Advocate Health is using volunteers to help improve the patient experience for inpatients.
Bradley Kruger, MA, MBA, vice president for patient experience at Advocate Health says the Charlotte, North Carolina-based health system is using volunteers to contact patients after they have been hospitalized to see whether they need help in the inpatient setting.
"At Advocate Health, we have more than 10,000 volunteers who contribute more than 500,000 hours of effort every year," Kruger says. "That time supports patients at the bedside—we are using the volunteers to improve patient experience, quality, and safety across the organization."
One volunteer initiative uses 100 virtual volunteers who are mainly pre-med students.
"They learn how to navigate Epic and how to talk with patients," Kruger says. "They call patients within 24 hours of them being admitted to a hospital, mostly patients over the age of 65 who have been admitted from the emergency room."
Click on the video below to see how the volunteer initiative works. Click here to read the accompanying HealthLeaders story.
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."
Wilmington Health has partnered with the AMGA to create the AMGA Value Care Network, a strategic initiative designed to help medical groups and health systems succeed in value-based care.
Medical groups and health systems have been implementing value-based care models such as accountable care organizations (ACOs) for more than a decade. But the fee-for-service model has remained stubbornly in place for many healthcare providers.
In 2013, Wilmington Health launched one of the first ACOs in North Carolina, adopting the Medicare Shared Savings Program ACO model. Currently, Wilmington Health is operating an ACO REACH accountable care organization—a Medicare ACO model that involves full risk.
"The AMGA Value Care Network gives us an opportunity to help other medical groups," says David Schultz, MD, CMO of Wilmington Health. "We have developed competencies with our accountable care organizations, and we think we can share these competencies with other medical groups."
View the infographic below to get four tips from Schultz on performing well in value-based care. Click on this link to see the accompanying HealthLeaders story.
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.
Instead of relying on doctor's office visits every few weeks, the health system's new program prompts virtual visits whenever blood pressure is uncontrolled.
AdventHealth is launching a remote patient monitoring (RPM) program to treat high blood pressure earlier and more consistently.
High blood pressure can lead to life-threatening medical conditions, including heart attack and stroke, according to the American Heart Association. Nearly half of U.S. adults have high blood pressure, the AHA says.
The standard of care for hypertension at most health systems, hospitals, and physician practices is for a patient to see their doctor in an office visit every few weeks, according to Jeffrey Kuhlman, MD, MPH, senior vice president as well as chief quality and safety officer at AdventHealth.
The health system's new hypertension program, which will launch this summer, is designed to make a leap forward in the standard of care for high blood pressure.
"Today, it is frustrating that people with high blood pressure only see their doctor every few weeks, when they get one office blood pressure reading," Kuhlman says. "What this new program helps us do is not only get the blood pressure readings at home as part of remote patient monitoring but also take that information and automatically upload it to the patient's electronic medical record."
Patients are trained to use the home-based blood pressure device, which sends remote patient monitoring data to AdventHealth's EMR via a Wi-Fi or cellular service connection.
"When patients get the blood pressure monitor, there is a QR code on the device that they can scan with a smartphone and access YouTube videos that are designed for adults with no medical training," Kuhlman says. "Patients can learn how to use the blood pressure monitor in a minute or two."
Patients also receive written instructions, which are crafted at a third grade reading level and available in several languages other than English.
Jeffrey Kuhlman, MD, MPH, is senior vice president as well as chief quality and safety officer at AdventHealth. Photo courtesy of AdventHealth.
The hypertension program includes an AI tool that analyzes the RPM data.
"If the blood pressure readings are in the normal range, AI will recognize this and send information to the patient and their physician that blood pressure is controlled," Kuhlman says. "If the blood pressure readings are out of control, the patient and their treatment team will be notified and a virtual visit arranged. Critical readings will also be identified and responded to quickly."
