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.
CDC official provides update on baffling neurological disorder that causes paralysis in one or more limbs.
Acute flaccid myelitis is a polio-like illness that has afflicted about 400 children over the past four years. There is no known cause. There is no known cure.
"There are currently no targeted therapies or interventions with enough evidence to endorse or discourage their use. We recommend that clinicians expedite neurology and infectious disease consultations to discuss treatment and management," Nancy Messonnier, MD, director of the National Center for Immunization and Respiratory Diseases, said in a briefing Tuesday.
The rare neurological disorder—less than 1 in a million Americans contract AFM annually—mimics polio with weakness in one or more limbs. Some patients have recovered quickly. Paralysis has persisted in others.
Most of the confirmed AFM cases have been in children, according to the Centers for Disease Control and Prevention (CDC). As of November 5, there were 80 confirmed cases this year, mostly in children between 2 and 8 years old, Messonnier said.
"As a mom, I know what it is like to be scared for your child, and I understand parents want answers. CDC is a science-driven agency. Right now, the science doesn't give us an answer," she said.
Limited treatment options
The CDC plans to release new treatment and care management guidance this week, Messonnier said.
"Since 2014, we have been working with clinicians treating AFM patients. In the next day or two, we are posting updated considerations that reflect the significant experience of those clinicians. Unfortunately, because we don't yet know the cause of all AFM cases, these considerations are not as specific as we would like," she said.
The CDC issued interim considerations for clinical management of AFM in November 2014. Although clinicians had tried corticosteroids, plasmapheresis, interferon, antivirals, and other targeted therapies, none of them were deemed safe or effective in the treatment of AFM.
The interim considerations include three primary recommendations for clinical management:
Patients with respiratory muscle weakness should be considered for ICU admission
Patients undergoing MRI should be closely checked with methods including telemetry, pulse oximetry, and blood pressure monitoring
As soon as patients are clinically stable, they should undergo intensive physical therapy, which could improve functional outcomes and prevent muscular atrophy, joint contractures, and other conditions resulting from severe and persistent limb weakness
Search for a cause
Diagnosis of AFM is primarily clinical—patients present the sudden onset of flaccid limb weakness—and MRI exam results showing spinal cord lesions mainly in gray matter and spanning at least one vertebral segment.
The CDC cautions that an initial MRI of an AFM patient may not show spinal cord lesions, which may not appear until 72 hours after the onset of flaccid limbs.
Viral infection has been a suspected cause of AFM since the first outbreaks of the illness in 2014.
Viruses are the suspected cause of at least two AFM cases this year, Messonnier said. In these cases, spinal cord fluid tested positive for two viruses.
"One had evidence of EVA-71 and one had evidence of EVD-68. One of the cases was an adult who was on immuno-depressive medication, and the other was in a child who had very rapid progression of paralysis," she said.
The findings are clues rather than definitive signs of a cause for AFM, Messonnier said.
"When a pathogen is found in the spinal fluid, it is good evidence that it was the cause of the patient's illness. However, oftentimes despite extensive testing no pathogens are found in the spinal fluid. This may be because the pathogen has been cleared by the body or it is in hiding in tissues that make it difficult to detect. Another possibility is that the pathogen triggers an immune response in the body that causes damage to the spinal cord."
Physician champions can help health systems and hospitals overcome challenges associated with changing supply items.
Changing devices, implants, and other products is challenging to hospital supply chain functions—often causing resistance from clinicians wedded to existing supply items.
That is why health systems and hospitals can drive change and value in their supply chains with the help of physician champions. And one system is doing just that.
Kettering Health Network is tapping the clinical expertise of physicians to tackle these predicaments. Trisha Gillum, director of supply chain management at the Dayton, Ohio–based health system, says physicians can play diverse roles in supply chain.
"It can be as small as a physician champion on a single project, to being a physician champion for a service line, to being on the payroll for supply chain," she says.
Here are three reasons to enlist physician champions to improve your supply chain.
1. Physician champions actively engage in supply chain projects
Gillum says the best physician champions for medical supply changes are personally engaged in the effort. "They are willing to understand both the financial and the clinical nuances to a project. They are also willing to speak with their peers—to be a cheerleader or champion for a project."
