Memorial Hermann leaders have been able to reduce preventable readmissions by closing care continuum gaps. They've tackled poor communication among disjointed or unaligned providers, a lack of systemic accountability and follow through, and inadequate human and IT resources.
This article appears in the November issue of HealthLeaders magazine.
Memorial Hermann in Houston is fortunate in some ways that it had a preview of the pain of readmissions almost a decade ago and decided to do something about it. Years before the Centers for Medicare & Medicaid Services started to penalize hospitals for preventable readmissions, Memorial Hermann had pain of its own: hundreds of millions of dollars in annual uncompensated care for a population that reached as high as 33% uninsured.
"We see a tremendous number of uninsured patients," says Memorial Hermann Chief Medical Officer Michael Shabot, MD. "We run 10 emergency departments, seeing over a half million patients a year, and we take care of everybody without regard to ability to pay. But what we found was that those individuals who weren't insured had a very high rate of readmission to the hospital or to our EDs or to observation. So we were actually paying for their admission and for every readmission. I mean literally just the hospital was paying for it."
It was decided that the right thing to do—as well as the most cost-effective—would be to undertake a comprehensive program to better manage high-risk patients. This program would close gaps in the care continuum that historically have led to readmissions: poor communication among disjointed or unaligned providers, a lack of systemic accountability and follow through, and inadequate human and IT resources.
The first step was to understand which patients were at higher risk for readmission. When the program began, risk stratification was based simply on a patient's number of previous hospital admissions. The team began to use a software program in conjunction with the Cerner-based electronic health record that scans the daily patient census and uses an algorithm to flag patients who may be at higher risk—based on their disease type or condition, as well as other demographic or clinical data. Those patients are added to a list that case management contacts for more follow-up.
The crux of Memorial Hermann's initial work in preventing readmissions has been in the expanded role of case management, which has evolved over the past seven years from a traditional inpatient episode role to one that takes a broad, continuum-spanning view of a patient's care. Pat Metzger, RN, chief of care management at Memorial Hermann, says the staff case managers at the system's 12 hospitals follow up daily once the system has identified patients as a risk for readmission.
"At each of the campuses, the case management staff has what they call one-minute rounds," Metzger says. "They go up on the units each morning and they meet with the nursing staff to ask, 'Who have we got today that we need to consider as high risk for readmission when discharged? Who was the new admission? What are their care needs that are driving this hospitalization? Who do we have that we're planning on sending home today? Have they met all their milestones?' "
The case manager makes certain that every discharged patient has a plan that maximizes the ability to avoid a readmission, Metzger says.
"No. 1, our case managers in the hospitals are focused on making sure that we're putting together a discharge plan that is the most cost-effective, but the least restrictive for the patients," Metzger says. For example, the case managers will review options for home health and other postacute providers that "we know we can trust to try to manage that patient in the ambulatory setting."
The staff case managers are "making every effort to get patients connected to the services that they're going to need back in the community before the patient leaves the hospital," Metzger says. Case managers will make the necessary doctor appointments for them, either within the Memorial Hermann physician staff or at area clinics. The case managers also coordinate with Memorial Hermann's ambulatory case managers to share care plans and to ensure there are no gaps in the care transition.
Case managers coordinate the discharge planning efforts, which are communicated via the health system's EHR platform.
"Our case managers do their discharge planning documentation right in … our electronic health record so that all the team members have access," Metzger says. "There's a particular folder in which they document interventions, such as who's going to be handling the patient, what arrangements have been made, or who the providers are so that anybody who accesses that patient's records can know where we are in the planning process and who are going to be the providers of services. The [time spent on] handoffs seems to get minimized because of the accessibility of the electronic data."
The organization is working to extend the accessibility of that data. Memorial Hermann owns many key pieces of the care continuum, including TIRR Memorial Hermann, one of the nation's leading rehabilitation hospitals, and its own home health agency. But for its readmissions program to be successful, the system had to find a way to work with a variety of community partners, says Carl Josehart, CEO of TIRR Memorial Hermann and System Rehabilitation Services.
"We're willing to share our data with them," Josehart says. "It's really being open about not only what we think they can improve, but also asking them if there was anything we did in our care that made it harder for them to receive our patient. We realized there are agencies in the community [for which] we may not share ownership, but when we share our patients, we are really working together in partnership to close the gaps in care."
In addition to discharge planning, the case managers also make certain that discharge education is tailored for the patient's situation, both clinically and at home. Nurses and nurse educators provide the instruction to the patient, while the case managers follow progress to make sure the education happens when it should and involves the right people, Metzger says.
"They're communicating with the families about what the plan is," Metzger says. "The case managers work with patients and their families to decide whether they have the resources, skill, or desire to help manage the process once they leave the hospital. Is it the family member we have to teach? Is it the patient we have to teach? Do we need to look at a postacute provider as an interim step for this patient? So they're doing a lot of assessment about the readiness of the patient, the family, or significant others to assume responsibility posthospitalization for care, and then they'll involve the right people in that."
Enhancing case management, sharing data, and linking to community partners are some of the organizational improvements Memorial Hermann has made, but some of the largest gains involved closing the more practical gaps that can trigger readmission, such as those related to:
Durable medical equipment: Some patients with a catastrophic illness or injury may require a substantial number of durable medical devices, often for the first time. The team found that patients would frequently be sent home before the DME was ready, says Josehart—so rather than just making a DME referral, the staff now manages the transition.
"Our standard is that all the equipment needed to care for a patient in the home is in the home 24 hours prior to discharge so the family has a chance to make sure that it's there, that it's working, to test it, and if it's different from what they expected, to resolve that issue prior to the patient going home. That's something that we track in our internal quality metrics. Although it's a home thing, we see that as part of our commitment to making sure that we're handing off to a safe environment," Josehart says.
Medication reconciliation: Even before discharge, the nurses and case managers work to ensure that the patient and family understand their medication, even something as seemingly simple as recognizing changes in shape or color of a medication, Metzger says. Whenever there is a question, a staff pharmacist is brought in to explain the new medications and any potential interactions. The team also makes sure the patients have enough medication to take home with them so they don't have to rush out in those first few days to get a refill.
"We have a relationship with Walgreens so that when we have patients we know will be leaving the hospital with a new prescription, they can opt to have a Walgreens that is located on our campus bring those prescriptions directly to their room so that in fact they don't have to try to stop at the pharmacy or have something delivered to their home," Metzger says.