Virtual visits, which will be held via video conferencing or telephone at the patient's convenience, will be staffed by nurse practitioners or medication-treatment-management pharmacists who are trained to care for hypertension patients. This care is part of their medical license and their area of specialty for which they maintain certification, Kuhlman explains.
"There are also guidelines from the American Heart Association that they follow," Kuhlman says. "There are clinical pathways that are available to them—it is the same information that is available through our nurse hotlines on these evidence-based pathways."
The hypertension program will strengthen the relationship between patients and their care teams.
"All of the interactions with the care team are documented in AdventHealth's electronic medical record, whether the patient goes to a doctor's office, goes to the emergency room, or has a virtual visit," Kuhlman says. "This program is an extension of the patient's primary care team, which strengthens that relationship."
The hypertension program reflects AdventHealth's focus on proactive care, according to Kuhlman.
"Chronic disease conditions such as hypertension, diabetes, or heart failure need to be more aggressively and proactively monitored and treated," Kuhlman says. "This is a large-scale project for thousands of patients to address controlling hypertension with remote patient monitoring and virtual extended care in conjunction with the primary care team."
Wilmington Health, which has a high-performing accountable care organization, is committed to helping other healthcare providers to perform well in value-based care.
Wilmington Health has partnered with the AMGA to establish the AMGA Value Care Network, a strategic initiative designed to help medical groups and health systems succeed in value-based care.
Medical groups and health systems have been implementing value-based care models such as accountable care organizations (ACOs) for more than a decade. But the fee-for-service model has remained stubbornly in place for many healthcare providers.
In 2013, Wilmington Health launched one of the first ACOs in North Carolina, adopting the Medicare Shared Savings Program ACO model. Currently, Wilmington Health is operating an ACO REACH accountable care organization—a Medicare ACO model that involves full risk.
"The AMGA Value Care Network gives us an opportunity to help other medical groups," says David Schultz, MD, CMO of Wilmington Health. "We have developed competencies with our accountable care organizations, and we think we can share these competencies with other medical groups."
Schultz shares the primary elements of Wilmington Health's value-based care success in the video below. Click here to read the accompanying HealthLeaders story.
Ivor Douglas shares perspectives on critical care leadership, recruiting physicians to serve in leadership roles, and mentorship.
There are several elements to success in critical care leadership, including an understanding that critical care requires a team approach, the new director of the Department of Medicine at Westchester Medical Center Health Network says.
In June, Ivor Douglas, MD, will become the director of the Department of Medicine at Westchester Medical Center Health Network and chair of the Department of Medicine at New York Medical College. He currently serves as professor of medicine at the University of Colorado as well as chief of pulmonary and critical medicine at Denver Health Medical Center, where he has directed the medical intensive care unit since 2002.
"There must be a recognition that critical care is a team sport and that leaders who are going to succeed in critical care need to understand the imperative that leadership is about both servant leadership in being a member of a multidisciplinary team and transformational leadership," Douglas says. "This is a discipline that is high-risk and expensive, which at times requires leaders to shift leadership style in a way that can transform the practice of the field."
Critical care leaders need to strike a subtle balance between subject matter expertise and high levels of self-regulation and emotional intelligence, with the willingness to step forward to lead a team when needed, according to Douglas.
"You need to have a full spectrum of leadership skills that are developed over time," Douglas says.
Douglas explains that there are three primary elements of physician leadership development in critical care: equanimity, humility, and altruism.
"Equanimity is important in its most reductionist sense that you have grace under fire, but it is a lot more than that," Douglas says. "I sometimes talk about the 'metronome effect' for my fellows and trainees, which is the recognition that to function when things are slow or things are fast, you must self-regulate and be cognizant of the things that get your metronome out of speed. When your metronome wobbles, the risk of error becomes high."
For physician leaders in critical care, humility includes the ability to speak to error, own error, and acknowledge that building redundancies in systems is important to manage error and harm risk, Douglas says. Altruism is also critical for leadership.
