotid endarterectomy.
Frail patients were found to be at higher risk for several negative outcomes.
62% of frail patients needed mobility assistance after surgery compared to 22% of non-frail patients
22% of frail patients were discharged to a non-home location compared to 6% of non-frail patients
8% of frail patients died within 30 days after surgery compared to 0% of non-frail patients
Frail patients faced more than a 12-fold higher risk of 30-day mortality or loss of independence.
Frail patients experienced a significantly longer hospital length of stay (6.4 days) compared to non-frail patients (4.2 days)
Multiple benefits
The ability of CFS to predict post-surgical outcomes has high value for vascular surgery practices and their patients, the researchers wrote.
"The decision to subject a frail patient to surgical stress associated with a major vascular procedure may result in a physiologic decompensation and lead to morbidity, loss of functional independence … or death, a conceptual framework that has been called the disablement process," they wrote. "Moreover, providing information on the risk for loss of independence or mortality before surgery is important as it may influence a patient's decision to undergo an elective vascular procedure."
Utilizing CFS scores can help vascular surgery practices enhance transitions of care, the corresponding author for the research told HealthLeaders.
"For patients electing to undergo surgery, sharing this information up front allows them and their families to prepare for the fact that they will not be going home immediately after surgery. As such, the CFS provides important data that helps patients prepare and optimize their transitions of care before and after surgery," said Benjamin Brooke, MD, PhD, chief of the Division of Vascular Surgery, Department of Surgery, University of Utah Health.
The CFS assessment tool is valuable for vascular surgery practices, Brooke said. "The CFS provides a fast, easy, and validated method to identify frailty and risk stratify every patient you encounter in clinic, emergency departments, or on the hospital wards," he said.
For vascular surgery practices, the CFS is a superior option to other frailty assessment tools, Brooke and his coauthors wrote.
"Although it is well recognized that risk assessment is an essential component of the preoperative surgical workup, most risk calculators are either too cumbersome or time-intensive to be employed on a routine basis in outpatient clinical settings. In comparison, the CFS score is a simple eyeball test that can be easily measured on all patients in conjunction with other vital signs collected during clinic visits," they wrote.
A strong association is found between burnout and considerations of resigning among residency program directors.
In 2016, one third of medicine residency directors were burned out and about half had considered resigning in the preceding year, recent research shows.
Residency director burnout and turnover can have several negative consequences for health systems, hospitals, and physician practices, including lower educational program effectiveness and long-term adverse effects on physicians in training.
"Turnover of a residency program director impacts not just the physician and clinical practice, but the residency program and residents in it. Over the past two decades, the proportion of program directors in the role three or fewer years has ranged from one third to one half; since 2009, the median tenure of an internal medicine program director has ranged from four to six years," researchers wrote in the American Journal of Medicine.
The researchers examined residency program director survey data from 2012 to 2016. The study focused on questions related to emotional exhaustion, depersonalization, and whether program directors had considered resigning in the previous year.
Less than half of residency program directors in 2012 remained program directors in 2016.
In 2016, 33% of program directors were burned out and 48% had contemplated resignation in the prior year.
In strong indicators of a relationship between burnout and resignation, 85% of the program directors who were burned out in 2016 had considered resigning, but only 30% of other program directors had mulled resignation.
The rate of burnout among program directors is lower than reportedphysician burnout, which rose from 46% in 2011 to 54% in 2014.
"While burnout was associated with program director turnover, we found a particularly strong association between consideration of resigning and program director turnover. Alarmingly, almost one half of the program directors in our sample had considered resigning in the preceding year," the researchers wrote.
Burnout sources and solutions
For residency program directors, the level of support from department chairmen and hospital leaders is likely a significant contributor to burnout, the lead author of the American Journal of Medicine research told HealthLeaders this week.