When Kettering identifies engaged and respected physicians who are interested in serving in the champion role, the doctors receive training from The Advisory Board Company. Physician champion programs at this Washington, D.C.–based consultancy range from individual sessions to a physician leadership track that has sessions held over several months.
Two primary elements of the education programs are business instruction and learning about the nuances of the changing healthcare industry.
"Many physicians are not in tune with everything that is going on in the hospital environment," Gillum says. "They don't understand when we say we need to save money. So, there is education about financial pressures and clinical pressures."
Another educational goal is giving physicians leadership skills, she says.
"We are asking them to step out of their traditional roles and communicate with their peers at an advocacy level. To do that, we not only need to provide the data to support product conversations, but also give them the tools necessary to have those conversations."
2. Physician champions contribute valuable input into supply choices
Physician champions play a potentially decisive role in proposed supply changes, Gillum says.
"If you really want a physician to get engaged, they will bring their own mindset about what the answers should be. You cannot expect a physician to come onboard and rubberstamp the process," she says.
Supply chain managers and other leaders should be open to opposing views from physician champions, she says. "They are going to want to engage in the process. They are going to want to modify it. So, you may end up in an entirely different place than you expected."
When physician champions object to proposed supply changes, open communication is essential, Gillum says.
"You have to be transparent. You can't ask a physician to own something like a cost-savings initiative unless you are willing to say how much we are going to make on a procedure. You have to be willing to share all of the data and to give physician champions all the facts to make intelligent decisions," she says.
Supply chain managers should treat physician champions as valued teammates, Gillum says. "You have to realize that you have asked physicians to play a supply chain role and to provide information. If you disregard what they are saying, you are going to lose partners."
The best-case scenario for physician champions is when they take ownership of a supply change project, she says.
"I had a physician who went out and talked with every one of his peers who performed a particular procedure. He convinced every one of them that we needed to make a change. He was able to accomplish more in those conversations than I could have accomplished in months of conversations with the same group of physicians," she says.
3. Physician-champions help decide supply changes that impact patients
Health systems and hospitals benefit from physician champion participation in supply chain, and the clinicians benefit as well.
Gillum says the two primary benefits for clinicians who assume physician champion roles are gaining experience that helps them compete for hospital administration jobs and helping to decide supply changes that could impact their patients.
"I had one physician say he was passionate about the supplies he used on his patients. The best way physicians can control the supplies that they get is to be part of the conversation and part of the decision," she says.
Inappropriate utilization of cardiac telemetry is wasteful spending with no significant clinical benefit.
Eliminating inappropriate use of cardiac telemetry can generate significant cost savings for health systems and hospitals, recent research shows.
Healthcare spending accounts for about 18% of the country's gross domestic product, with the figure expected to reach nearly 20% by 2025. Wasteful spending is estimated to represent about one-third of healthcare expenditures.
Cardiac telemetry is an observation tool that allows continuous monitoring of electric and other heart signals.
Research published this month in the American Journal of Cardiology found a significant level of wasteful utilization of cardiac telemetry at a 432-bed tertiary hospital. The researchers examined data from 250 consecutive patients admitted to telemetry-capable beds:
The patients were hospitalized a total of 1,640 days, with 1,399 days on telemetry.
The researchers found that only 334 telemetry days were appropriate based on established national guidelines.
Compared to a patient's non-telemetry hospital day, the cost of telemetry was about $34 per day.
For the patients in the study, the hospital could have saved $37,000 by eliminating inappropriate telemetry utilization. The estimated annual savings from a similar patient cohort would have been more than $500,000.
The researchers found no significant clinical benefit from overutilization of cardiac telemetry.
For the 250 patients in the study, 16 significant arrhythmias were detected during their hospitalizations. All of the arrhythmias were detected during appropriate telemetry days.
There were similar findings for clinical decisions driven by telemetry days and code calls, the researchers wrote.
"All five code calls were due to respiratory arrest, with four being on appropriate telemetry days and one on an inappropriate telemetry day. There were 18 significant clinical decisions motivated by telemetry findings during appropriate telemetry days, with only one such decision made on an inappropriate telemetry day," they wrote.
