Hospital admission for a serious condition over a weekend or holiday has been linked to compromised patient outcomes, but researchers have found discharges may not be susceptible to the 'weekend effect.'
Discharge over weekends or holidays does not appear to impact readmission rates for major cardiac surgery patients, new research shows.
The finding runs counter to earlier research that has shown a negative impact on outcomes for major illness patients admitted to hospitals over weekends or holiday.
"Given the vast literature demonstrating the impact of the 'weekend effect' on admission outcomes, we expected a similar phenomenon surrounding the complex discharge process after cardiac surgery," Yas Sanaiha, MD, lead author of the new research in The Annals of Thoracic Surgery, told HealthLeaders this week.
"Our team was somewhat surprised to find that day of discharge did not impact adjusted odds of readmission," said Sanaiha, a resident physician in the Division of General Surgery at the David Geffen School of Medicine at UCLA.
The research features more than 4,800 cardiac surgery patients discharged from a UCLA Health hospital, with 20% discharged on a weekend or holiday. For all patients, the readmission rate within 30 days was 11.3%. The readmission rates for weekends (11.4%) and holidays (10.9%) were closely comparable.
"In this retrospective single institution study of patients undergoing elective major cardiac operations, weekend or holiday discharge was not associated with worse readmission performance after adjusting for patient comorbidities and intraoperative variables," Sanaiha and her fellow researchers wrote.
The research team found three predictors of readmission for the patients in the study. "Use of preoperative b-antagonist medications, tobacco use, and surgical site infections were independent predictors of rehospitalization within 30 days," they wrote.
Gauging 'weekend effect'
Readmission reduction is a complex challenge with multiple variables, Sanaiha told HealthLeaders.
"Hospital readmission reduction programs have focused on various measures such as patients with more severe baseline comorbidities, postoperative complications, poor social support, discharge to facilities other than home, among a variety of factors that impact continuity of outpatient care such as transportation for postoperative visits. To further complicate matters, each patient population and operation likely confer variable significance to risk factors, undermining a standardized method of identifying high risk-patients," she said.
The range of readmission variables motivated Sanaiha's research group to evaluate one potentially modifiable aspect of the discharge process—day of discharge. Specifically, the researchers sought to determine whether the "weekend effect" of worse outcomes after admissions for heart attack, stroke, sepsis, and other serious conditions over weekends and holidays also applied to discharges.
"This effect has been attributed to decreased staffing and increased transitions of care. The aim of the current study was to evaluate whether this 'weekend effect' also applied to the discharge process, which is an equally resource intensive phase of hospitalization that requires medical providers to be familiar with a patient and family's needs," Sanaiha said.
"Our study demonstrated that patients with active smoking and depressed ejection fraction (preoperative heart failure) were at higher odds of readmission. Further, we found that weekend or holiday discharge—after controlling for patient medical complexity, complications, and discharge disposition—did not impact odds of readmission."
Preventing readmission
While Sanaiha's team did not identify individual components of post-acute care that reduce readmissions for cardiac surgery patients, the researchers did glean insights.
"Bundled discharge interventions may diminish the impact of limited weekend staff and restricted outpatient resources on risk of rehospitalization after cardiac surgery," Sanaiha said.
Several elements of the UCLA Health bundle of discharge interventions for cardiac surgery patients likely help reduce readmissions, she said.
"Our discharge protocol includes early postoperative planning of clinic visits, and a thorough educational resource named our 'Healing Heart Handbook' tailored to institutional practices with approachable information about the numerous modifications to patient routine after cardiac surgery. Arguably the most important component of the discharge protocol is accessibility at any time of day to the cardiac surgery team who are familiar with discharged patients," Sanaiha said.
When integrated into the continuum of care, home health helps ensure that patients discharged from acute care settings and skilled nursing facilities do not suffer relapses that require rehospitalization.
Stakes are high with hospitals and health systems facing financial penalties under Medicare's Hospital Readmission Reduction Program for a half-dozen conditions including heart attack, pneumonia, and coronary artery bypass graft. Beyond the HRRP penalties, readmissions increase total cost of care.
As a way to address the readmissions challenge, savvy healthcare clinical leaders at health systems can use home health divisions to reduce hospital readmissions. When properly integrated into the continuum of care at health systems and hospitals, home health becomes a pivotal component of ensuring that patients discharged from acute care settings and skilled nursing facilities do not suffer relapses that require rehospitalization.
Data shows home health services can reduce readmissions:
Recent data from Paramount—a health insurance company affiliated with Toledo, Ohio–based ProMedica—shows that patients who utilize home health services within 14 days of discharge from an acute care facility are about 25% more likely to avoid a readmission within 30 days of discharge.
In a systematic review of heart failure patients published in the Annals of Internal Medicine, home nursing visits reduced readmissions and mortality for as long as six months.
In an observational study published in the journal Health Services Research, a combination of home health services and clinician visits decreased probability of readmission by 8%.
