A robust command center has helped Carilion Clinic manage its stretched hospital bed capacity.

Carilion Clinic has mastered the intricacies of operating a command center that manages patient transfers into and out of the health system.

Like many health systems across the country, Carilion Clinic is grappling with patient volumes that stretch bed capacity. Under these circumstances, managing patient flow and patient transfers into and out of the health system are crucial.

"We have real-time assessment of every hospital bed in the health system, including emergency departments," says Paul Haskins, MD, SVP medical director of the Carilion Transfer and Operations Center. "So when you have an enterprise command center, it has all aspects of patient flow, including a real-time situational awareness of the primary drivers of hospital systems, which include the transfer process into the system, the operating rooms, and the emergency departments."

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A month-long rotation program gives residents experience in what it is like to live and work in a rural community.

Sanford Health and Hennepin Healthcare have established a rural rotation program to encourage medical residents to practice in rural communities.

About 20% of the U.S. population lives in rural areas but only 9% of the country's physicians practice in rural communities, according to the Bureau of Health Professions. A study published in Annals of Emergency Medicine found that 92% of emergency physicians practice in urban areas.

Minneapolis-based Hennepin Healthcare, which includes a 484-bed academic medical center, is sending emergency medicine and psychiatry residents on a month-long rotation to Sanford Health Bemidji in northern Minnesota. Sanford Health Bemidji includes Sanford Bemidji Medical Center.

Bemidji, Minnesota, has a population of nearly 16,000 and is surrounded by rural communities.

The rural rotation is designed to give residents experience in living and working in a rural setting.

"Most residents do not know what it is like to practice medicine in a rural hospital," says Daniel Hoody, MD, CMO of Sanford Health Bemidji. "In addition, if residents practice in an urban area, they are not well-equipped to understand what it is like to send a patient from a rural area into an urban center."

Unlike other rural residency programs across the county, where residents drive from an urban center to a rural hospital then drive home at night, the Bemidji program provides residents with an immersive experience. The program provides housing for residents in a welcoming environment, according to Meghan Walsh, MD, MPH, chief academic officer at Hennepin Healthcare.

"Residents go to and from the hospital every day, then at the end of the month, the residents return to their regular programming in Minneapolis," Walsh says. "We are already seeing that one month of a lived-in experience is leading to an interest in practicing in Bemidji and other rural communities."

The program separates the myths and truths about physicians living and working in a rural community.

"It is more exciting for the residents than they might have anticipated," Hoody says. "There are things going on in town, and we try to get the residents engaged in some of the things people experience if they live in town their whole lives."

The program shows residents that there is a good quality of life in a rural community. Hoody believes that it's easy to achieve work-life balance when you are not tethered to traffic or other discomforts of a big city.

"I like to tell recruits that you can do two things after work rather than one in Bemidji," Hoody says. "You can ski for an hour or two, go home and shower, then still have time to go out for dinner with friends. That is often not tenable in a major metropolitan area."

Daniel Hoody, MD, is CMO of Sanford Health Bemidji. Photo courtesy of Sanford Health.

Exposure to rural medicine

The Bemidji program gives residents exposure to the practice of medicine in rural areas and dispels misconceptions about what it is like to practice in a rural community.

In Bemidji, residents learn how to practice medicine with limited resources compared to practicing in an urban center, according to Walsh.

"If a patient falls and hits their head, they can have a brain bleed. In our Level 1 trauma center, literally within 10 minutes at the bedside, you can have a neurologist, a neurosurgeon, a trauma surgeon, an internist, and a critical care team for the patient," Walsh says. "At Bemidji, it is different. You do not have every single Level 1 trauma center resource at your fingertips within 10 minutes."

Many residents assume that they will be treating low acuity patients in a rural setting, but the Bemidji program shows them that rural medicine can be a challenging experience, Walsh explains.

"Residents have been ending their month-long rotation with an appreciation for the complexity, acuity, and challenge of treating patients at Sanford," Walsh says. "They feel their Level 1 trauma center skills were taken to the edge of their comfort zone, with supervision and appropriate support."

The Bemidji program residents learn how to treat patients safely in a rural setting as well as the value of treating patients close to home rather than transferring them to larger medical facilities, according to Hoody.

"The residents bring the latest and greatest care from an academic medical center to Bemidji, and they learn from the decades of experience on the ground at Bemidji to take care of patients when you have limited resources," Hoody says.

When it comes to acute care, the decision to transfer patients from Bemidji to a larger medical facility is not taken lightly, Hoody explains.

"It's a huge deal if we have to transfer a patient to Fargo," Hoody says. "The whole family must go over and stay at a hotel. They must take days off from work. It's better if we can keep patients here in Bemidji."

Bolstering Sanford Health Bemidji's staff

Hoody hopes the rotation program will help fill a need at Sanford Health Bemidji.