"We don't speak about altruism enough when we talk about emulating or role-modeling behaviors," Douglas says. "People come to medicine for a particular set of reasons, and they come to critical care leadership or physician practice a lot because of an altruistic drive."
Ivor Douglas, MD, has been named director of the Department of Medicine at Westchester Medical Center Health Network and chair of the Department of Medicine at New York Medical College. Photo courtesy of Westchester Medical Center Health Network.
Recruiting physicians to serve in leadership roles
For CMOs and other clinical leaders, the biggest vulnerability in recruiting physicians to serve in leadership roles is the tendency to advance people who look like them or behave like them, according to Douglas.
"There is a large and dominant practice in the professions that has weakened our ability to achieve workforce efficiency and diversity," Douglas says. "This practice says, 'I am successful; these are my behaviors and skills, therefore, the people I want to recruit to be leaders need to look like me, behave like me, and emulate my practices.'"
Recruitment of physician leaders should be based on hard-wiring principles such as diversity, equity, inclusiveness, and belonging, Douglas explains.
"These principles should be the strength of our healthcare system," Douglas says. "The imperative in academic leadership particularly involves the ability to ensure workforce effectiveness and resilience."
When they are recruiting physician leaders, CMOs and other clinical leaders should try to identify candidates who possess the skill sets and aptitudes that will ensure fulfillment of the organization's mission, Douglas says.
Qualities of successful physician leaders
The most successful physician leaders have endured adversity and survived professionally, according to Douglas.
"There is a lot to be said of folks who have demonstrated resilience and have learned and grown through the process of career development," Douglas says.
The best physician leaders are willing to acknowledge their mistakes and to learn from them, Douglas explains.
"The ability to speak coherently, humbly, and honestly about past failures is revealing about an individual leader's capability for adaptability and resilience as well as the individual's ability to step into a role where emotional intelligence and maturity must be demonstrated," Douglas says.
Keys to success in mentoring
Mentoring relationships between leaders and physicians should be bi-directional, according to Douglas.
"The most valuable mentoring experiences I have had involved the recognition that the mentoring interaction was as valuable to me as the mentor coaching and exploring as it was for the mentee," Douglas says. "Uni-directional relationships exist; but almost universally, when we look at performance assessments in uni-directional mentoring experiences, they are far less satisfying and durable than bi-directional experiences."
Mentoring relationships should also have a contractual element, Douglas explains.
"A mentoring relationship needs to be one where the roles and expectations are established formally," Douglas says. "The expectations for functional mentoring and the benchmarks must be clear between the mentor and the mentee."
A three-member panel including one CMO shares their perspectives on using technology in clinical care.
The latest webinar for HealthLeaders' The Winning Edge series was held this week on the topic of bolstering clinical care technology.
Artificial intelligence is the hot topic in clinical care technology, but this week's discussion focused on other technology capabilities in the clinical care space. The webinar topics included remote patient monitoring, wearables, standardizing clinical pathways in the electronic health record, and establishing alerts and prompts in the EHR to avoid waste in clinical care.
Tune in to view a video of the webinar to gain all the insights of the panelists on effective strategies to use technology in clinical care, which help position healthcare organizations for success.
This week, a three-member panel of experts convened to participate in a clinical care technology webinar as part of HealthLeaders' The Winning Edge series.
Artificial intelligence may be getting the most hype when it comes to clinical care technology, but there are a range of other technology capabilities such as remote patient monitoring and wearables in the clinical realm.
In the latest webinar installment of The Winning Edge series, three experts discussed a range of clinical care technology capabilities, including how to optimize the electronic health record to make it user-friendly for clinicians. The panelists were as follows: Ruric "Andy" Anderson, MD, MBA, chief medical and quality officer at RWJBarnabas Health; Joey Seliski, MBA, director of technology strategy and digital health at Allegheny Health Network; and Lori Walker, MSN, chief medical information officer at Presbyterian Healthcare Services.
Click on the infographic below to get the panelists' top tips for optimizing the EHR.