Appropriate utilization
There are two sets of national standards for the appropriate utilization of cardiac telemetry: the 2004 American Heart Association Practice Standards and 1991 American College of Cardiology guidelines.
Under the 2004 AHA practice standards and 1991 ACC guidelines, there are more than a dozen indications for cardiac telemetry including the following:
Patients emerging from sedation or anesthesia for procedures
The AHA and ACC directives are likely a key component of eliminating inappropriate utilization of cardiac telemetry, the American Journal of Cardiology researchers wrote.
"Potential reasons for telemetry overuse include lack of awareness of the AHA/ACC guidelines, nonadherence to these guidelines, lack of provider awareness of ongoing telemetry use, and a lack of telemetry auditing. These causes have been described in previous studies and should be a target for future study and intervention."
Addressing inappropriate utilization
This week, the lead author of the research told HealthLeaders that some hospitals are trying to address inappropriate utilization of cardiac telemetry.
"Some centers are instituting daily huddles regarding ongoing care in order to improve quality and reduce waste," said Daniel Morin, MD, MPH, medical director of cardiovascular research at John Ochsner Heart and Vascular Institute in New Orleans.
"These meetings may include review of which patients are on telemetry. These patients are then reviewed for whether they should remain on telemetry, and if not, telemetry may be discontinued, at a significant savings as we discussed in our paper. Conversely, when an indication for telemetry is present for a nonmonitored patient, telemetric monitoring can be initiated."
National data indicates the Hospital Readmissions Reduction Program is having a positive impact on patients under 65 as well as patients with Medicaid and private insurance coverage.
Medicare's Hospital Readmissions Reduction Program (HRRP) is having a positive impact beyond Medicare beneficiaries and beyond the medical conditions targeted in the initiative, recent research shows.
"There appears to be a systematic improvement in readmission rates for patient groups beyond the population of fee-for-service, older, Medicare beneficiaries included in the HRRP," researchers wrote this month in the American Journal of Medicine.
The primary implication of the research is that health systems and hospitals have made broad improvements to quality of care rather than changes aimed only at Medicare beneficiaries treated for the conditions targeted by HRRP.
In 2012, the Centers for Medicare & Medicaid Services started financial penalties for high readmission rates for three conditions: acute myocardial infarction (AMI), heart failure and pneumonia. Under HRRP, hospitals are penalized if they have higher than expected risk-standardized readmission rates.
The American Journal of Medicine researchers examined data from the Healthcare Cost and Utilization Project's Nationwide Readmissions Database (NRD), a nationally representative all-payer database. They focused on readmission rates across six age-insurance groups for the three HRRP targeted conditions as well as conditions not targeted by HRRP. The data features nearly 60 million hospitalizations and more than 18 million readmissions.
The six age-insurance groups were patients over 65 with Medicare, Medicaid, or private insurance; and patients younger than 65 with Medicare, Medicaid, or private insurance.
Broad readmission gains
The NRD data shows reductions in readmissions rates across all six age-insurance groups.
Readmissions for AMI patients over 65 declined significantly for all three forms of healthcare coverage: the readmission rate for patients with Medicare coverage dropped from 19.2% in 2010 to 15.5% in 2015; for the privately insured, the readmission rate dropped from 14.6% to 12.4%; and for patients with Medicaid coverage the readmission rate dropped from 23.4% to 18.3%.
Readmissions for AMI patients under 65 also declined significantly: decreased readmission rates for privately insured and Medicaid patients mirrored the lower readmission rates for patients over 65. Medicare patients under 65 experienced a modest decrease in readmission rates from 19.7% to 18.6%.
Similar to AMI, readmission rates for heart failure decreased significantly for all six age-insurance groups.
Readmission rates for pneumonia decreased for all six age-insurance groups, but the decline was significantly larger for patients over 65 compared to those under 65.
For conditions not targeted under HRRP, there was a small decrease in readmission rates in most age-insurance groups. For example, among Medicare patients over 65, readmission rates dropped from 16.3% in 2010 to 15.5% in 2015; but among the privately insured, readmission rates dropped from 14.0% in 2010 to 13.5% in 2013, then rose to 13.8% in 2015.