Discharge packets: One of the gaps that physician leaders noted in medication reconciliation failures was that patients did not understand their discharge instructions. That's no surprise, considering the volume and complexity of the material given to them, says Keith Fernandez, MD, president of MHMD Memorial Hermann Physician Network. "Historically our patients might go home with 30 pieces of paper," he says.
"It was hard for the patient to determine which piece of paper was the most important. And even the important ones were hard to read and in language that the average patient could not understand," he says.
A physician-led team spent a year organizing and editing down discharge instructions to a critical few and embedded those into the EHR. Now, discharge instructions are distributed consistently to every patient based on that patient's specific condition. "The group came up with a very streamlined process for discharges," Fernandez says. "In fact, the discharge process probably would qualify for a discharge summary as well. So when the patient leaves, they take home a relatively clean sheet of information that has everything critical in that process for the patient to know—and only that."
The secret, if there is one, is in effort and attention, Metzger says.
"There is no magic to this," she says. "It's paying attention to the details and it's making sure that the patient and the family always understand where they are in a trajectory. It is constant, precise execution on those kinds of things every single day."
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This article appears in the November issue of HealthLeaders magazine.
After a move, ED patient satisfaction and throughput measures "tanked" at Sharp Memorial Hospital in San Diego. By eliminating duplication, leaders not only improved operational efficiency, but patient experience as well.
This article appears in the July/August issue of HealthLeaders magazine.
When Sharp Memorial Hospital moved into its new patient care tower in 2009, the emergency department team expected better patient flow and, as a result, improved patient satisfaction to come along with the new facility. It didn't happen.
"We had a beautiful space, but we brought ineffective and cumbersome processes into the new building that really were not optimal for our patients," says Susan Stone, senior vice president and CEO of Sharp Coronado Hospital and Healthcare Center, who at the time was chief operating officer and chief nursing officer at Sharp Memorial in San Diego. "It was one of those examples where we thought going into a new space would fix the problems and it didn't."
For an organization that prides itself on being patient-centered, and that only two years previously had been awarded the Malcolm Baldrige National Quality Award, having ED patient satisfaction and throughput measures "tank," as one team member described it, got everyone's attention. Rather than try to tweak the process, Stone and the hospital leadership team decided to evaluate the ED from top to bottom.
"The first thing that we did was to observe and do a lot of data collection about the patient experience overall," Stone says. "And then when we met together to prioritize, we decided to come at this project from the patient's lens rather than my perceptions as a CNO or my team's perspective as healthcare providers."
Sharp's Lean Six Sigma team was brought in to "look at the whole process from the time an emergency patient presents all the way to head in bed upstairs," says Kurt Hanft, Lean Six Sigma Master Black Belt.
But Hanft and the team recommended that rather than just do a Kaizen event—designed to address a particular issue over the course of a week—the ED team at Sharp needed to "create a department of problem solvers," Hanft says. "And that is not something that you just do overnight. You need executive involvement and a lot of training at the staff level so they can be a part of it because it's really about frontline engagement."
A value stream map—a Lean process of analyzing the flow required to bring a service to the consumer—resulted in some shocking data: 82% of the patient's time was wasted in waiting and assorted delays.
"Our goal was to eliminate all the delay and waiting from the patient experience so that we were optimizing their time for every moment they were with us," Stone says.
The waste began with an all-too-familiar triage process where the patient was often telling his or her story "up to four and five times," Stone says. The flow was typical: Talk to admitting nurse. Go back and sit down in waiting room. Talk to triage nurse. Go back and sit down in waiting room. Triage nurse again. More waiting. Then back to a bed in the ED to explain all over again to the ED nurse. Stone says the team realized it already had a model of sorts for how ED patients should be treated.
"We looked for examples of when we were best meeting the patient needs," Stone says. "And we found the experience of an active chest pain patient: The patient arrives. The patient's immediately taken to a bed in the ED. All the team members gather around, listening to this story. Everybody's working shoulder to shoulder getting everything done and expediting the patient care. So what we did was try to use that model for every single patient who arrives to the ED."
With the model determined, the next step was "to adopt the philosophy that triage is not a location, it's a function," Stone says. "The philosophy became that patients presented and they were taken to a bed."
A change in philosophy meant a change in workflow. Some hospitals across the nation are adopting an ED "ambassador," a nonclinical role to greet patients and get basic information, and also supplementing physicians with midlevel providers to take simple cases. But Sharp decided to continue with the same staff mix.
"We don't use nurse practitioners," says Christopher Walker, MS, RN, NP, CNS, director of emergency services at Sharp Memorial Hospital. "We're a physician-only model. We contract with a physician group and they chose no midlevel providers. When you walk in the door, you are walking in to talk to a nurse, not an ambassador. It is a specially trained ER triage nurse. They are taking that basic registration information, but they're also already making that first-level assessment that's at a higher level than any ambassador could."
Triage assessment used to be for determining which patients had the highest acuity and needed to get back to an ED bed. Under the new system, ED acuity assessment only has the goal of getting to patients in the quickest way, Stone says.
"Triage assessment helps us assess what the needs are of the patient and to expedite the care each hour as opposed to determining who should be seen next from the lounge," Stone says. "Everybody's coming into a room. If they have a lower acuity, it just means that our goal is to get them out faster."
One of the overall goals of the redesign project was to decrease length of stay to fewer than three hours in the ED. Tactically that means the ED staff had to refocus on freeing up beds, which changed the way they viewed triage, Stone says.
"If there is a patient with a low acuity, that gives the team an opportunity to say, 'We can get this patient out in less than two hours.' So then there will be an open bed and the next patient does not have to wait. It became a different philosophy about how you use those triage assignments. They're an important function of the ED and we still use them, it's just not to prioritize who's sitting in the waiting room and who's not."
This story is drawn from an HLM Live event that took place on August 20th.
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This article appears in the July/August issue of HealthLeaders magazine.
By redesigning the care model using uniform best practices borrowed from surgical procedure, leaders at Geisinger Health System reduced perinatal variability.
This article appears in the July/August issue of HealthLeaders magazine.
The women's health physician and leadership team at Geisinger Health System started with a challenge: Could they take the core fundamentals of the health system's ProvenCareTM model of best practices from a surgical procedure such as a coronary artery bypass graft and apply those to perinatal care?