In a study published in the Journal of Post-Acute and Long-Term Care Medicine, patients discharged from skilled nursing facilities to home care with a home health visit within a week of SNF discharge had a reduced hazard of hospital readmission (adjusted hazard ratio of 0.61).
In coordination with a health system's hospitalists and primary care physicians, home health divisions can help avoid patient readmissions by deploying nurses, physical therapists, and personal care attendants into patients' homes after discharge. In addition to skilled nursing and physical therapy, some home health divisions perform infusions, which offers a relatively high-cost service in a low-cost setting.
Home health provides services that can keep patients from having to return to a hospital, says Bob Pritts, MHA, president of SSM Health at Home and Post-Acute Services, a division of St. Louis, Missouri–based SSM Health. "Most patients want to go home, they recuperate better at home, and home health gives them the opportunity to have the option to go home while still getting the care that they need."
SSM Health at Home offers a robust set of services that helps prevent readmissions, he says. "We do wound care, infusion, [and] a number of procedures in the home that have become regular practice. It's all designed to avoid the patient having to go back to the hospital."
Teamwork helps
To avoid readmissions, a team-based multi-disciplinary approach is important, Pritts says.
"If I have a personal care attendant who goes into the home to help with a shower, if she sees something with the patient, she calls the nurse. If I have a physical therapist in the home and they see an issue, they can call the nurse; or the nurse can call physical therapy if the patient is having trouble with balance or with gait. Everybody who is involved with patient care needs to assess that patient every time they come into the home," he says.
Multi-disciplinary teamwork is indispensable to avoid readmissions because no single team member is in the home every day.
"Nursing comes in once a week, and it's hard to identify a problem in visits once per week. Home health aides can be in the home twice per week, and physical therapy is in the home one-to-three times per week. So, you have multiple people in the house and they are all taking care of the patient," Pritts says.
SSM Health at Home care teams also coordinate care with the patient's primary care physician and specialists based on patient needs.
Within a year, the care coordination process will become more technologically advanced, he says. "We are in the process of doing a conversion from our postacute EMR to Epic, which is what the rest of the health system has. Once that is completed, physicians will be able to follow their patients no matter what level of care they are in, as long as there is a medical record and it is documented."
Cost and quality
Home health is a crucial element of limiting readmissions at ProMedica, says Steve Cavanaugh, MBA, president of the HCR ManorCare division of the health system.
"Home care is a critical link. When folks go home, often they are not fully ready to care for themselves, or they have rehab needs and nursing needs to fully complete their recovery. Home health plays an important role because if needs are not met, the patient is likely to suffer a setback and go back to the hospital or another care setting," he says.
ProMedica views home health as an opportunity to lower costs and improve clinical outcomes in the post-acute realm, says President and CEO Randy Oostra, DM, FACHE.
Home health is a way for health systems to help bend the cost curve on the local, regional, and national levels, Oostra says. "When you start thinking about general trends in healthcare—affordability and costs of healthcare in America—there is a cost differential between treating patients in a hospital and treating patients in a home setting."
ProMedica acquired HCR ManorCare this year. The division features 110 hospice locations across the country, about 30 home health locations primarily in the Midwest and Mid-Atlantic states, and dozens of SNFs.
Cavanaugh says a primary goal at HCR ManorCare is to become an integral component of ProMedica's continuum of care. "We see ourselves as being part of an integrated care delivery model—using home health and hospice as one of the ways to manage costs and improve outcomes."
"One of the things that has been really eye-opening for us in home health and hospice is that ProMedica has done a lot of good work on being a leader in social determinants of health. They do screenings and put active interventions in place," he says.
"We need to implement both a clinical plan of care and address social issues that get in the way of people getting healthy and staying healthy. We have to find ways to make that work—it can't always be us alone because we have to partner with others in the community and find the right resources," Cavanaugh says.
For health systems that are considering establishing a home health division, Pritts says regulatory considerations related to the Centers for Medicare & Medicaid Services are prominent.
"Medicare is looking at new ways to stratify which patients we see and how often we see them. You need to have a clinical person in place to keep you compliant with all of the changes CMS is making for home health," he says.
As health systems continue to expand into retail clinics, telehealth and other nontraditional offerings, gauging patient expectations and engagement are primary goals.
Navigating, measuring, and marketing are crucial to successfully establishing healthcare services beyond the hospital walls, according to a pair of patient access executives at this week's ATLAS conference in Boston.
"The entry points into the system are complex—there are a lot of different entry points into your health system. Hard wiring all of those so you can create some sort of seamless experience is a challenge," said Julie O'Toole-Black, vice president of access and operations at Indianapolis-based Community Health Network.
Along with measuring performance and marketing new service offerings, helping patients to navigate increasingly complex and sprawling integrated health networks is essential.
Providence St. Joseph Health has pursued a two-pronged navigation strategy for patients, said Karen Appelbaum, MHA, director of patient engagement and operations at the Renton, Washington-based health system.