"Emergency medicine and psychiatry are areas of recruiting need," Hoody says. "For both emergency medicine and psychiatry, we are not fully staffed with employed clinicians, so this program is a nice adjunct to other recruiting efforts by exposing residents to rural medicine."

The partnership with Hennepin Healthcare gives Sanford Health Bemidji a capability that would be hard to achieve on its own. According to Walsh, the model is leveraging the strengths of an urban teaching hospital and a rural community that does not have the infrastructure, resources, and personnel to build their own teaching hospital.

"There is data to show that as few as one or two months of a rural experience for residents is enough to create interest in practicing in a rural setting," Walsh says. "We are testing this hypothesis."

The rural rotation program is giving Sanford Health Bemidji a chance to recruit more residents as employed physicians than they could do with their own residency programs, according to Walsh.

"If Sanford Health Bemidji had an emergency medicine residency, it would be a three-year program and probably have a couple of residents each year," Walsh says. "Every three years, there would be about six residents who came through Bemidji, and you may or may not be able to recruit all six of them to remain in Bemidji."

With the rural rotation program, Sanford Health Bemidji is working with 12 emergency medicine residents per year.

"In one year, there is the potential to recruit about six ER doctors at lower cost and lower investment than an in-house emergency residency program," Walsh says. "This allows Bemidji to put its energy into faculty recruitment and boost physician recruitment in general because physicians get to teach."

Carilion Clinic has managed its stretched hospital bed capacity with a command center and post-acute referral hub.

Carilion Clinic has mastered the intricacies of operating a command center and post-acute referral hub that manages patient transfers and efficiently transitions patients out of its hospitals for post-acute care.

Like many health systems across the country, Carilion Clinic is grappling with patient volumes that stretch bed capacity. Under these circumstances, managing patient flow and patient transfers into and out of the health system are crucial.

"We have real-time assessment of every hospital bed in the health system, including emergency departments," says Paul Haskins, MD, SVP medical director of the Carilion Transfer and Operations Center. "So when you have an enterprise command center, it has all aspects of patient flow, including a real-time situational awareness of the primary drivers of hospital systems, which include the transfer process into the system, the operating rooms, and the emergency departments."

Carilion Clinic's command center and post-acute referral hub are focused on streamlining.

"You have people and technologies, and you use them together to streamline the processes to affect patient care," Haskins says. "To have an efficient process for transfers, you must have physician-to-physician communication. In the beginning, you put the right physicians on the line, then you eliminate any sort of communication that is duplicate."

The command center manages patient transfers into and out of the health system.

"We receive transfers into our health system from several health systems," Haskins says. "We send out transfers for a few conditions such as burns, pediatric cardiology, and some transplants. It is about making the transfer process smoother—whether it is into or out of our health system."

The post-acute referral hub helps Carilion Clinic manage length of stay.

"When we look at length of stay, the patients who go to a long-term care facility or a rehab facility tend to have the longest length of stay, which makes sense based on patient needs," Haskins says.

By eliminating duplication of processes, the post-acute referral hub can streamline processes, according to Haskins.

"By having the paperwork in a repeatable and consistent environment and having relationships with different facilities, then you can streamline processes based on a mutual agreement that the facilities will take patients and trust builds up over time," he says.

Paul Haskins, MD, is SVP medical director of the Carilion Transfer and Operations Center at Carilion Clinic. Photo courtesy of Carilion Clinic.

Staffing models

To make its command center and post-acute referral hub cost effective, Carilion Clinic leadership focuses on the right mix of healthcare professionals. The post-acute referral hub poses an easier staffing challenge, with the assignment of case managers and social workers. The command center, meanwhile, has been more challenging because of the question about whether a physician needs to be on the staff.

"A big question is do you need a physician in the command center to review transfers and see whether patients can stay in their facility," Haskins says. "It is about a $1.5 million expense to have a physician in the command center at all times."

After considering the question, leadership decided to staff its command center with registered nurses who have either ICU or emergency medicine training.

"If you have a physician on the line, then that is a huge expense," Haskins says. "The nurses are experienced, so they know who needs to be on a phone call and how to streamline the process. So the right phone call goes to the right specialist or the emergency department 99% of the time."

"You can scale up and scale down [the number of nurses needed], depending on the size of your health system and how many facilities you are overseeing," Haskins adds. "We oversee seven of our own hospitals. So we have anywhere between six and seven RNs in the command center most of the time; in the middle of the night, we will go down to three."

Benefits of command centers and post-acute referral hubs

The command center concept offers health system leadership several benefits.

"We have improved transfers into our health system, [and] we have also streamlined the transfer process out of our health system when it is necessary," Haskins says. "We have also decreased length of stay compared to national benchmarks."