Geisinger's model—which combines a uniform set of best practices with accountable systems to make certain the right care is followed at the right time—had demonstrated results in surgical procedures. But could it work in an episode of care that is nine months long?
Harry O. Mateer Jr., MD, director of obstetrics and gynecology at Geisinger Medical Center, says despite some obvious differences between perinatal care and a surgical procedure, delivering consistent care involves the same elements.
"The basis behind ProvenCare is that we know that for certain procedures, whether it's a surgical procedure or a complex nine-month ordeal such as pregnancy, that there are certain aspects of care that should be offered to all patients at various points during the procedure," Mateer says. "So if it's a surgical procedure, all individuals should be offered certain things prior to the surgery, during the surgery, and then after the surgery, and those are usually called best practices in most modern health literature. Most physicians know what they have to do. It's just really making sure that it does get done."
In prenatal care, the best practices can sometimes be lab work, education, family history, social history, or radiology studies, Mateer says. What matters is that "all of those best practices are offered at the appropriate time for each and every individual, and that people don't fall through the cracks because you think somebody else did it and you don't have a good way of documenting and making sure it was done."
So how does a clinical team make certain it gets done? Hans P. Cassagnol, MD, associate chief quality officer of Geisinger Health System and director of obstetrics and gynecology for Geisinger-Northeast, says implementation is built around two primary tools.
"We actually used evidence-based medicine and the electronic medical record to come up with a set of best practice measures that we were going to hold all providers to," Cassagnol says. "What we have done over the past several years is use those two components with different ways of actually guiding the providers into delivering the evidence-based medicine at every single opportunity."
The first speed bump that many health systems may face is to create the initial set of best practices. Geisinger began with a set of 103 distinct best practices for perinatal care. "Some of those best practices can be as easy as something like taking vital signs," Cassagnol says, "recognizing that a blood pressure has to be taken at each and every visit. And some of those best practices are things that may just have to be offered once but at a specific time during the pregnancy. So in those 103 best practices, there are usually between about 240 to 300 times when those particular best practices need to be validated during a normal pregnancy."
Even with its history of integration and consistency of care, when the Geisinger team started the exercise it found "unnecessary variation" in how care was delivered across its 25 clinic locations in the region. The leadership team made certain to communicate that the goal of the program was not to restrict physicians but to give them a defined framework, Cassagnol says.
"One of the biggest misconceptions is that whenever we actually go through the process of delivering the best practice measures, people tend to think we are restricting providers from practicing a certain way," he says. "The goal is to provide overall guidance of what's the expected level of care in a particular situation. There's always going to be deviation from the guidelines. We just want to make sure people are thinking about the guidelines and what should be done within the best practice measure. If there's a good reason to deviate from that, we just want to make sure there's an active thought process behind
the deviation."
Any set of best practices has to be fluid to embody the latest evidence. One example is when growing evidence from the American College of Obstetricians and Gynecologists suggested that women who delivered via elective cesarean prior to 39 weeks saw an elevated risk of complications.
John Nash, MD, chairman of the department of obstetrics and gynecology at Geisinger Health System, says the physician team quickly moved to adopt procedures to avoid elective cesareans prior to 39 weeks.
"All we had to do as a group was say, 'This is now what [ACOG] says is the standard. It is the best practice.' How can we justify putting babies and moms at risk?" Nash says. "That risk is fairly small, but why put them at any risk? How could we defend ourselves if we got a bad outcome? So our Geisinger docs got together and said, 'We are not going to accept anybody that schedules a C-section prior to 39 weeks.' "
To hardwire this particular best practice, the electronic health record tracks all C-sections throughout the system, along with the gestational age of the baby and the reason for the C-section. If by chance an indication shows up in the system for an elective C-section prior to 39 weeks, a red flag alerts the senior obstetricians to contact the delivering physician in real time to review, Nash says. For the past two years, Geisinger's elective delivery rate prior to 39 weeks has been zero.
The order sets embedded into the health record are meant to support and remind physicians about the benchmarks of care, but not to bog down workflow. One revamp they call the "Result Consult" allows the physician to divide all of the different lab and radiology work by weeks of pregnancy. So a physician can simply check if a patient at 20 weeks has had all of the recommended studies, and if not to order them according to the timeline. If an opportunity is missed, then the alert reminds the physician at the next visit that the recommended care is overdue but still within the time window to correct, Cassagnol says.
"Hard stops"—orders that a physician has to click though in the course of the patient encounter—are built into the health record selectively, Mateer says.
"We also have what are called best-practice alerts for certain high-importance areas, such as receiving Rh immune globulin for our pregnant patients who are Rh-negative," Mateer says. "If something has not been completed at a particular point in the pregnancy, an alert will come up at the very top of the patient encounter. Then a drop box will allow you to complete that in a very easy, timely fashion. We didn't want to have best-practice alerts for every component because that can get overwhelming if you have a hard stop to every component of care, but for certain crucial areas of care we felt that hard stops were beneficial and would then be harder for a physician to miss."
HealthLeaders Media LIVE from Geisinger: Women's Health Leadership Discover how Geisinger Health System used its ProvenCare model to streamline perinatal care, created stronger patient engagement and communication, and drove better outcomes for both safety and quality.
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This article appears in the July/August issue of HealthLeaders magazine.
Not knowing a patient's wishes for end-of-life care can lead to expensive and sometimes unwanted medical interventions. Gundersen Health System is trying to change that, by embracing a conversation around end-of-life care that is not about dying.
This article appears in the May 2013 issue of HealthLeaders magazine.
Editor's note: This piece is excerpted from a full case study that is available as part of the June 4 event, HealthLeaders Media Live from Gundersen Health System. For more information, visit www. healthleadersmedia.com/live.
It is human nature to avoid difficult conversations about dying. We often simply don't know what to say. Given the intimate nature of these discussions, they also require a lot of trust. That is why hospitals, health systems, and physicians have done a generally poor job of initiating meaningful, timely conversations with patients and their families about the difficult issues surrounding care in the final years of life.
In healthcare macroeconomic terms, a 2012 Wall Street Journal analysis found that Medicare spent 22.3% of its total annual hospital expenditures on the 6.6% of seniors (1.6 million) who died in one year. A major contributor to that expense is not knowing a patient's wishes for care, which can lead to often expensive and sometimes unwanted tests, procedures, and other interventions.