A three-member panel of experts shares how to effectively use technology such as remote patient monitoring, wearables, and electronic health records.
The latest webinar for HealthLeaders' The Winning Edge series was held yesterday on the topic of bolstering clinical care technology.
Artificial intelligence is the hot topic in clinical care technology, but yesterday's discussion focused on other technology capabilities in the clinical care space. The webinar topics included remote patient monitoring, wearables, standardizing clinical pathways in the electronic health record, and establishing alerts and prompts in the EHR to avoid waste in clinical care.
It is essential to have an operational staffing model to support remote patient monitoring. Health systems and hospitals need to have internal staff to manage RPM programs and act on RPM data, the panelists said, adding that a strategic partner can supplement internal staff.
Similarly, health systems and hospitals should have a device management strategy that can be managed internally or with a third-party partner, the panelists said.
Regarding RPM devices, they should be patient friendly, and they should be deployed with patient perspectives in mind.
For clinicians, an RPM program should have a defined purpose such as management of chronic illnesses, including congestive heart failure and diabetes, the panelists said. In addition, the data generated by an RPM program should be actionable for clinicians.
Strategies for wearable success
Successful utilization of wearables in the inpatient and outpatient settings mirrors the best practices for RPM programs, according to the panelists. Wearables should be patient-friendly and provider-friendly, and they should generate actionable data for clinicians.
There are many use cases for wearables in the inpatient and outpatient settings, ranging from monitoring heart conditions to monitoring daily habits of patients to encourage them to embrace healthy lifestyles, according to the panelists. In the inpatient setting, wearables are helpful for patient monitoring because they can allow clinicians and nurses to focus on the most critically ill patients.
Ease of use is important with wearables from both the patient perspective and the clinician perspective, according to the panelists. Wearables should generate data that is instructive for patients, and they should produce minimal notifications for clinicians to avoid alert fatigue. The panelists said vendor support can help achieve these goals.
As is the case with RPM programs, staffing models are pivotal in utilization of wearables, and partners can provide clinical staff to augment the staff at health systems and hospitals.
Standardizing clinical pathways in the EHR
Successful strategies for standardizing clinical pathways in the EHR must be designed with clinicians in mind, according to the panelists.
These clinical pathways must be integrated into clinician workflows, physician leaders should be engaged from the beginning when crafting order sets, and frontline physicians should be engaged in the process to help drive change.
Standardizing clinical pathways in the EHR has a positive impact on outcomes, including reductions in readmissions and mortality, the panelists said.
Efforts to standardize clinical pathways in the EHR should be tested and assessed to avoid alert fatigue for clinicians, and efforts that add "clicks" in the EHR should be selective and thoughtful. As part of these processes, there should be a broad audience for feedback and leaders should be prepared to pivot based on feedback.
Establishing alerts and prompts in the EHR to avoid waste
Clinical and operational rules in the EHR can define next steps for clinicians to avoid waste such as unnecessary laboratory tests, with the necessity of tests set on evidence-based guidelines, according to the panelists.
As is the case with standardizing clinical pathways in the EHR, leaders should be mindful of alert fatigue and have a process in place for establishing new alerts that includes an annual review of alerts.
Alerts should be monitored to know who is getting them and what those staff members are doing with the alerts, the panelists said, adding that health systems and hospitals need to ensure there are not too many alerts while acknowledging that they have a stewardship obligation to control waste.
Paul Haskins, MD, is SVP medical director of the Carilion Transfer and Operations Center at Carilion Clinic. Photo courtesy of Carilion Clinic.
Jeffrey Kuhlman, MD, MPH, is senior vice president as well as chief quality and safety officer at AdventHealth. Photo courtesy of AdventHealth.
Ivor Douglas, MD, has been named director of the Department of Medicine at Westchester Medical Center Health Network and chair of the Department of Medicine at New York Medical College. Photo courtesy of Westchester Medical Center Health Network.