Systematic changes
The data collected in the American Journal of Medicine study indicate HRRP is having a widespread impact on hospital readmissions, the researchers wrote.
"From 2010-2015, 30-day all-cause readmission rates for acute myocardial infarction, heart failure, and pneumonia declined across all age-insurance groups. Readmission rates decreased modestly for conditions not targeted by the HRRP in all age-payer groups, with larger declines among Medicare patients aged ≥65 years," they wrote.
This finding implies hospitals have made extensive changes to clinical care rather than changes targeted only at HRRP-impacted patients, the researchers wrote.
"These patterns are consistent with the hypothesis that implementation of the HRRP was associated with systematic changes in the care of patients and reduced readmission risk beyond the HRRP's target population of fee-for-service Medicare beneficiaries."
A Florida-based community hospital is using AI tools to examine patient data and formulate new treatment protocols for deadly illnesses such as sepsis.
Artificial intelligence (AI) is sometimes seen more as hope and hype than as a solution for healthcare that can improve patient outcomes and reduce costs.
Now, a community hospital in Florida is not only proving healthcare AI can generate observable results in the clinical arena, but also showing that initiatives can be launched and sustained without the deep pockets of a large health system.
Flagler has already realized financial gains from new care pathways for pneumonia and sepsis. The pneumonia and sepsis care pathways have generated nearly $850,000 in costs savings in less than a year. Once care pathways are established for about a dozen other high-risk conditions, cost savings could be as high as $20 million over the next three years, says Michael Sanders, MD, CMIO at Flagler.
For health systems and hospitals seeking to capitalize on AI technology, Flagler is a case study on how AI can be used to develop new care pathways that simultaneously cut costs and improve clinical outcomes.
In 2017, Flagler decided to use AI to mine the hospital's clinical information and focus on deadly and costly conditions. The goal was creating new care pathways for conditions such as sepsis to boost clinical outcomes and drive down cost of care.
Early this year, Flagler signed a three-year AI technology contract with Menlo Park, California–based Ayasdi to help with this initiative.
The AI-powered process reviews thousands of patient records from the hospital, then identifies the patient cohort with the best outcomes, such as the lowest direct variable cost, readmission rate, length of stay, and mortality. The commonalities of this patient cohort drive development of new care pathways such as revision of the emergency department order sets with new treatment protocols.
The hospital also has internally published a new care pathway for COPD, and is set to rollout diabetes, total knee replacement, heart attack, and coronary artery bypass graft pathways next.
"Any hospital can do this," Sanders says.
Here are three ways Flagler implemented AI into its organization to improve patient outcomes and reduce total cost of care.
1. Create a Staffing Strategy
To limit costs, Flagler decided to staff its AI capabilities internally, Sanders says.
"We do not have a data scientist at our hospital. All of this work has been done internally, which I think any community-based hospital can do. We have a couple of folks, including myself and a SQL query guy who has great SQL skills," he says.
Most of the work done by humans in a new care pathway effort involve setting up the parameters and queries for data extraction. Once the data has been verified, the AI tools sift through the hospital's data to combine patients into cohorts.
2. Start With a Simple Pilot
In the pilot phase of Flagler's AI initiative, Sanders wanted to pick a condition with relatively few variables to compute.
Picking the right place to start—pneumonia—was essential to the effort, Sanders says. "I wanted something that would be relatively easy and straightforward, so we could get our feet wet with something that wasn't too complicated."
It took nine weeks to complete the pneumonia project—from data extraction to AI analysis, to refinement of new treatment protocols, to internal publication of the new care pathway.
The next care pathway project—sepsis—took two weeks, with learning gains speeding data extraction and the treatment protocol refinement process.
3. Collect and Crunch Patient Data
Flagler took multiple steps to extract and organize the patient data used to form new care pathways:
Patient data is extracted from the hospital's Allscripts EHR, surgical system, enterprise data warehouse, and financial system
Data is loaded to a cloud technology, where it can be stored and manipulated
Three rounds of semantic and syntactic validation are conducted to make sure the data is accurate
AI tools are used to carve out patient cohorts
Once the analytical work has been completed, the AI team members engage the hospital's physicians to craft the new care pathways.