In smaller, more human terms, not knowing a patient's wishes for his or her end-of-life care can create heartbreaking choices for the family, says Jeff Thompson, MD, CEO of La Crosse, Wis.–based Gundersen Health System.
"You want something that's draining for the staff and family? Be at the bedside of an 80-year-old person who has been in declining health and now has a stroke and can't talk," Thompson says. "Now the family is saying, 'I wish I knew what she wanted.' The medical staff and the nurses are saying, 'I wish we knew what she wanted.' Nobody knows what she wanted. She didn't say. No one had the conversation and now people are just guessing. That's hard on staff. That's hard on the family."
Gundersen has succeeded in changing the mind-set of those in its own health system and the surrounding community by embracing a conversation around end-of-life care that is not about dying.
"Of course we're all going to die. We're not going to escape that," Thompson says. "But these conversations are about how are you going to live, and do you want to have a say in how you're going to live."
La Crosse now boasts rates among the nation's highest for advance care planning. As Atul Gawande, MD, wrote in his New Yorker piece "Letting Go," residents in La Crosse "have unusually low end-of-life hospital costs. During their last six months, according to Medicare data, they spend half as many days in the hospital as the national average, and there's no sign that doctors or patients are halting care prematurely. Despite average rates of obesity and smoking, their life expectancy outpaces the national mean by a year." An article in the Journal of the American Geriatric Society also found that:
95% of severely or terminally ill patients in La Crosse have an advance care plan, compared to the national average of 50%
98% of physicians are aware of the advance care plan, compared to a national average of 35%
98% of the time there is consistency between the known care plan and the treatment provided, compared to a national average of 50%
Having a conversation with patients and their families about end-of-life care wishes needs to happen at the appropriate time, with a member of the care team who is appropriate for the need, and with someone trained in the nuances of difficult conversations. The current norm for advance care planning is much less structured and much less effective, says Bernard Hammes, PhD, director of medical humanities and Respecting Choices® for Gundersen Health System.
"The standard approach in the past was to tell patients about advance directives, hand them a document or maybe a brochure, and then tell them that they need to fill it out," Hammes says. "That kind of simplistic approach clearly has not worked. The evidence is pretty overwhelming that it's outright failed to do much of anything."
A flaw in many medical communities is the idea that only physicians can have advance care conversations with the patient and their family. "Medical leaders have to get out of the mind-set that the docs are going to spend hours and hours a day having these conversations," Thompson says. "Our job is to lead on this, not to have all the conversations. We can encourage it. We can make sure the system is set up. We can review the occasional confusing case. You can answer the patient's questions."
Hammes adds that telling physicians they should do more is rarely an effective engagement strategy anyway.
"You actually have to create a structure in your system to make advance care planning part of the routine of care," Hammes says. "That new system has to both prompt physicians and be designed so it's realistic in demands on physician time. The role of the physician is to initiate the conversation. That takes an additional few minutes. Then the physician can hand that work off to someone on the team who can now spend 30 or 40 or 60 minutes having that conversation with the patient and family."
Effective communication regarding end-of-life care involves a carefully constructed series of at least three conversations:
First steps: The initial conversation is called "first steps," which is held with generally healthy adults by the age of 65. The basic plan would be to complete a power of attorney for healthcare to appoint a well selected and prepared healthcare agent and indicate, for example, when a serious, permanent brain injury would be so bad that the goals of care would no longer be to extend life. The first steps can be initiated by a physician (perhaps during a routine physician exam), one of the trained facilitators, or a larger community of trained coaches from churches or other local networks.
Next steps: The "next steps" stage is initiated for adults with a progressive, life-limiting illness so that the healthcare team can determine goals of treatment in the event of complications or bad outcomes. This stage of planning is for individuals who have a serious, incurable illness and may be suffering serious complications. The goal is to undertake disease-specific planning and determine when an outcome from a complication would be so bad that the goals of care would change. The next steps phase is handled only by Gundersen's trained facilitators in consultation with the physician team.
Final steps: This last stage is for those patients whose illness has progressed to the point that death is likely within 12 months. In those cases the facilitators and physician collaborate with the patient to develop a specific plan of care for medical orders, including a physician order of life-sustaining treatment.
When the physician perceives that the patient and family are ready to have an advance care conversation, the handoff goes to a specific team of facilitators depending on the stage of planning. At Gundersen, there are 70 active first steps facilitators, 10 next steps facilitators, and five last steps facilitators.
The staged approach allows each phase in the advance care plan to be discussed at a time that is most appropriate, says Carol Berra, RN, the lead next steps facilitator. These next steps conversations, she says, are discussions that involve at least three people: the patient, the facilitator, and "the primary agent," a friend or family member who has been designated by the patient to make medical choices for them.
"We explain that when you're sick and not feeling well is not a good time to have these conversations; it's when you're feeling well and relatively stable," Berra says. Timing is especially critical for the next steps conversation for those facing a potentially terminal illness, she says.
"We have found the conversation makes the most sense to a patient who is advanced in their illness but not yet appropriate for and accepting of hospice care," Berra says. "If a patient is too early in their illness, the situations presented in the next steps ACP do not make as much sense to them."
These steps are typically not handled by one facilitator in a close series of conversations, but more likely conversations by different facilitators over many years of care.
What supports the timing is that ACP takes place as a routine matter. If the concept is introduced individually and at random times, the patient might react with misconceptions about the reason for the discussion: "What do you know that I don't?" Berra says.
"We've made this conversation as part of our model of care," Berra says. "So lots of times that's easier for patients to accept when they just know we offer it to all of our patients at certain stages of their illness. So it's normalized."
Adds Hammes: "Every patient in our cancer center is approached about two months into their chemotherapy to undertake the first steps planning. It doesn't matter what their prognosis is. It doesn't matter what their type of cancer is. We want to initiate and say we approach all patients in our cancer center and we really prompt them and try to motivate them to take this one first step to do basic planning."
Even with a careful plan of care and good timing, an effective ACP program must teach the skill needed to have these conversations, Hammes says.
"Have you ever been in a situation where someone just told you they're very sick and you just don't know what to say?" Hammes says. "Our natural tendency is not to say anything. Physicians and nurses are often caught not knowing what to say and so they avoid the topic completely. Many people believe that they avoid the topic because of the content. My belief is that they avoid the topic because they lack any knowledge or skill in having this conversation. We have developed an expertise in this, training people to not only competently have these conversations but to comfortably have these conversations."