"We thought of it partly as a digital strategy—designing better digital tools so people could self-serve and navigate to their best options. But that does not happen overnight and we're not quite there," she said.
"The other part is our contact center strategy—we call it our patient engagement center. While we are building our digital tools, we want to have great human service to help people navigate care."
Providence St. Joseph has made the two approaches complementary, Appelbaum said. "We have been able to learn from our human service to inform the digital strategy. With the data we have been collecting from the contact center, we have been building a chat bot to help patients navigate to the right setting."
Measuring new offerings
Providence St. Joseph monitors several measures to gauge the performance of nontraditional services such as the health system's Express Care Clinic retail settings, Appelbaum says.
"We look at factors such as our new patient acquisitions—how many new patients are we bringing into our system. We also look at how well we are tethering them to our system—are they connected with us, do they establish primary care? At our contact center, we measure conversion rates—do we set appointments when people call us, do we refer them to Express clinics, do we get them into primary care?"
A key metric has prompted Community Health Network to scrutinize its telehealth partnership with MDLive, O'Toole-Black said.
"It has not met the volumes we set to measure. We've attempted to reach out to those patients to ask how it could be a better experience. What we are hearing time and time again is, 'If you could offer virtual connections with my doctor or with my physician office, that is what I am looking for.'"
Offering telehealth as a service is much more than establishing a technical capability, she said.
"You have to take a progressive approach to an alternative care delivery mechanism and recognize it is not just about the means by which patients access care but also who is being accessed. You can throw out a lot of different options, but if consumers don't feel truly connected with their primary care physician, it may not be a popular solution."
Marketing dimensions
Marketing nontraditional service offerings has internal and external facets, Appelbaum said.
"For internal marketing, one area that came up right away was our primary care providers. In some cases, their response was, 'Don't take my patients.' We had to engage and partner with them. Part of what we showed in those discussions was we were going to lose consumers anyways if we did not meet their needs," she said.
Appelbaum said the external marketing challenge was similarly pressing because many of the health system's PCP panels were full. "Patients could not get in for months. So, we needed help from our primary care offices. Rather than just turning someone away, we asked them to set up appointments months out but also to refer patients to one of our Express clinics."
Community Health Network has a multifaceted marketing strategy for its nontraditional services, O'Toole-Black said.
"We have a connected-care strategy that is both digital and voice. We engage patients through our website, through direct marketing, and through Facebook and various other social media to make sure we permeate the external environment with our service offerings," she said.
O'Toole Black said external communications about services such as Community Health Network's retail clinic partnership with Walgreens cannot be one-way.
"The typical metrics for success are market share, conversion rate, and patient volume, but mining the voice of the customer is key. As we stand up these alternative sites of care like Walgreens, we have to keep listening to our consumers."
Overlapping shifts for attending physicians in a busy pediatric emergency department have decreased patient handoffs and reduced opportunities for patient harm.
To boost patient safety and physician efficiency, Seattle Children's Hospital adopted overlapping emergency room shifts for physicians and achieved a dramatic reduction in patient handoffs, recent research shows.
"A total of 43,835 patient encounters were analyzed. Immediately after implementation of the new model, there was a 25% reduction in the proportion of encounters with patient handoffs, from 7.9% to 5.9%," the researchers wrote in the Annals of Emergency Medicine.
Patient handoffs bear high risk for compromised patient safety. An earlier study of ER shift-change handoffs showed that vital signs were not communicated for as many as 74% of patients, and another study showed errors or omissions occurred in 58% of handoffs.
At the Seattle Children's ER, the original physician shift model featured shifts ranging from 7 to 9 hours long. When there was a shift change, the outgoing and incoming physician would sign out the entire patient list.
The original model had several shortcomings:
Multiple patients were handed off to the incoming attending physician, creating multiple opportunities for communication errors and omissions.
As trainees and nurses waited to review patients with the incoming attending physician, patient care was delayed.
Attending physicians worked at full capacity through their shifts and often stayed late for charting.
Sign-out was stressful during peak arrival times, when patients would arrive during the handoff process.
The new "waterfall" ER physician shifts addressed pitfalls of the old model:
On arrival to the ER, an attending physician assumes a primary role. The next attending arrives 3-5 hours later, assumes the primary role, and immediately starts treating new patients.
The first attending transitions to a secondary role and completes work on existing patients while treating new, less complex patients with the intention of being able to treat and discharge them prior to the end of their shift.
"With overlapping shifts and change in patient care prioritization, the goal was to decrease the number of patients who require handoff at the end of the first attending physician’s shift, and if handoffs had to occur, they would be for patients with less complex disease," the researchers wrote.
Waterfall model implementation
Hiromi Yoshida, MD, MBA, the lead author of the research, told HealthLeaders that the waterfall shifts can be implemented at most ERs that have multiple attending physicians.