"This has many important practical manifestations, including the amount of administrative (non-clinical) time protected for the program director and the receptiveness of the chair to helping fix the highest priority problems facing the residency program," said Alec O'Connor, MD, MPH, professor of medicine and director of the Internal Medicine Residency Program at the University of Rochester School of Medicine and Dentistry in New York.
Lack of support from department chairmen can fuel burnout, he said.
"Ultimately, if the program director feels like he or she has to fight with the department chair every time a critical issue has to be addressed—and loses some or all of these critical issue fights—then frustration and feelings of being put into an impossible position will outstrip feelings of accomplishment, leading to burnout and resignation," O'Connor said.
Maintaining time for residents to pursue academics can be a draining challenge for residency program directors, he said.
"One of the most common critical issues program directors face is protecting residents from growing volumes of patient care in academic medical centers, which crowd out time for education and contribute to resident and faculty burnout. These issues can be costly and difficult to fix with a non-resident workforce, but they are core to maintaining the educational mission at residency programs."
O'Connor said more research is required to determine how burnout of residency program directors can be limited, but he said mentoring new program directors could be helpful. Mentoring efforts could ease navigation of stressful duties such as dealing with a struggling resident as well as striking a healthy balance between work and home life, he said.
At the time of hospital discharge, ill-informed patients often face time-pressured decisions to find an appropriate post-acute care provider.
Hospital discharge to a post-acute setting is often among the most daunting challenges that patients and their families face.
An estimated one in five hospitalized patients are discharged to post-acute care settings such as skilled nursing facilities (SNFs) or long-term care hospitals. However, the decisions are usually rushed, and options are often unclear, which can result in placements with low-quality care and negative outcomes such as hospital readmission.
A recent report from the United Hospital Fund found discharge planning can fail patients seeking to find high-quality post-acute care providers.
"The system-centered interests of payers, providers, and regulators often take precedence over patients' needs—when the interests of patients, whose recovery is at stake, should be front and center. Support for careful assessment of post-acute care options, an ingredient that should be essential to discharge planning, is hard to come by and risky if missing," the report's researchers wrote.
Patients and their families face several hurdles when selecting post-acute care providers, the United Hospital Fund report says.
In a speedy discharge process that is usually less than 48 hours, patients and families play the leading role in finding post-acute care providers often with little familiarity about the services offered or health insurance coverage.
Quality of care varies between providers, which can result in poor outcomes and significant out-of-pocket costs.
In markets with multiple providers, patients and families are usually ill-equipped to make informed decisions.
Most patients want hospital staff to help them find post-acute care providers, but federal law gives Medicare beneficiaries choice in selecting providers and blocks hospitals from offering specific recommendations.
Post-acute care is costly. In 2016, the cost of care for Medicare beneficiaries in post-acute settings was more than $60 billion.
In the discharge process, patients and their families are often given bewildering lists of providers, the report authors wrote.
"Patients who will be discharged to home with certified home health agency services are generally given a list of the names, addresses, and phone numbers of agencies in the surrounding area and asked to choose an agency. When post-acute care at a facility is required, discharge planners distribute similar contact lists for SNFs located in the region, indicate which ones accept a patient's insurance, and ask patients to identify several choices," they wrote.
Better discharge planning
Hospitals and their discharge teams can help patients and their families rise to the challenge of selecting appropriate post-acute care providers, the co-author of the report told HealthLeaders this week.
"There are tradeoffs involved in many decisions about post-acute care, which discharge planners could discuss with patients and family members. That kind of guided discussion or review could help patients and families weigh the advantages and disadvantages of their options, and determine how their priorities and needs could be best accommodated," said Lynn Rogut, director of Quality Measurement and Care Transformation at the United Hospital Fund's Quality Institute.
Re-engineering discharge planning to make it less complex is a significant hurdle for hospitals, Rogut said.
"For the most part, discharge planning continues to lack standardized protocols, and it can vary from patient to patient, and hospital to hospital. Placing patients at the center and standardizing the process to the extent possible could begin to help, but the involvement of external parties such as health plans, the individual needs of each patient, and other 'system' constraints will also need to be considered," she said.