Physicians are trained to be direct and scientific, which may lead them to ask blunt questions of the patient, such as, "What do you want me to do if your heart stops?" Hammes says. Most patients are not emotionally equipped to make that leap, so the conversations start with finding common ground.
"You start out by asking if they have ever been in a situation where someone in their family or a close friend had serious medical problems and someone else had to make decisions for them," Hammes says. "And almost every patient has some story to tell about when [their] grandma died and there was a lot of conflict in the family."
The facilitators flip the question around and ask the patients what they learned from that experience and how it may help them in their own illness, Hammes says.
"Probably for the first time they say, 'Oh, well, I guess what I learned is that when families don't have these conversations in advance that things could really go wrong and it can really lead to a lot of unnecessary distress.' You're not lecturing to them. You have personalized it."
After the patient is engaged in the idea of having the conversation, the facilitators can get more specific, Berra says. "It starts with the patient talking about their understanding of their disease and what's happening with them right now. How has it changed their life? What are the complications they can expect or know about? What are their hopes for their treatment? So the nature of the conversation starts at a level that they are pretty comfortable with and then moves them into what might not be as comfortable."
In cancer care, for example, the facilitators ask patients about their understanding of their cancer, their goals and values or faith and experiences, and then go into specific scenarios that may happen as a result of their disease. "So it helps the patient talk about their illness," Berra says. "The conversation clarifies goals, values, and choices. It also helps the person the patient has chosen to make medical choices for them."
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This article appears in the May issue of HealthLeaders magazine.
This article appears in the April 2013 issue of HealthLeaders magazine.
Editor's note: This piece is excerpted from a full case study that is available as part of the upcoming May 21 event, HealthLeaders Media Live from Dean Clinic. For more information, visit www. healthleadersmedia.com/live.
One of the beauties of running an integrated delivery system that has physicians, a health plan, and affiliated hospitals is the ability to look at influencers of healthcare costs in a systematic way. Craig Samitt, MD, president and CEO of Madison, Wis.–based Dean Clinic, says a few years ago he asked the organization's health plan to pull some data on primary care.
"We asked our health plan what percent of total cost of care goes to pay primary care, essentially to pay primary care physicians," Samitt says. "We were shocked to hear that it was only 6% of the total cost of healthcare. And then we asked our health plan to what degree does the work of primary care—referral patterns, prescribing, everything that they do—influence the remaining 94%. And the health plan said our primary care physicians directly and indirectly drive another 80% of the costs. So if you're going to start some place to catalyze value-based transformation, primary care is the best possible place to start."
In 2009, Dean Clinic was not getting the kind of quality and experience results it wanted from primary care, says Mark Kaufman, MD, chief medical officer for Dean Clinic. At that time Dean's primary care network was not unlike others across the country—somewhat fractured, with difficulty in recruiting physicians and keeping patients happy.
"We said we really needed to make this a major effort," Kaufman says. "I think primary care redesign is one of if not the most critical pieces of clinical redesign that a health system has to undertake if you're going to get to that goal of flipping the paradigm from a sick model of care to more of a wellness and maintenance model of care."
The first step was to concentrate on six primary care pilot sites in a patient-centered medical home pilot project with TransforMED, a subsidiary of the American Academy of Family Physicians.
"It was a way to get started," Kaufman says. "It was a bit messy. In retrospect it wasn't data-driven enough, but a couple of really good things came out of that."
The pilot sites—which included 30 physicians at five Dean Clinic locations and one that is part of Dean's joint venture with St. Mary's Hospital—reached Level 3 PCMH certification for the National Committee for Quality Assurance program, which includes such foundations as access and communication, use of paper or electronic charting tools to organize clinical information, and adoption and implementation of evidence-based guidelines for three chronic conditions.
The other real benefit was a new physician compensation formula meant to align physician performance with the goals of value-based care, and not by volume. Five years ago, Dean's PCPs were compensated on the industry standard relative value unit (RVU) formula, in which a standardized dollar amount is given for each encounter or procedure. Dean initially had introduced a 2% incentive for patient satisfaction, but as part of the PCMH pilot, leaders radically redesigned the formula, Kaufman says.
Under the new compensation formula, 60% of primary care compensation was still RVU-based; another 20% was based on age/gender-adjusted panel size; and 35% was built around incentives for service, financial performance, clinical quality, and growth goals. The formula intentionally totals 115%, Kaufman says. "We purposely made it possible for our physicians to earn above market compensation, but the way our physicians did that was by performing well on the incentives that were really all about the goals of primary care redesign."
The formula has been tweaked in recent years and has been spread beyond the six pilot sites to the rest of Dean's primary care system. For 2013 the package is 50% RVU-based, 30% for panel size, and up to 30% for incentives, including 10% related to medical cost control and a 20% standard package.
Albert Musa, MD, medical director for primary care, east region, for the Dean Clinic, says the reaction to the new comp plan has been well received by the primary care staff but is still a work in progress.
"You know, it actually has been good," Musa says. "Our physicians knew it was aligning them more with the right things."
But there are limits and practical challenges, he says. "When you're doing more non-RVU work and you're getting less for RVU work, you can only scale back your RVU work to a certain point." Other questions leaders found along the way include how best to balance the panel size for each physician and how to divide that care among different providers who may all care for that same complex patient. And one complication that persists is that—for all the incentives to physicians to encourage patients to use alternate means of contact, other than the office visit, "there are many patients who still want that visit, and so we can't deemphasize [the office visit] too much.
"And ultimately there is a fear that it becomes a total salary," Musa says, "A salary gives you some comfort, but I think administratively we really worry about taking away people's work ethic, too. So there's a tough balance there."
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This article appears in the April 2013 issue of HealthLeaders magazine.
This article appears in the March 2013 issue of HealthLeaders magazine.
Editor's note: This article is excerpted from a longer case study that is available as part of the upcoming April 18 event, HealthLeaders Media Live from Parkview Health: The New Readmissions Plan. For more information on the event, visit www. healthleadersmedia.com/live.
Too often, hospital-based care teams start to develop a plan for readmissions as part of the traditional discharge process. Maybe a patient navigator is brought in or the education nurses are consulted, often in the last hours of what has likely been a prolonged inpatient stay. It's just not the best time to start planning for an effective transition of care, says Greg Johnson, DO, chief medical officer of Parkview Health based in Fort Wayne, Ind.