She said there are three primary implementation factors:
Getting buy-in from all parties involved in the change, including attending physicians and charge nurses. The waterfall schedule involves cultural changes such as the timing of shifts, so all attending physicians should review the new model individually and at ED division meetings.
Getting support from hospital leadership is crucial to help drive change. The leadership team can help encourage the implementation of the new model and provide support for staff as it is rolled out.
To maximize efficiency and enable patient evaluations, there must be enough patient care space to allow incoming physicians to see new patients.
Efficiency gains
Yoshida said the waterfall staffing model generates several efficiency gains:
Fewer handoffs ease the cognitive workload from interruptions and interactions in busy ERs. "It has been shown that excessive cognitive workload and increased stress negatively affect performance," she said.
With incoming physicians jumping into treating patients instead of spending time receiving handoffs, patient care is not delayed.
Decision-making is focused at the beginning of the shift, when physicians have better decision-making capacity. This also may lead to less decision-making fatigue throughout the shift.
The waterfall model ensures that a rested and refreshed physician is coming in at staggered times, which provides relief for the staff that has already been in the ED for several hours.
In the research, physicians reported an increased ability to leave on time and to complete charts prior to the end of their shift.
There are more opportunities to collaborate and interact with other physicians throughout the shifts instead of just the short period of time during end-of-shift handoffs.
Seattle Children's implemented waterfall shifts in the ER five years ago and the hospital is continuing to fine-tune the model, Yoshida said.
"We are continuing to monitor feedback from the division and improvements are made to the model as the environment changes. This is a QI project and we aim to continuously improve."
Emergency medicine pharmacists can do a lot more than just dispense medications.
Deploying clinical pharmacists in emergency departments can ease staffing shortages, improve patient safety, increase efficiency, and operate cost effectively, recent research shows.
A new generation of emergency medicine (EM) clinical pharmacists can do far more than the medication distribution role that hospital pharmacists have played historically, according to the authors of a research article published in the American Journal of Emergency Medicine.
"EM clinical pharmacists aid in medication selection, optimal dosing and delivery, provision of drug information to patients and the interprofessional medical team, research and scholarly activities, and administrative and operational responsibilities to optimize the efficiency of care delivered to ED patients," the researchers wrote.
1. Staffing shortages: The corresponding author for the research article told HealthLeaders this week that EM clinical pharmacists help ease ER staffing shortages in several ways.
"In an already busy emergency department, emergency medicine pharmacists can help streamline overall pharmacotherapy-related care. Instead of physicians or nurses having to call the central pharmacy with questions, the pharmacist is right in the department and can provide consultation at the bedside. This minimizes phone calls and interruptions," said Nicole Acquisto, PharmD, an associate professor in the Department of Emergency Medicine at University of Rochester Medical Center in Rochester, New York.
EM clinical pharmacist also can take medication burdens off other ER staff members, she said.
"The EM pharmacist also understands the needs of the ED regarding medication availability and order entry in the electronic medical record and can optimize these functions to make overall drug selection, distribution, and administration easier."
2. Patient safety: Acquisto and her coauthors say medication errors are common in the ER setting in processes including prescribing, dispensing, and administration. EM clinical pharmacists can limit many of these errors, they wrote.
"Including clinical pharmacists on the ED team leads to increased error interception and fewer medication errors. ED pharmacists are well equipped to correct the majority of prescription-related errors, especially those containing multiple medication orders and those prescribed by EM residents. A prospective multicenter study of four geographically diverse academic and community EDs found EM pharmacists caught 364 medication errors during a 1000-hour study period."
3. Increased efficiency: There are multiple opportunities to insert EM clinical pharmacists into an ER workflow and realize efficiency gains, the researchers wrote.
These workflow opportunities include: drug therapy consultation after the ER physician has evaluated a patient, medication procurement and preparation for critically ill patients, drug therapy monitoring after the administration of medication, recommendations for discharge prescriptions, and patient education and counseling at time of discharge.
4. Cost-effectiveness: A study cited in the American Journal of Emergency Medicine research indicates that interventions by EM clinical pharmacists such as avoided medication errors significantly reduce ER costs. The study over a six-month period found 9,568 interventions by EM clinical pharmacists generated cost savings of $845,592.
Acquisto told HealthLeaders that EM clinical pharmacists cut costs on several fronts: cost avoidance from optimizing pharmacotherapy and preventing medication errors and adverse effects, preventing readmissions through antimicrobial stewardship and culture follow-up, and streamlining care to improve physician and nurse productivity.
Acquisto said EM clinical pharmacists also improve hospitals organizationally.
"Since the ED collaborates with several consult services throughout the hospital in addition to emergency medicine—trauma, critical care, infectious disease, neurology, toxicology, and cardiology—the EM pharmacist can act as the pharmacy liaison. As the expert on the medication use system and related workflow in the ED, the EM pharmacist can contribute to organizational initiatives," she said.