Discharge planners should strive to help patients and their families understand their options, Rogut said.
"The range of options any individual patient has can be limited by medical care needs, social factors such as the home environment, insurance coverage, availability of community services and supports, and many other factors. Still, it is important for discharge planners to clearly explain the full range of options available at home, in the community such as adult day healthcare, in assisted living facilities, or in skilled nursing facilities. They should also ensure that patients and families understand and know what to expect from post-acute care services."
Information online
Patients and families often turn to online resources to find post-acute care providers, Rogut and her co-authors wrote.
"Most hospital discharge planning staff refer patients and family caregivers to the 'Compare' sites for home health agencies and nursing homes that are sponsored by the Centers for Medicare & Medicaid Services (CMS). Home Health Compare contains performance ratings for all Medicare-certified home health agencies based on data from insurance claims, standard patient assessments that agencies submit to CMS, and other information collected by state regulators and CMS," they wrote.
Home Health Compare features a pair of star ratings—one gauges quality of care and the other reflects patient experience.
Nursing Home Compare provides star ratings for Medicare- and Medicaid-certified nursing homes. The star ratings reflect the results of state health inspections and data that nursing homes submit to CMS on staffing levels and quality performance.
Yelp and Facebook have reviews of SNFs and home health agencies. However, the report's co-authors say these websites are not as reliable as the Compare sites. "Until the numbers of consumer reviews grow, they can be subject to bias and should be interpreted with caution," they wrote.
As seen in the news recently, rising maternal morbidity and mortality is an alarming negative health trend across the country. What can health systems and hospitals do to prevent these adverse events and keep patients safe?
One health system, West Orange, New Jersey–based RWJBarnabas Health, which features 13 hospitals, has launched a pair of programs to reduce maternal morbidity and mortality: an obstetrics department collaborative at the health system's eight hospitals that offer birthing services, and an emergency department initiative.
The federal Centers for Disease Control and Prevention have been monitoring maternal mortality since 1986. The number of pregnancy-related deaths has risen steadily since the monitoring effort began, from 7.2 deaths per 100,000 live births in 1987 to 18.0 deaths per 100,000 live births in 2014.
Here are the two approaches that RWJBarnabas implemented to reduce maternal morbidity and mortality rates.
1. Establish an obstetrics department collaborative
RWJBarnabas' OB collaborative was launched three years ago.
"Our OB collaborative is a leadership committee of physicians, nurses, and other stakeholders in our system with the common goal of improving the health of women, children, and our communities," says Suzanne Spernal, DNP, administrative director of Women's Services at Monmouth Medical Center, a RWJBarnabas hospital in Long Branch, New Jersey.
Spernal says the health system started the collaborative effort in 2015, and members meet bimonthly to review metrics, practice guidelines, best practices, research, innovation, and to standardize practices so that patients receive the same quality at any of RWJBarnabas' birthing hospitals.
Reducing Cesarean sections is a top objective of the OB collaborative.
"The OB collaborative has been focused on reducing the number of unnecessary Cesarean sections being performed in all of our facilities. All eight of our birthing hospitals are participating in the New Jersey Perinatal Quality Collaborative initiative, which is designed to reduce the NTSV Cesarean section rate," she says.
NTSV Cesarean section is used on a subset of women considered at lowest risk and appropriate for vaginal birth.
Limiting Cesarean sections is an important component of reducing maternal morbidity and mortality, Spernal says.
"We want to facilitate a vaginal birth because we know that when a woman gives birth by Cesarean section in the first pregnancy, the likelihood of her having a Cesarean section in any subsequent pregnancy is very high. With Cesarean sections come all of the risk factors of maternal morbidity and mortality," she says.