"Typically in the last two hours of the admission the nurse is trying to get everything done and the patient's thinking about getting home, and it's not an ideal state for learning, retention, and understanding," Johnson says. "So one of the things we're doing is we've moved our discharge education to begin at the day of admission."
The first step is to identify patients on admission who might be at risk for readmission, most often for congestive heart failure, diabetes, pneumonia, acute myocardial infarction, and chronic obstructive pulmonary disorder. Patients who may be at higher risk for readmission include those who have already been readmitted within the past 30 days, those who have an overall elevated number of admissions in the past 6–12 months, or those whose combination of demographic and clinical data put them at high risk, Johnson says. Then Parkview's transition care nurses get an email alert so they can make contact with that patient on the day of admission, or within 24 hours at the latest, he says.
"The key is that early, consistent contact helps build what has often been missing in preventing readmissions: relationships with the patient," says Johnson. "Bringing the transition care nurse in at the initial hospitalization begins establishing a relationship. They touch bases with them. They will actually set up the expectation that there'll be some telephone monitoring within 48 hours of discharge and at least weekly until the end of the 30 days. They'll help recognize and manage symptoms. They'll make sure appointments and medications are being adhered to. They'll help with education to see if the patients and their caregivers are following their diet or whatever the plan of care may be."
Joni Hissong, director of case management, says it helps that the two staff transition care RNs are former home health nurses who know firsthand the issues that many patients face when they go home. "We have a saying that everyone looks the same in a hospital gown, but when you walk into their home, your eyes are opened to many opportunities," Hissong says. "As you assess the patient, you can see all of the things that you could maybe do for this patient to prevent that readmission. Maybe they don't have transportation back to their follow-up appointment. Maybe they really couldn't afford the
medication because they don't have prescription coverage."
Developing that early trust can even mean knowing such simple things as an accurate contact number, Johnson says. "The thing that I found fascinating is that when our transition care nurses were talking to patients and setting clear expectations of what the goal was and what they were going to do, often the patient or patient's family would say, 'Well, here, let me give you a phone number that really is our phone number.' So I think we're not perfect at it by any means, but we're beginning to establish that relationship so that the patient isn't just somebody at the end of the phone after they get home. The nurses know their problems, and they can speak to them on a very personal basis."
Jim Molpus is strategic relationships director for HealthLeaders Media. He may be contacted at jmolpus@healthleadersmedia.com.
Reprint HLR0313-10
This article appears in the March 2013 issue of HealthLeaders magazine.
This article appears in the January/February 2013 issue of HealthLeaders magazine.
Of all the strategic shifts facing health systems in the coming years, none involves so many underlying fundamentals of the business as the shift away from a fee-for-service model of reimbursement to one based more on risk-bearing contracts and population health models.
Roundtable panels of members at the HealthLeaders Media CFO Exchange and CEO Exchange, invitation-only events held last fall, described the shift as a great leap forward with both high potential and a big downside.
"It's definitely an opportunity, but it's the most unpredictable opportunity I've ever seen in my career," says Chris McLean, executive vice president and CFO at Methodist Le Bonheur Healthcare in Memphis, Tenn.
McLean says the shift poses questions such as, "Are we really prepared for a different model and different way of taking care of patients? Are we big enough to be able to really pull that off with the infrastructure that's going to be needed? How do you know you're taking the right steps to prepare?"
CEOs and CFOs alike agreed that a move away from a sick care model to one based on health is the right direction for healthcare, but the mystery is in how fast to get there.
"We are moving incrementally into population health because we believe that is the only future," says Chris Van Gorder, president and CEO of Scripps Health in San Diego. "I often get myself in trouble for saying this, but I think accountable care organizations are a fad, because it's still episodic care payment for the most part. What we're moving toward is full risk capitation again, but we want to do it in a risk-adjusted model."
Some of the more integrated health systems already have several of the components for risk-based contracts in place and are already involved in pilot programs.
"We've been an early adopter, opting into the Pioneer [ACO] program in a significant way with 50,000 Medicare members," says Dennis Dahlen, senior vice president of finance and CFO for Phoenix-based Banner Health.
"And we have learned some very good insights from the program in just the nine months it's been up and running, results that suggest there is a way to save the Medicare program by just being smarter about how we treat Medicare patients."
Dahlen says that about 18% of Banner's revenue is risk-based today, but in five years the organization projects that figure will be upwards of 45% across its 23 hospitals. "So we're moving pretty fast. The pace may not be as important as the direction, but we're pretty certain of that direction and that faster is better than slower at this point."
Britt Berrett, president of Texas Health Presbyterian Hospital Dallas and executive vice president of Texas Health Resources, says that "the name of the game now is outside the walls of this hospital."
Under the fee-for-service model, there has been little incentive for the hospital to manage postdischarge medication reconciliation or navigation, but that is changing. "We [are] forced to do something we should have been doing in the past. We have an obligation to identify what the needs are, where before we just didn't worry about it."
Van Gorder says that to succeed, hospitals must recognize that the shift to population health changes more than just a business model; it also creates a new relationship with patients.
"I asked my people the other day, 'What is it we really sell? Is it healthcare?' I said we sell relationships, and yet we really haven't cared much about the relationships." Van Gorder remembers his own experience as a patient in a gatekeeper health maintenance organization, where he had to sign up for a primary care doctor and never heard from that physician again.
"So, I think, for the time first ever, we're going to have to actually build an ambulatory relationship with our patients," he says, "and then find out what their needs are and find a way of meeting those needs to keep them healthy."
Every hospital with hopes of a future has a number they use to project the amount of cost they must squeeze out of their organizations in the next few years. The lucky few may have a number that is in single digits, but most healthcare organizations are looking at double-digit cost reduction to match shrinking reimbursement levels.
We asked the members of our HealthLeaders Media Chief Financial Officer Exchange for their organizations' estimated percentage reduction of operating costs for the next 3-5 years. The average was set at 11%. In our just-released 2013 Industry Survey: Strategic Imperatives for an Evolving Industry, cost reduction was rated as the third-highest priority by the 823 respondents, close behind patient experience and clinical quality.
What strikes me as one of the more telling responses to our survey was that while 92% rated reduced reimbursements as the top threat facing their organizations, only 4% rated reduced reimbursements as an opportunity. That paints a picture of an industry scared of a future of forced efficiency and competition on value.