The post-acute referral hub has generated gains in patient satisfaction, but the biggest benefit is in improving patient flow.

"We have patients who come to our hospitals, but it is not the input that is the problem; it is the output," Haskins says. "You must do the best job that you can to streamline the discharges out of the hospital."

A pair of clinical leaders shares how their health systems have implemented embedding behavioral health professionals in primary care practices.

Embedding behavioral health professionals in primary care practices drives significant benefits for patients and health systems.

Providing patient access to behavioral health services is a challenge for health systems.  But Sentara Health and Virtua Health are taking on this challenge by integrating those services with primary care providers.

"For Sentara, it is about access to care," says Charles Dunham, MD, the health system's executive director of medical operations for behavioral health. "For us, the primary lesson learned is that we can get patients seen faster. Patients appreciate this care—they consider it as part of their normal routine of care."

For patients, embedding behavioral health professionals in primary care practices reduces the stigma of seeking behavioral healthcare, says Samuel Weiner, MD, vice president and CMO of Virtua Medical Group, which is part of Virtua Health.

"By embedding psychiatrists in our primary care practices, patients don't have to worry that they have been referred to a psychiatrist's office or a therapy office," he says. "They are just going to their primary care office."

Samuel Weiner, MD, is vice president and CMO of Virtua Medical Group, which is part of Virtua Health. Photo courtesy of Virtua Health.

Models of care

The embedded mental health therapist model at Sentara meets a need for primary care patients, according to Dunham.

"Primary care providers do an excellent job with most patients with behavioral health needs, but there are patients who we wanted to refer to mental health therapists or psychiatrists, and it took a little while," he says. "We came up with a couple of ways to deal with this situation, and one of them was the embedded therapist model."

These therapists provide care in a hybrid model, Dunham explains.

"Therapists spend some of their time in the clinic and some of the time providing services through telehealth," he says.

At Virtua, the model for embedding behavioral health professionals in primary care practices has evolved over time.

"We started with physically embedding a handful of licensed clinical social workers in our primary care practices to provide therapy for patients," Weiner says. "We also had a psychiatric nurse practitioner who was available to support the licensed clinical social workers. The psychiatric nurse practitioner was also able to consult with our primary care physicians regarding diagnoses and recommendations regarding therapy and medications."

The next step was bolstering the medical side of behavioral health services by adding three psychiatrists to primary care practices.

"The psychiatrists can offer what amounts to a consult service for our primary care patients," Weiner says. "So when our primary care physicians are faced with challenging cases in terms of behavioral health or mental health, they can refer patients to be seen by the psychiatrists or psychiatric nurse practitioner, who will then evaluate the patients and start them on medication."

Adding psychiatrists to primary care practices has allowed Virtua to maximize a scarce resource, according to Weiner.

"There is a practical issue that there are just not enough psychiatrists to go around," he says. "If these psychiatrists took patients on and continued to see them forever, they would quickly fill up their patient panels and would not be able to provide services for our primary care patients. They are available for short-term support, then get patients back to their primary care physicians."

Virtua is now offering comprehensive behavioral health services through their primary care practices.

"We have the medical piece with the psychiatrists and the psychiatric nurse practitioner, and we have the therapy piece with the licensed clinical social workers," Weiner says.

Charles Dunham, MD, is executive director of medical operations for behavioral health at Sentara Health. Photo courtesy of Sentara Health.

Advice for other health systems

For health systems that don't know where to start when it comes to embedding behavioral health professionals in primary care practices, Virtua's experience is instructive.

"We had to start somewhere, and we started by establishing our licensed clinical social worker team to come in and provide therapy," Weiner says. "From there, we were able to build the medical capabilities of psychiatrists. Now, we are building a non-clinical social work capability. You need to pick a starting point, then build from there. The needs of the patients are going to guide you."

Some health systems may be concerned about scarce resources and return on investment. According to Weiner, Virtua has seen a strong ROI.

"There is clearly a return on investment in terms of patient satisfaction—patients love these services being embedded in their primary care practices," he says. "It makes them feel like they are being cared for as a whole person."

The ROI also includes reductions in hospitalizations and emergency department visits, Weiner explains.

"There is a clear benefit when patients have easy access to behavioral health and mental healthcare—they just do better in leading healthy lives," he says.

The strategy also benefits health systems, according to Dunham.

"It is better for us financially," he says. "If we have a therapist who can work with a primary care physician either in the office, virtually, or both, then we do not have to pay for extra office space or pay for extra front-desk staff. From an administrative standpoint, this model helps us make sure that these services are sustainable. We have a good contribution margin from the therapists working in this model."

Implementing a model of care such as embedding mental health therapists in primary care practices is "very doable," Dunham explains.

"If you can find a physician champion in primary care who would like to have this kind of support, primary care practices would love to have the support of mental health therapists," he says.