Survey finds overemphasis on physical health and treatment compared to underlying components of health such as diet and environmental factors.
There is a gap between what primary care physicians (PCPs) discuss with their patients and several core elements of health, a recent survey found.
The survey, which was conducted by The Harris Poll on behalf of Samueli Integrative Health Programs, features responses from more than 2,000 adults. The data shows a disconnect between what PCPs are discussing with their patients and many underlying determinants of health.
The survey found 74% of conversations between PCPs and their patients were focused on physical health, but discussions of other key health factors were far less frequent:
Non-medication approaches to health such as massage: 10%
Wayne Jonas, MD, executive director of Samueli Integrative Health Programs at H&S Ventures in Alexandria, Virginia, and a practicing family physician, presented the survey data during an online press conference this week. He said PCPs are not discussing enough of the underlying factors and social determinants that account for about 80% of health, including education, employment, income, family and social support, and community safety.
"Unfortunately, fewer than half were discussing core determinants of health that we know are in the 80% of what produces good health. For example, diet and sleep habits were discussed by only 44% and 40%, respectively, during office visits. Even fewer—only 20%—talked about why it was important to be healthy; in other words, what aligns in your life goals and your health goals," he said.
The survey's finding on PCP discussions with patients about behavioral health were striking, said Jonas, former director at the Office of Alternative Medicine for the National Institutes of Health.
"Mostly alarmingly, even though a large portion of the population suffers from mental health conditions such as depression and anxiety, only about a third of the conversations with doctors engaged in these psychological conditions."
The survey also showed PCPs were out of sync with the topics that many patients want to discuss, Jonas said.
"We found that for many of these areas, people did want to have these conversations with their doctor. About 45% said they wished they talked about their life goals—what matters to them and how it aligns with their health goals. Surprisingly, even more younger adults—those 18 to 24—indicated they wanted to talk about the behavioral determinants of health with their doctors more than they did."
Promoting broader discussions
Jonas acknowledged that the volume-driven, fee-for-service payment model prevalent in PCP offices is ill-suited for broader discussions about health with patients.
"This is a major problem and one that I hear all the time. I struggle with it myself in my own practice—finding enough time to address what matters to the patient about chronic conditions and management of chronic conditions. … What we really need to do is restructure how we do primary care—especially for chronic diseases—to allow more time for conversations."
Jonas said he has found ways to spend more time with his patients, with transformative impact.
"A lot of chronic pain patients are referred to me. They have had many visits and they have spent 20 minutes getting pills and procedures several times. No one has sat down with them and asked how they can be empowered to improve their own pain and lives, and how they can set up a team to manage their care themselves. If we do that, oftentimes we can break the cycle of dependency on continued medical care that occurs in the 20-minute visit."
Broadening discussions about health with patients is a crucial part of shifting to value-based care, Jonas told HealthLeaders before the press conference.
"Physicians need to make time to address what is of value to patients. It's a shift in our thinking. This could be as simple as integrating a few questions into a routine office visit to evaluate those aspects of a patient's life that facilitate or detract from healing. Doing this can help our healthcare system transition to a value-based care model and directly impact goals like the Triple Aim."
Medical education
Jonas also told HealthLeaders that changes are required in medical education to improve the quality of primary care.
"Medical education is lacking in key areas that are fundamental to a patient's health. … The key areas that need to be added to most office visits are behavioral and lifestyle, social and emotional, and mental and spiritual. Medical training sharply limits the ability of physicians to make healing their primary mission, and the current model of care does not allow for much time to capture the personal, social, behavioral, and environmental factors that contribute to most chronic diseases."
Nutrition and prevention should be enhanced in medical education curriculums across the country, he said.
"Medical students receive minimal education on nutrition, yet we know that diet influences a great deal of a person's health and risk for developing disease. Our medical training needs to expand outside of the realm of diagnosis and treatment and focus on prevention as well."
Bellin Health shares how the health system achieved the top composite quality score in the first performance year of Next Generation ACO.
While the Next Generation ACO program has generated modest financial gains, top-performing participants are posting strong quality metric scores.
Next Generation ACO has more than 30 quality measures, including access to specialists, medication reconciliation, and depression screening.
In quality performance, Bellin Health was the top quality metrics performer in the first year of Next Generation ACO. In 2016, the Green Bay, Wisconsin–based health system posted the highest composite score (64.54% out of a potential 100%) for the ACO's quality measures and registered shared savings totaling $1,400,148.
Chris Elfner, director of accountable care strategies at Bellin Health, says quality and shared savings should not be competing goals.
"High-quality care attains shared savings. A lot of providers start with their high-cost, high-risk patients and try to put all kinds of extra resources on them, but if you take a full-population view, you get paid on the low-cost, low-risk patients," he says.
He continues, "You benefit from keeping patients low cost and low risk. The way you do that is by achieving quality—by closing care gaps, by managing chronic conditions, and by making sure people are taking care of their health. Although that approach raises the cost of care in some areas for low-cost, low-risk patients, it lowers the total cost of care, which generates shared savings."