Granted, no one in a regulated industry that has only the most tenuous ties to a retail economy likes looking at a future in which its income streams are chopped by a combination of market pressures and government cutbacks. Still, often the best and only time for corporations to make a significant leap in their market position is when the underlying dynamics of an industry shift. That's when there are opportunities for innovative players to make a stake. Whether it's Walmart or Target reinventing discount retail or Southwest creating a new category of airline, industries are reshaped by a disruptor that focuses on the "turn" and not the "down" in "downturn."
It takes a special vision to compete without a net in a healthcare market where service, quality, and efficiency all have to hum at the same time. I would wager that the same 4% of health systems who view reduced reimbursement as an opportunity also understand that their view of cost containment has to evolve. The axiom that you can't cut your way to growth has never been truer.
To face a future where cost is an opportunity, healthcare systems must blend three values or skills:
Hardwired thriftiness. In an industry where even a midsized health system can have an annual budget approaching eight figures, it's tempting to chase only items with the largest opportunities for cost savings. That leaves too much money in the margins, as it were. Curt Kretzinger, chief operating officer at St. Joseph, MO–based Heartland Health, says his health system set a goal a while back to find $10 million or more in savings annually, which means they have to look harder each year. "To get the savings, we've had to find it in multiple smaller areas," he says. "We have one team that's looking at $2 million on a redesign of a technology. So we will still probably have one or two of that size, but the vast majority is smaller savings of $100,000 here, $80,000 there, and $300,000 here. When we start adding them all up, it becomes real money. It's a lot of small efforts that become a big win for the organization."
Data, analysts, and accountability. If you don't have the data to understand where you are really losing money, the analytics in your IT system to poke it out, and then the analysts who can translate those opportunities into a plan for transformation, your opportunities for cost saving are invisible. Heartland Health uses what they call PASTE teams—problem, analysis, solution, transition, and evaluation—to identify ground-level opportunities for reducing waste and shaving cost. When there is a need for more resources, including Six Sigma black belts, those requests are submitted to an oversight team where initiatives are prioritized and results tracked with an organizational scorecard.
A line to the patient. Cutting just for the sake of cutting poses risks. But the typical healthcare encounter has so much process waste that cuts can be made that also improve the patient experience. Savings have to pass the "voice of the customer" test at Heartland Health, says Dottie Bray, process leader for performance management. For example, in a typical primary-to-specialty referral, the patient may have to be the one who actually calls to schedule the appointment. When Heartland was redesigning its scheduling portal, it created a module so representatives in any office could see and schedule appointments in others within the Heartland network. It's better for the patient, Bray says, while also cutting down on the call volume (which equals time which equals money) in both primary and specialty care.
To be fair, I'm fairly certain a broad swath of healthcare systems have the vision to understand there is opportunity in the value side of delivery. I'm just not so sure there are many like Heartland—which was a 2009 Malcolm Baldrige National Quality Award winner—which have built the hard-won capability to contain costs that will enable them to compete in a high-quality, high-value care market.
To learn more about Heartland Health's journey, download the free HealthLeaders Media Live case study. To join our three-hour HealthLeaders Media Live videocast from Heartland Health on March 19 (noon-3 p.m. ET), please go to our registration page, where you can find a full agenda and list of speakers.
In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is the story of Nancy M. Schlichting.
This profile was published in the December, 2012 issue of HealthLeaders magazine.
"We have also built and doubled the size of the organization, but you make some very hard choices. It is not just what you do but how you do it."
As visionary as he was, auto pioneer Henry Ford could not have dreamed in 1915 when he financed and built the hospital bearing his name in Detroit that in another century it would be his healthcare system—not just his automaker and its brethren—at the table leading the rebirth of a region hit hard by the loss of more than a million jobs.
This year, the Detroit Regional Chamber elected Henry Ford Health System CEO Nancy M. Schlichting as its chairman for the year. While Henry Ford Health system ranks eighth in the chamber's list of largest employers in the region behind the Big Three automakers, healthcare is one of the industries that region is looking to for leadership out of its economic woes. Schlichting appreciated the symbolism of her appointment.
"They have never had a healthcare system leader do that," she says. "It has always been the big autos and banks. It's kind of symbolic of the role that healthcare is playing in the Detroit community."
Henry Ford would have been proud to have Schlichting leading his health system. After joining the health system in 1998 as chief administrative officer, she quickly assumed the top leadership role in 2003. Since then she has reinvented the culture at Henry Ford around solid fundamentals of performance and quality, all while keeping a close eye on changes in the healthcare marketplace and the Detroit area in particular. She created a culture built around careful accountability and measurable improvement, culminating in the 2011 Malcolm Baldrige National Quality Award. During her tenure the $4 billion, five-hospital health system started an audacious "No Harm" campaign with the goal of reducing all causes of patient and employee harm by 50% in three years. In 2010, she oversaw the creation of the Henry Ford Physician Network to tie Henry Ford's 1,200-member employed physician group and another 1,700 affiliated providers into a single ACO-style regional network for clinical integration and quality.
Schlichting says her role as CEO boils down to doing three things correctly. First is, of course, leadership itself, which she defines as "how you build the team, how you create the culture, and how you manage conflict," she says. "It's also how you provide leadership both within and outside the organization. And it is having a good sense of yourself and what drives you—your values and guiding principles that help you make decisions that are not always perfectly aligned with everything."
Schlichting says she relied on those values when she and her leadership team made the difficult decision to close Henry Ford Macomb Hospital, Warren campus, this year after years of declining census and revenues.
"It was tough," she says. "I have closed three hospitals in the past 10 years. We have also built and doubled the size of the organization, but you make some very hard choices. It is not just what you do but how you do it." The "how" in this case was to close the hospital but to find new assignments in the health system for the approximately 500 affected employees. "We just could not make it work at this hospital. The scale was too small, but we tried everything," she says. "We did not want the employees to suffer so we made the decision that we were going to absorb those 500 people into the organization. It was a cost hit for us, but it would have been a cost hit no matter what we did. Those issues really define our organization."
The second leadership quality that defines her is "having clear and sometimes risky strategies," she says, which for her included investing in the health system's main inner-city campus at a time when other employers were leaving.