Cesarean sections are associated with four of the most commonly documented causes of maternal mortality: hemorrhage, sepsis, anesthesia complications, and pulmonary embolism, Spernal says.
In addition to reducing Cesarean sections, the OB collaborative is working to address maternal hypertension.
"We are participating in another initiative through the New Jersey Perinatal Quality Collaborative that looks at the recognition and treatment of severe hypertension in pregnancy. With this initiative, we are tracking process measurements that focus on the length of time from the event of severe hypertension to treatment. This is a new initiative for us, so we only have preliminary data, but what we have looks very good," she says.
2. Involve the ER
RWJBarnabas also recently launched an initiative to include the health system's emergency departments in the effort to reduce maternal morbidity and mortality.
The heart of the initiative is a single question asked of female ER patients of child-bearing age: "Have you had a baby in the past 42 days?"
[A yes answer from the patient] "will automatically alert the care team that this is a patient who may require immediate attention and that the protocols for her treatment may be different than a non-postpartum woman in the same-age population," Spernal says.
The ER initiative started with staff education.
"Our first step was making the emergency room care teams aware of the data for the United States and New Jersey. Then we discussed the national guidelines for treatment and the best way to implement the guidelines in our emergency rooms," she says.
RWJBarnabas will likely involve more service lines in the health system's maternal morbidity and mortality prevention efforts, but emergency departments were a logical next step after the OB collaborative, Spernal says.
"We are starting with the emergency room because we know the majority of adverse events happen in the 42-day window and the biggest opportunity to improve outcomes is in our emergency departments. More than likely, that is where patients are going to present," she says.
For example, a woman who recently had a baby and arrives at the ER complaining of calf pain could have a blood clot, she says. "You would fast-track that patient and get her into a room to be seen by a provider. A woman of the same age who has not had a baby and has calf pain could have a muscle injury."
Impact of the approaches
"The data we have shows improvement in clinical outcomes that are typically the cause of maternal morbidity and mortality, such as Cesarean section rates," says Spernal.
"Six of our hospitals have reduced their overall Cesarean section rate from 2017 to 2018. Seven hospitals have reduced their NTSV Cesarean section rate from 2017 to 2018," Spernal says.
The health system is primarily monitoring a pair of clinical metrics to gauge the impact of maternal morbidity and mortality prevention efforts, she says.
"We are looking at Cesarean section rates, and at the process measurement of the time that the patient presents for labor and delivery, then has an event of severe hypertension and receives treatment—the time that the patient's blood pressure is reduced," she says.
RWJBarnabas' maternal health initiatives have not increased costs for the health system, Spernal says.
For example, the ER initiative has not required hiring new staff members.
"We have not had to add new staff. It's really about asking that basic question to identify women right out of the gate. These are patients you want to pay attention to—you want to fast track them once you find out that the answer to the question is yes," she says.
Both the OB collaborative and the ER initiative are generating benefits with no costs, Spernal says.
"It's a win for everybody. Obviously, there is no cost to having a meeting and having different people attend to share information. If we are identifying these patients earlier and treating them earlier, then the downstream savings come from a timely admission and treatment for something that may not have been recognized in the appropriate time frame," she says.
Many behavioral health patients boarded in emergency departments are discharged after an inpatient bed request has been made.
Behavioral health patients who are discharged from an emergency department after clinicians request an inpatient bed admission face high risk for return visits to the ED, recent research has found.
Boarding of mental health and substance abuse (MHSA) patients in emergency rooms is one of the most vexing challenges at hospitals across the country. With a shortage of behavioral health inpatient beds in hospitals and mental health facilities, patients can spend days or even weeks boarded in an ER awaiting placement in an inpatient setting.
"MHSA patients who were discharged from ED after bed requests were placed were at greater risk for return visits to the ED. This implicates that these patients require outpatient planning to prevent further avoidable healthcare utilization," researchers wrote this month in American Journal of Emergency Medicine.