Bellin Health shares its strategies to scoring well in the quality measures for Medicare's newest accountable care model.
1. Internal tracking of quality performance
Bellin Health participates in several ACO contracts. To avoid an overwhelming administrative burden, the health system tracks quality metric performance according to internal standards, which capture most of the Next Generation measures, Elfner says. "We are tracking in real time. We have dashboards built into our Epic system that are tracking the Next Gen ACO metrics—not exactly, but we track the critical metrics in a way we feel they should be calculated."
Tracking the ACO quality metrics at the patient level is essential to encourage providers to achieve quality metrics, he says.
"It's tracked at the point of care—at the patient level. When a provider or clinician brings up a patient chart, there is a sidebar report that has all of the quality measures [symbolized] as red, green, or not applicable. They can see that information, and we have other information in that sidebar such as whether the provider is in the Next Gen ACO. For us, that means [the providers] are eligible for waivers and the $25 wellness visit payment," Elfner says.
Physicians can view the quality metrics from a pair of perspectives, he says. "When they log in, providers see those metrics for their panel of patients, or the population for their specialty."
Tracking quality data in real time also gives Bellin Health the ability to identify and influence low-performing clinicians in a timely manner, says Naomi Wedin, executive director of Bellin Health Partners.
"We rely heavily on the physicians and the physician leaders that we have in the organization. They talk with their peers and get their peers to understand the importance of why things need to be done—not just from a reporting standpoint but also from the standpoint of the overall care of the patient," she says.
Metrics data helps drive those conversations.
"We provide information that helps support the need to have various quality measures achieved. For example, there are annual wellness visits for the Next Gen population, and this is one of the ways we close care gaps and meet quality measures," Wedin says.
2. Solitary measurement
At Bellin Health, a simplified approach to quality measurement is an important element of success in the Next Generation ACO quality scores.
"Our approach to quality measures has always been that we needed to define quality for our care in a single and solitary way; so, rather than looking at HEDIS metrics and Next Gen metrics, we have a collaborative here in Wisconsin called the Wisconsin Collaborative for Healthcare Quality that has slightly different versions of the same metrics," Elfner says.
The solitary approach is better for physicians and the health system, he says.
For example, he says Bellin wants to avoid having providers working with multiple quality metrics for a single clinical measure such as A1C control. "We have always defined quality internally and tried to achieve whatever that quality is, then match those metrics to the payer-contracted metrics. To me, that's the biggest best practice," Elfner says.
3. Understanding the data
Comprehension and capabilities are crucial to success in Next Generation ACO quality measures, he says.
"As a contract starts, you need to understand what the quality metrics are and what needs to be captured to meet those quality metrics. Then, you need to make sure the system and the EMR can capture those metrics. The next question is whether we have an [administrative] process in place to capture those metrics. The last question is whether we have an automated way of calculating," Elfner says.
The Next Generation ACO program is geared to generate accurate information, and Bellin Health has seized on the opportunity that the high-quality data presents, Elfner says.
"[Next Gen's ACO] quality metrics do not vary drastically from any other quality metrics we look at. What the Next Gen ACO gives us, such as claims files, is by far the best information we get from any ACO. It is the cleanest, it's the most consistent, and it's the most useful. We would encourage all private and commercial payer organizations to mimic Next Gen ACO."
A new set of guidelines features recommendations for nearly a dozen focal points where medication errors can be avoided in the hospital setting, including admission, monitoring, and discharge.
The American Society of Health-System Pharmacists has released guidelines on preventing medication errors in hospitals.
The guidelines, which are targeted at health system and hospital settings, are designed to give pharmacists ground rules and best practices to improve patient safety and avoid medication errors.
"Some medication errors result in serious patient morbidity or mortality. Thus, medication errors—including close calls—must not be taken lightly, and risk-reduction strategies and systems should be established to prevent or mitigate patient harm from medication errors," the guidelines say.
The guidelines feature best-practice recommendations in 11 areas and processes where medication errors can occur:
Planning such as an event-reporting system
Selection and procurement
Safe storage
Patient admission
Ordering, transcribing, and reviewing
Preparing
Dispensing
Administration errors such as wrong patient or wrong drug
Monitoring medication effects
Patient discharge
Evaluation of systems and processes to avoid medication errors
Errors or failings can arise at any one of these points and pharmacists are best equipped to address problems, the guidelines say. "Health-system pharmacists have the responsibility and expertise to lead and participate in multidisciplinary committees to examine and improve systems currently in place."
Patient-centered recommendations
At least four of the guideline focal points involve direct interaction with patients or their clinical care teams: patient admission, administration, monitoring, and patient discharge
1. Patient admission: "Prescribing errors commonly occur during hospital admission for many reasons, and patients taking numerous medications are at a higher risk for adverse drug events (ADEs), which can include medication errors," the guidelines say.