"We did it because our hospital in Detroit, the flagship, is a jewel," she says. "It had been undervalued, underappreciated, and under-invested in for a long time. I also wanted to tell the community we had not abandoned them in any way. While we were building a hospital in the suburbs, we were very committed to the city. Those things end up being very strategic but are also symbolic of who were are and what we stand for."
The third leg of her leadership is definitely one that fits the time and the city's history: solid results.
"The third in my three buckets is operating performance. You have got to get results. You can have the smartest strategy and a great team that all love one another, but if you don't create results you are not going to be around for very long. You have to create outcomes that are effective, appropriate, and something that is sustainable. And that is tough in today's environment. There is a lot of pressure on all aspects of operations."
Schlichting does not get too caught up in fads or leadership tricks. She lets people use a variety of tools that work toward the desired goal. In addition to her reliance on leadership, strategy, and performance, she attributes her success as CEO to something she kept as a personal trait when she started in healthcare leadership: openness.
"I didn't start my career thinking I was going to hire a chief wellness officer," she says. "I didn't start my career knowing I would hire someone from the Ritz-Carlton to run a new hospital and redefine the way we deliver healthcare. But I did start my career knowing that I was going to be open all the time to new ideas and new thinking and people who could bring their gifts to the organization. That is the thing that doesn't change. It's really your own inward makeup of who you are."
This article appears in the October 2012 issue of HealthLeaders magazine.
Editor's note: This piece is an excerpt from a full case study that is available as part of an upcoming Rounds Event, Cancer Service Line Leadership: Baylor Health Care System.
Cynthia Robinson-Hawkins, RN, remembers when she got her cancer diagnosis 23 years ago. She was a labor and delivery nurse at the time and even with her clinical training, was just as unprepared as any patient. "I didn't know anything about cancer and all of sudden you hear ‘The Big C.' You have cancer," she says. "I didn't know where to go, what was going to happen, or who was going to do what. I didn't know anything."
That experience is not unusual even today in cancer treatment, which can be a disconnected, confusing chain of appointments, tests, and results that can quickly overwhelm a cancer patient. Now in her role as manager of the patient navigation program at the Baylor Charles A. Sammons Cancer Center at Dallas, Robinson-Hawkins wants patients to be focused only on beating cancer, not on fighting through the treatment itself.
"I tell patients that they should not be worried about who, what, when, where, and how," she says. "They should be focusing on their cancer and getting well because we all know that the stress of cancer or the stress of trying to figure out where to go and what to do is not helping you overcome your disease."
Baylor Health has invested more than $275 million in improving cancer facilities in the past year with the opening of the outpatient Baylor Charles A. Sammons Cancer Center at Dallas in late 2011 and the inpatient Baylor Cancer Hospital in February 2012. Combined into a single campus, the two facilities are meant to position Baylor's cancer services as a destination center for those in North Texas and elsewhere. John McWhorter, president of Baylor University Medical Center at Dallas, says for that goal to be reached, service and coordination have to be at the forefront.
"Embarrassingly enough, hospitals generally don't do a good job of helping the patient and family navigate through all these options," McWhorter says. "I think that's why our patient navigation office has been such a hit."
The six full-time cancer navigators have several roles. The first, as a facilitator, is to help patients manage appointments or referrals so that, for example, they can see a team of specialists in a single day rather than spread out over a week or two. For instance, a patient with a renal mass might need to see as many as four specialists: a urologist, a surgeon, a medical oncologist, and a radiation oncologist, Robinson-Hawkins says.
"Why can't we get those initial appointments scheduled all on the same day?" Robinson-Hawkins says. "That patient makes one trip down here. He may see the urologist at 8:00. He will see the oncologist at 11:00, and he will see the radiation doctor at 2:00. A patient's time is not wasted. Gas is not wasted. We're coordinating the care of the patient to make sure we're all on the same wavelength. And then the navigators will get everything that that physician needs to make an informed medical decision—from medical records to CT scans to x-rays to a patient's pathology slides."
Facilitation comes with familiarity, which is why the staff navigators are divided into focus areas: one handles breast cancer; another lung, head, and neck; a third takes on skin cancer; and Robinson-Hawkins handles the rest.
"We broke them up by disease and disease processes because I want each navigator to become close with that physician and close with that physician's team," Robinson-Hawkins says. That closeness had an unintended consequence: Some of the physician office nursing staff thought the navigators were there to take over their responsibilities. Once the navigators were able to demonstrate that their role was coordinating care, not providing it, the office nursing staff saw the value, she says.
An equally important role for the navigator is as an educator. After the initial diagnosis or referral, the navigator will work with the patient to research the condition and suggest where to find trusted sources for reference and education about what to expect in treatment, Robinson-Hawkins says.
"We are there to educate the patient to make sure they're making the right decision for them and their family," she says. "Every patient is different. Nobody is the same. You know, when you have cancer people like to tell you their aunt had the same kind of cancer and they did this or that. What worked for their aunt may not work for them. So if you educate the patient on the disease, the treatment, and what can and what is going to happen, they have a better outcome."
Cancer's nature as a life-threatening disease means that compassion has to ride along with navigation. Robinson-Hawkins stresses that the navigators are not counselors, but they are there to recognize the signs that a patient may have a social or behavioral issue that could affect his or her outcome, and to connect that patient with a broader support team of social workers, chaplains, and psychologists. Robinson-Hawkins recalls a cancer patient who was about to be discharged, but started talking about suicide. With the intervention of a social worker, it was clear that the patient was not suicidal, but alone.
"The social worker figured out there's nobody there to help him along," she says. "So then we have all of these community resources that you can utilize. And you've just got to keep a closer eye on him because he is by himself." Another patient who had head and neck cancer was not responding well to treatment at another hospital and had become withered and lost his voice. One of the navigators was able to find a physician with a new course of treatment, and the therapists and nutritional counselors to help him recover, Robinson-Hawkins says. Navigators at their best can intervene to put patients in the right place, but the rest is up to the patient.
"It's very important for patients to understand that if they're not participatory in their care, it's not going to work," Robinson-Hawkins says. "We do all we can to make sure that they're involved. But while we can tell patients all day what to do, they've got to be willing to participate and be involved in it."
Too often the missing piece in service is hardest to measure: compassion. "There is no question that we don't get to have a bad day," McWhorter says. "Our staff cannot have a bad day, because these patients just received news that is the worst news they've ever received. So, no question, service has to be at the forefront of everything we do."
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This article appears in the October 2012 issue of HealthLeaders magazine.