The researchers examined post-discharge outcomes for 492 patients at University of Iowa Hospitals & Clinics, The Hawkeye State's only academic medical center.
"An ED revisit within 12 months was significantly higher among patients discharged who had a bed request in place prior to departure (54.0%), than those discharged from the ED (40.9%) or admitted to inpatient care (30.5%)," the researchers wrote.
The most common reason patients were discharged after bed requests was stabilized patient condition (85.1%). For 11.8% of patients, they became frustrated and the provider did not think hospitalization was mandatory. For 2.5% of patients, they left against medical advice.
Rising to the challenge
In addition to a shortage of beds, there are daunting obstacles to providing behavioral health patients with inpatient placement from the ED setting, the researchers wrote.
"As EDs often function as a last resort for psychiatric patients, providing effective psychiatric services are important to ensure patient safety. However, in the ED, the patients are often subject to the complex processes of the mental healthcare system, including medical clearance, insurance verifications, regulatory and institutional requirements, and patient disposition. The complex processes result in psychiatric boarding."
In the absence of increased access to inpatient beds for behavioral health patients, there are strategies to boost support for patients discharged from an ED after a bed request has been made, the researchers wrote.
"[A] recent ED-based study utilizing universal screening plus an intervention consisting of an expanded suicide screening and provision of a self-administered safety plan in the ED followed by a telephone-based intervention holds promise," they wrote.
Emergency psychiatry services, mental health social workers (MHSWs), and mobile crisis outreach (MCO) programs are valuable resources, the lead author of the American Journal of Emergency Medicine research told HealthLeaders.
"The utilization of emergency psychiatry service to reassess boarding patients is important when available. The use of MHSW and MCO is also an option," said Sangil Lee, MD, MS, of the Department of Emergency Medicine at the University of Iowa Carver College of Medicine.
Outpatient care is crucial, he said.
"In a resource-abundant region, these patients simply need to wait for their inpatient bed, but that does not work in most acute care settings in the U.S. When they are released, it is important for these patients to have outpatient resources available, such as an expedited psychiatry visit and follow up provided by an MCO."
Post-discharge outcomes
Compared to other MHSW patients treated in an ED, mortality 12 months after discharge is not higher for behavioral patients released following an inpatient bed request, the American Journal of Emergency Medicine researchers found.
However, patients discharged after an inpatient bed request were found at higher risk for other negative outcomes 12 months after discharge.
For MHSW patients discharged after an inpatient bed request, 24.8% returned to the ED for psychiatric conditions and 16.8% returned for suicidal conditions
For MHSW patients admitted to an inpatient bed, 14.4% returned to the ED with a psychiatric condition and 6.0% returned with a suicidal condition
For MHSW patients who were discharged from the ED with no inpatient bed request, 14.0% returned to the ED with a psychiatric condition and 6.7% returned with a suicidal condition
The decline in primary care physician (PCP) office visits was partially offset by a 129% increase in office visits with nurse practitioners (NPs) and physician assistants (PAs) from 2012 to 2016.
The rise of NP and PA office visits reflects a broader trend toward greater utilization of NPs and PAs in primary care and other healthcare settings.
The recent decrease in office visits to primary care physicians (PCPs) and increase in NP and PA visits is likely linked to three primary factors, Amanda Frost, PhD, senior researcher at HCCI and lead author of this week's report, told HealthLeaders.
First, there has been an expansion in scope of practice laws for NPs and PAs, Frost says. "Scope of practice laws are largely defined by individual states and have changed quite a bit over the last decade. These laws cover things such as whether non-physicians are allowed to prescribe prescriptions, what type of care they can provide, and whether they can practice independently or require physician oversight."
Second, health plan changes are impacting patients' choice of providers, Frost says. "Benefit design features can influence the choices that patients make about where to seek care. For example, under an HMO model, primary care is emphasized, and patients are often required to seek referrals from their PCP prior to seeing specialists. In contrast, Preferred Provider Organization and Point of Service arrangements often do not require PCP referrals for specialist care."