"We sit down with one physician from every physician group in the hospital. We have been having meetings every first and third Wednesday of the month, and we go through the care paths and make changes that are deemed appropriate based on our evidence and experience," Sanders says.
The new care pathways are used to set treatment protocols in the emergency department and inpatient wards, he says. "We publish the care paths and make changes to the ED order sets and admission order sets based on the care paths, [then] we begin monitoring them."
Operationalizing Care Pathways
Care pathways are road maps for treatment, Sanders says.
"The pathway includes everything, from the moment patients enter the ER to when they are admitted and discharged. There are two sets of orders involved—the care that is given in the emergency department and the care that is given after admission," he says.
Positive patient outcome data has fueled physician engagement in the AI-driven care pathways, Sanders says.
"We had 557 patients with septic shock. For all but 19 patients, the sepsis order set was used. When we looked at the data, the mortality in our hospital is below the national average at 9%. If a patient had the sepsis order set used, they had a readmission rate of 6%. If we look at the group where the order set was not used, the readmission rate was 21%."
If you are going to change your discharge model for at-risk geriatric patients, there are four elements you are going to need.
Geriatric inpatient care and the transition of patients to postacute care are among the most daunting challenges for health systems and hospitals because of the possibility of patient functionality losses in the inpatient setting and costly readmissions after discharge.
In one effort to rise to these challenges, Philadelphia-based Penn Medicine has launched Supporting Older Adults at Risk, or SOAR. SOAR which served its first patient in January, is modeled after the "flipped" discharge program crafted at Sheffield Teaching Hospitals in the United Kingdom.
Penn Medicine has modified the U.K. approach to "flipped" discharge, which features in-home patient assessments after hospital discharge more prominently than in-hospital assessments at discharge, says Rebecca Trotta, PhD, RN, director, nursing research and science, at the Hospital of the University of Pennsylvania in Philadelphia.
"We tried to adhere to the central tenets of flipped discharge: maintaining a geriatric focus; having comprehensive services, not just medical services; and offering services early and intensively," she says.
SOAR has served 46 patients so far, and the early data is promising, Trotta says. A primary goal of the initiative is decreasing hospital length of stay, which has dropped about 1.5 days for SOAR patients.
Lowering length of stay reduces risks associated with hospital care, she says. "We are thinking about how we can maximize care in the home setting because we know when patients are in the hospital they are at higher risk for falls, functional decline, and delirium."
Flipping the discharge model at Penn Medicine means equipping its SOAR program with the following four elements:
1. Geriatric nurse consultants
Four nurses who serve as geriatric nurse consultants in the inpatient setting are a building block of the SOAR initiative. They are staffed through the department of nursing.
"Their full-time job is to identify older adults upon admission who could benefit from a comprehensive geriatric assessment, to share recommendations and findings with the interprofessional team, to follow up on those recommendations, and to collaborate with caregivers," Trotta says.
The geriatric nurse consultants establish working relationships with patients that underpin the SOAR program, says David Resnick, MEd, MPH, innovation manager for the Acceleration Lab at the Penn Medicine Center for Health Care Innovation in Philadelphia.
"The geriatric nurse consultants spend a lot of time with patients in the hospital conducting assessments and getting to know them and their caregivers, which builds trust. So, we have seen refusals of home care at the door—which happen about 15% of the time with traditional home care—fall to zero with SOAR," he says.
2. Home assessments
SOAR provides home health services through Penn Care at Home, a division of Penn Medicine. When patients return home, a Penn Care at Home staff member conducts an assessment.
The home assessments confirm or revise discharge assessments conducted in the hospital including physical therapy and occupational therapy evaluations, she says. "SOAR verifies what is needed. We often find patients need more or different things than we thought in the hospital."
Home assessments help recovering patients to live at home, Trotta says.
"The goal for our older patients is to maximize their ability to take care of themselves, which includes their daily living and functioning. They need to do things like get to the bathroom, prepare food, do laundry, and keep their house clean. Seeing how that unfolds in their real environment lets us see where they might need help versus seeing it in the hospital," she says.