Recommendations to avoid ADEs at the time of a patient admission include obtaining a medication history with pharmacy participation and conducting medication reconciliation.
2. Administration: "Common administration errors include wrong patient, wrong route, wrong dosage form, wrong time, wrong dose or rate, and wrong drug. Additional errors in this category may include errors of omission or missed doses," the guidelines say.
Recommendations to avoid administration errors at the bedside include checking patient allergies, obtaining two patient identifiers, and communicating with the patient about medication indications and side effects.
3. Monitoring: "Examples of failing to monitor medication effects include not checking a scheduled blood glucose level and checking the level but not reacting to the level. Incorrect interpretation errors might include checking the blood glucose level but giving the wrong amount of corrective or sliding-scale insulin for the value," the guidelines say.
Recommendations to avoid monitoring errors include training staff to identify common negative effects in patients and establishing protocols to respond to adverse reactions. In addition, clinicians should be trained to monitor medication efficacy through methods such as checking vital signs, performing electrocardiograms, and evaluating laboratory results. Inadequate response to medications should prompt changes in therapy under established protocols.
4. Patient discharge: "Pharmacists' involvement in activities before patient discharge provides a valuable opportunity to prevent potential medication errors. Data show that adverse events are a major cause of avoidable hospital readmissions; more post-discharge adverse events are related to medications than other causes," the guideline say.
Recommendations to avoid medication errors during and after patient discharge include a medication discussion with the patient featuring open-ended questioning and active listening to effectively share information, patient education focused on medications such as insulin administration, and providing the patient with an accurate list of medications to be taken after discharge.
Health systems and hospitals can effectively reduce medication errors, the guidelines say.
"While medication errors cannot always be prevented, organizations can mitigate and reduce harm through robust system redesign, help employees make safe behavioral choices, and understand why people make the choices they make. If system faults and behavioral choices are understood, risk-reduction strategies can be created."
Limiting waste of perishable supplies and other products reduces costs in a way that goes straight to the bottom line.
Editor's note: This article is based on a roundtable discussion report sponsored by Vizient. The full report, Supply Chain Success: Achieving Efficiency Gains, is available as a free download.
Hospitals and health systems can drive supply chain efficiency with waste management efforts such as limiting the waste of perishable products.
To limit waste of products, the onus is on supply chain teams to make sure inventory strategies match how products are used, says Ryan Martter, strategic sourcing manager at Rush University Medical Center in Chicago.
"If we only stock sutures by a box of 12, but clinicians are consuming sutures one at a time and it's a specialty item that they use four or five times a year, the balance in that box is just going back to sit on a shelf. If the box expires and you place a new order, you're buying another full box to use a handful of sutures."
Physician culture is also a key factor in waste management, Martter says.
"Do you have a culture where everything is immediately opened and ready to go before the case even begins? If so, a supply might be on a preference card just in case it is needed, but if it is always being opened and never runs into the scenario where it's needed, it always becomes a wasted item."
The preference card process should be dynamic, says Stephen Downey, Group SVP of supply chain operations at Vizient Inc. in Irving, Texas.
"If you look at other industries, you don't take a bill of materials and say this is it, then only use half those bills every time. That would just not survive in a manufacturing industry. You would adjust your bill," he says.
Preference cards should be adjusted for what gets consumed, Downey says. "Everybody feels a sense of success when you realize what you saved through that process, but it's a continuous improvement."
Surgical technicians and physicians should document the supplies and implants that are used during a procedure, says Theodore Pappas, who works in supply chain management at Mayo Clinic in Jacksonville, Florida.
"They have to tell us what they're using—if they are opening and not using items and wasting product. We need to be able to identify that. We have to be able to collect that information and share it with the stakeholders. … That kind of cost goes right to the bottom line. If you can eliminate waste, that reduces your cost significantly," he says.
Hoarding prevention
In addition to cutting costs, efficient product management also limits hoarding of supplies, Pappas says.
"When it comes to waste and product on the shelf, you talk about hoarding and hiding things in drawers and other types of activities that caregivers are accustomed to in certain circumstances. In many cases, we are failing as a supply chain if we allow that to happen—we are not putting the right things in the right place at the right time so it's easily attainable for caregivers," he says.
Clinician hoarding often leads to waste of perishable products, Pappas says.
"If a supply is readily available for them, they are not going to have to hoard it the next time. We also need to teach them why that's important and the implications of hoarding. You need to share the cost of expired product expense," he says.
Changing behaviors
Waste management often requires changing behaviors among clinical care teams.
Altering the behavior of staff members should be a collaborative process, Downey says.
"You help everybody understand what the organization is up against and why you're working on change. You're trying to help care teams do their job better. Together, you look at waste and the information that has been gathered. You also have to accept that changing habits and behavior is not going to happen quickly. You can't expect that everybody leaves on Friday and on Monday there's an entirely new process," he says.