Third, physician shortages are driving patients to seek alternatives to PCP caregivers, she says. "Patients may increasingly see nurse practitioners and physician assistants as a substitute for primary care physicians, especially in areas with PCP shortages where scheduling an office visit to a PCP is more difficult."
Key data points
To the extent that patients are shifting away from PCP office visits to see NPs and PAs, the cost savings is minimal, according to the HCCI report, which is based on employer-sponsored insurance data.
In 2016, the average cost of an office visit to a PCP was $106, and the average cost of an office visit to an NP or a PA was $103, the report says.
The report has several other primary findings:
Across all types of providers, there was a 2% overall drop in total office visits
In 2012, 51% of office visits for patients under age 65 were to PCPs and that figure dropped to 43% in 2016
The rise in visits to NPs and PAs accounted for only 42% of the drop in PCP visits
On a state-by-state basis, the decrease in PCP office visits ranged from 6% in Washington, D.C., to 31% in North Dakota
On a state-by-state basis, increases in NP and PA office visits ranged from 37% in New Mexico to 285% in Massachusetts
Whether it is delivered by PCPs or NPs and PAs, primary care offers a high level of value for patients, the report says.
"Access to PCPs helps keep healthcare costs low, as spending is lower on PCPs than specialists or emergency care. Primary care also helps keep people healthier and out of emergency rooms," the report says.
The role of NPs and PAs in primary care is evolving, the report says.
"Having more NPs and PAs provide primary care may ease potential shortages in PCPs and allow PCPs to focus on more clinically complex primary care. However, the laws governing scope of practice for these non-physician providers vary widely by state. In some states, NPs and PAs have full practice authority, while in others they are restricted from independent practice and require the oversight and billing of a physician."
Patients with both heart failure and chronic obstructive pulmonary disease have a high cost of care, but there are multiple strategies to limit readmissions.
Improving clinical management of patients with both heart failure (HF) and chronic obstructive pulmonary disease (COPD) can lower cost of care, research published this month shows.
Readmissions are among the most prominent areas to reduce cost of care. Earlier research found that a regional general hospital experienced negative total margins in both COPD and HF, costs that could have been avoided by limiting readmissions.
Healthcare clinical leaders who seize opportunities to limit readmissions not only lower cost of care, but can also boost quality of life for patients and avoid financial penalties under the Hospital Readmissions Reduction Program for HF.
"Patients with both COPD and HF pose particularly high costs to the health-care system. These diseases arise from similar root causes, have overlapping symptoms, and share similar clinical courses. Because of these strong parallels, strategies to reduce readmissions in patients with both conditions share synergies," researchers wrote this month in the journal CHEST.
The CHEST researchers focus on 10 approaches to reduce readmissions for patients with both HF and COPD that your health system can adopt.
1. Make accurate diagnoses
Particularly for COPD, hospitalization is often the first opportunity for accurate diagnosis, the researchers wrote.
"Hospitalization for an acute exacerbation often represents the first time COPD is diagnosed in an individual patient. This may be attributed to the fact that spirometry is underused in outpatient settings to establish the diagnosis of COPD," they wrote.
Several tests, including echocardiography, can diagnosis HF in COPD patients.
"Because spirometry is not thought to be accurate during acute HF exacerbation, anatomic assessment of lung parenchyma with CT scan may offer valuable adjunctive information at reasonably high sensitivity and specificity. In addition, chest CT scan may offer valuable ancillary information regarding right heart size,
the diameter of the pulmonary artery, and the presence of coronary calcification," the researchers wrote.
2. Strive for early detection of exacerbations
To reduce readmissions, early detection of patients with both COPD and HF is helpful for two reasons, the researchers wrote.
First, specialists can be involved quicker, which allows for faster determinations about root causes of patients' COPD or HF. Specialist involvement also quickens development of treatment plans.