3. Rigorous handoff
"We do a handoff call with the geriatric nursing consultants that includes highlighting key things they have learned about the family and caregivers. They also work on medication reconciliation jointly with the home care team," Resnick says.
Hospital staff and the home care team work together closely for the first 48 hours after a patient has been discharged, he says.
"For the first two days that a patient is home, the home care team is tethered back to the hospital. The home care team can either call or message the acute care provider and talk with the geriatric nurse consultants for issues that arise in the home such as medication discrepancies and other concerns. They are not on their own," he says.
4. Intensive services
SOAR provides a level of service that is more extensive than traditional home healthcare, Trotta says.
"It is organized differently than standard home care. Typically, across the country the average time to the first home visit is at least two to three days. For an older person leaving a hospital without a connection to their next provider for two or three days, there is a risk of something going wrong in that time," she says.
With SOAR, patients get a same-day visit after discharge. They leave the hospital in the morning, then see a home care nurse that afternoon. They also see that same nurse the next day.
Same-day and next-day visits following hospital discharge allow home care team members to address immediate needs such as questions about medications and usage of durable medical equipment, Trotta says. "There is more immediate attention as patients transition from the hospital to the home."
SOAR provides a level of services, which are reimbursable by Medicare and commercial insurance, that is often not included in traditional home care, she says.
"Our patients are defaulted to receive physical therapy, occupational therapy, and social work. In traditional home care, those services can be delayed or not recognized as needed at all," Trotta says.
Collection of patient-generated data and embracing patient-centered communication are called crucial factors in avoiding harm from diagnostic errors.
Drawing information from patients can help boost understanding of why diagnostic errors happen and reduce the risk of future errors, research published this week says.
Diagnostic errors are a serious patient safety problem, impacting about 12 million adult outpatients each year and causing as many as 17% of adverse events for hospitalized patients.
"Health systems should develop and implement formal programs to collect patients' experiences with the diagnostic process and use these data to promote an organizational culture that strives to reduce harm from diagnostic error," researchers wrote in an article published today in the journal Health Affairs.
The research features an examination of 184 narratives from patients or family members about diagnostic errors collected in a new database maintained by the Empowered Patient Coalition.
The data provide unique and valuable insight into diagnostic errors, the researchers wrote.
"Patients' reports of their experiences of diagnostic errors can provide information that traditional measurement mechanisms often fail to capture. Given the absence of diagnosis-specific experiences in most surveys and patient-reported outcomes, the only current way to capture patients' experiences of diagnostic error is via patient complaints. However, complaints are often viewed as satisfaction matters rather than safety signals," the researchers wrote.
Pain points
The Empowered Patient Coalition narratives identified four areas where poor clinician-patient relations contributed to diagnostic errors.
Patient knowledge was ignored in 92 of the narratives. Patients or family members said that clinicians ignored or disregarded reports of clinical indications such as symptoms and changes in patient status.
Disrespect of patients was considered a possible contributing factor in several diagnostic errors. Clinician disrespect of patients was reported in several forms such as belittling, mocking, and stereotyping.
Failure to communicate was another theme in the narratives, with clinician failings ranging from ineffective communication styles to refusal to talk with patients and family members. Examples of poor communication included unanswered phone calls and unresponsiveness to questions.
Manipulation or deception was reported in 15 of the narratives. This behavior fell into two categories: Clinicians using fear to influence care decisions or patients who were misled or misinformed.
Addressing the problem
To help reduce diagnostic errors, the Health Affairs researchers propose five methods to collect patient experience data and encourage better communication between clinicians and patients.
Creating new requirements for clinicians to conduct lifelong communication training. These requirements could include training to manage patient expectations through discourse.
Including communication skills, professionalism, and safety knowledge in certification and continuing medical education programs.
Health systems and providers should encourage patient engagement in safety through active and systematic collection of patient observations of clinician behaviors. These patient engagement efforts should be incorporated in mechanisms that are designed to change clinician behaviors.
Patient reports identifying clinician behaviors that pose a risk of diagnostic errors should result in interventions to foster patient-centered communication. These reports should be corroborated through the medical record or some other form of independent analysis.