Pappas says sharing waste information data with staff is critical to achieve changed behaviors such as sharing the overall expired product that's being wasted. "You need to share information in various formats. It's not just an email. It's not just a conversation. It's both, and it's also presenting the information to the teams involved."
View the complete HealthLeaders Media Roundtable report: Supply Chain Success: Achieving Efficiency Gains.
Nearly 12% of Takotsubo Syndrome patients are readmitted to a hospital within 30 days of an inpatient stay, recent research shows.
Patients are far less likely to die from broken heart syndrome than they are to die from a heart attack, but that doesn't mean providers can safely ignore the risks associated with the less-severe condition.
Patients diagnosed with broken heart syndrome, or Takotsubo Syndrome (TTS), still face a significant risk of hospital readmission, recent research shows.
"Two thirds of the hospital readmissions within 30-days of TTS occurred in the first two weeks post-discharge, highlighting the need for careful follow-up in these vulnerable patients," researchers wrote this month in an article published in the European Heart Journal—Quality of Care and Clinical Outcomes.
The research compares TTS to acute myocardial infarction (AMI) for measures including predictors, readmissions, mortality, and cardiovascular risk factors.
Broken heart syndrome features transient left ventricular dysfunction with symptoms and electrocardiography results that mimic heart attack, the researchers wrote.
There are about 12,000 cases of TTS each year, accounting for 1-2% of all acute coronary syndromes, according to lead author Nathaniel Smilowitz, MD, an assistant professor at the New York University School of Medicine.
Mortality for broken heart syndrome is much lower than that for a heart attack. During a first admission for TTS, mortality was 2.3%, while the mortality rate for acute myocardial infarction admissions was 10.2%, according to the research.
Despite the lower mortality rate, broken heart syndrome poses a significant risk for readmission—which carries potential health risks for patients and possible financial penalties for providers.
Health and financial risks
Among TTS survivors, 11.9% were readmitted within 30 days, and mortality associated with readmission was 3.5%, the researchers found. The most common readmission cause was heart failure at 10.6% of readmissions.
Among the heart attack survivors in the study, 16.7% were readmitted within 30 days.
For TTS survivors, the researchers found age, malignancy, peripheral vascular disorders, chronic lung disease, heart failure, drug abuse, and anemia were predictors of 30-day hospital readmissions.
Although broken heart syndrome is not one of the conditions listed under Medicare's Hospital Readmissions Reduction Program, some broken heart syndrome cases are likely drawing HRRP penalties, Smilowitz told HealthLeaders.
"These patients may be improperly diagnosed with myocardial infarction, and myocardial infarction readmissions are subject to penalties in HRRP. Therefore, hospital readmissions for the proportion of TTS patients who are assigned AMI diagnosis codes may contribute to penalties under HRRP," he said.
More research is needed to optimize treatment of TTS in the inpatient setting and post-discharge, but there are indicated treatments and guidance for follow-up care, Smilowitz said.
"The care of Takotsubo Syndrome in the acute setting depends on the clinical presentation, the severity of left ventricular dysfunction, and the presence of left ventricular outflow tract obstruction or shock. There are unfortunately no randomized clinical trials guiding the treatment of Takotsubo patients, but large observational studies have indicated better long-term outcomes among Takotsubo patients treated with ACE inhibitors," he said.
Monitoring TTS patients after discharge is essential to avoid readmissions, Smilowitz said.
"Our study shows that heart failure may complicate Takotsubo Syndrome in the near term, so we now recommend close follow up after discharge to evaluate for signs and symptoms of heart failure, which can be treated appropriately with medical therapy such as diuretics."
Characteristics and predictors
The researchers found several distinguishing characteristics and predictors for broken heart syndrome compared to heart attack:
TTS patients were more often to be women (89%) compared to female heart attack patients (41%)
Cardiovascular complications were less common during a first admission for TTS patients compared to AMI patients. For example, 2.7% of TTS patients experienced cardiac arrest compared to 4.4% of AMI patients.
TTS patients were younger and more likely to have a history of depression, psychosis, alcohol or drug abuse, hypothyroidism, rheumatoid arthritis, collagen vascular disease, and chronic pulmonary disease than AMI patients.
There are important distinctions between patients with broken heart syndrome and heart attack patients, the researchers wrote.
"Patients with TTS had a lower incidence of underlying cardiovascular risk factors and established cardiovascular disease than patients with AMI. In contrast, TTS patients were more likely to have psychiatric disease diagnoses in comparison to patients with AMI," they wrote.
Mortality rates are lower for broken heart syndrome compared to heart attack, but TTS is a deadly condition, the researchers wrote.
"Although outcomes of TTS appear favorable when compared to acute MI, patients with TTS have a substantial risk of in-hospital death and 30-day readmission among survivors. Thus, TTS is associated with morbidity and mortality in thousands of patients in the U.S. each year."