"Second, early identification during hospitalization allows time to deploy multidisciplinary interventions, such as disease management education, social work evaluation, follow up appointment scheduling, and coordination of homeservices. These interventions are less effective, and are often not implemented, if initiated toward the end of hospitalization," the researchers wrote.
Early detection of exacerbations can also allow care teams to perform risk stratification, particularly for HF, they wrote. "It may be possible to identify the 20% to 30% of the population who are at low risk for readmission. These patients, if identified early, may be good candidates for observation care and may not need intensive services."
3. Ensure specialist management in the hospital
Specialists not only maximize the quality of inpatient care but also can play a key role at the time of discharge, the researchers wrote. "Because specialists are often tasked with the outpatient follow-up of HF and COPD, specialist involvement while in hospital allows for treatment plans to be created in continuity with those that will be effected as an outpatient."
4. Address root causes
HF has several correctable root causes, the researchers wrote. "Identification of and treatment of occult ischemic heart disease, valvular heart disease, systemic hypertension, and pulmonary hypertension all have potential to make the HF syndrome more tractable."
Addressing root causes of COPD is more difficult, they wrote. "Regarding COPD, particularly in younger patients or patients in whom exposure to cigarette smoke has not been high, consideration should be given to … referral for evaluation for lung volume reduction surgery or lung transplantation."
5. Use evidence-based therapies
"Medical therapies improve outcomes for both HF and COPD. These should be initiated in hospital where feasible because initiation of therapy while in hospital or soon after discharge likely translates into improved rates of outpatient therapy," the researchers wrote.
For HF, several kinds of medications have shown effectiveness such as beta-blockers, angiotensin receptor blockers, and aldosterone antagonists. "Not only are there long-term outcome benefits for these therapies, evidence suggests early
initiation of HF therapies can reduce 30-day readmissions," the researchers wrote.
There are fewer evidence-based therapies linked to reduced readmissions for COPD, but earlier research has shown that noninvasive positive pressure ventilation reduces readmission at 28 days compared with oxygen alone.
6. Engage patients in their care
Enlisting HF and COPD patients as active participants in care and monitoring exacerbations is essential, the researchers wrote.
"Many strategies for engaging patients in care have been tested, including teach to goal, motivational interviewing, and teach-back methods of activation and engagement. Often these methods are time intensive. Because physician time is increasingly constrained, a team approach is particularly useful. Patient activation strategies focus on developing critical health behaviors in patients that can engender better health," they wrote.
7. Establish feedback loops
Creating mechanisms for care plan course corrections is critical to outpatient success, the researchers wrote.
"Feedback loops can allow for clinical stabilization before rehospitalization is necessary. Self-care plans for both COPD and HF have been found to be effective. Nurse-led telephone follow-up for COPD and HF at 48 to 72 hours may also help support patients post-discharge."
8. Schedule follow-up appointments
Before hospital discharge, a follow-up appointment should be established with an advanced practice provider or nurse with pharmacist support.
"The purpose of early follow-up is (1) to identify and address gaps in the discharge plan of care, (2) to retailor the discharge plan of care to better suit the patient in the outpatient environment, (3) to reinforce critical health behaviors, and (4) to advance the plan of care, time permitting," the researchers wrote.
9. Address other comorbidities
Multiple comorbidities such as septicemia and renal dysfunction are common for patients with COPD and HF, the researchers wrote.
"This underscores the need for involvement of the primary care physician for assistance in managing comorbidities. In a study evaluating process of care metrics associated with better outcomes in patients hospitalized with HF,
partnering with community physicians and arranging to send discharge summaries to the primary physician were among the strategies most associated with lower readmission risk."
10. Arrange home health services
For HF patients, home services such as physical therapy, patient education, and medication instruction have been associated with reduced readmission rates at three to six months. Telehealth has shown effectiveness in managing COPD.