Hospitals and health systems should include patient reports of diagnostic errors into training and patient safety programs.
A multi-pronged approach is needed to address aberrant clinician behaviors that lead to diagnostic errors, Traber Giardina, PhD, lead author of the Health Affairs research, told HealthLeaders today.
"We recommend health systems use a systematic method to collect patient reports of these types of behaviors. This would allow for these behaviors to be identified and monitored. A safety culture that encourages not just patients but also clinicians and staff to report these behaviors is needed. Additionally, we suggest reforms in medical education that highlight patient safety," she said.
These efforts require walking a fine, said Giardina, a patient safety researcher at the Michael E. DeBakey VA Medical Center and assistant professor of medicine at Baylor College of Medicine, both in Houston.
"Fostering clinician accountability for the unprofessional behaviors experienced by the patients who reported diagnostic errors is sure to be challenging and will need to be balanced by the need to address pressures on clinicians that lead to burnout, which may even contribute to these behaviors. These at-risk behaviors that compromise patient safety must be addressed though. More policy priority to nurture the patient-physician relationship is long overdue."
The new rules, which focus on the 2019 and 2020 calendar years, update payment regulations, support expansion of remote patient monitoring, and seek to ease regulatory burdens.
The Centers for Medicare & Medicaid Services (CMS) are updating payment and innovation rules for home health.
As home health agencies expand and health systems establish more robust capabilities for post-acute care including home health services, a CMS final rule announced last weekfinalizes calendar year 2019 and 2020 payment and policy changes, including regulations to promote remote patient monitoring and ease regulatory burdens.
"[The final] rule overhauls how Medicare pays for home health, refocusing on the needs of patients, promoting innovation, and reducing burden for physicians and home health providers," CMS Administrator Seema Verma said in a prepared statement.
Medicare payment
Medicare payments to home health agencies in calendar year 2019 are estimated to increase 2.2%, or $420 million, based on the agency's finalized policies, according to a CMS fact sheet.
A rule change that eases operations for home health agencies as well as health systems and hospitals that offer home health services speeds Medicare payments.
The rule change under the Home Health Prospective Payment System alters the unit of payment under HHPPS from 60-day episodes of care to 30-day episodes of care. The change is set to be implemented on Jan. 1, 2020.
Another new payment regulation slated to start on Jan. 1, 2020, is designed for Medicare to pay for value rather than volume of services. Under this change, Medicare will discontinue the practice of determining home health payments based on the number of visits provided. Instead, a patient's medical condition and care needs will be the determinative factors.
"Therapy thresholds encourage volume over value and do not acknowledge that all patients are not the same, with some patients having complex needs that do not involve a lot of therapy," the CMS fact sheet says.
Remote patient monitoring
The final rule sets a new definition for remote patient monitoring and makes it easier to receive Medicare payment for the service.
The final rule states remote patient monitoring can be a beneficial service in the home-health setting.
"Fluctuating or abnormal vital signs could be monitored between visits, potentially leading to quicker interventions and updates to the treatment plan. Additionally, … remote patient monitoring may improve patients' ability to maintain independence, improving their quality of life," the final rule says.
Some patients garner major health benefits from remote monitoring, the final rule says. "Particularly for patients with chronic obstructive pulmonary disease and congestive heart failure, research indicates that remote patient monitoring has been successful in reducing readmissions and long-term acute care utilization. Other benefits included fewer complications and decreased costs."
The final rule's new definition of remote patient monitoring is relatively succinct: "The collection of physiologic data—for example, ECG, blood pressure, glucose monitoring—digitally stored and/or transmitted by the patient or caregiver or both to the home health agency."
Under the final rule, remote patient monitoring is billable to Medicare as an administrative cost.
Regulatory burden reduction
Reducing bureaucratic costs is a central theme of the final rule.
For example, CMS is ending a requirement that certifying physicians estimate how long home-health services are needed. "This policy is responsive to industry concerns about regulatory burden reduction and could reduce claims denials that solely result from an estimation missing from the recertification statement," the CMS fact sheet says.
For calendar year 2019, CMS estimates this rule change will generate $14.2 million in cost savings for certifying physicians.
