Beyond the Hospital, Another 'Right' Place for Care

Collaboration between hospitals and drugstore chains can improve access to healthcare by helping to fill gaps in the continuum.

This article appears in the July/August 2015 issue of HealthLeaders magazine.

If any philosophy could capture what success looks like in both patient care and the efficiency needed to alter the steepening slope of healthcare cost increases, it's a saying many in healthcare have adopted: Right care, right place, right time.

It's trite, but it's also accurate and succinct. That phrase, often cited by wonks, policymakers, hospital and health system leaders, employers, and commercial health plan leaders, is the key to many of the challenges that plague healthcare, such as uneven quality, overutilization, and high variation and cost. The difficulty, as always, is in the execution, because providing the right care in the right place at the right time requires coordination of a vast array of complex moving parts, not to mention the cooperation of the patient.

An innovative research and practical partnership between Baltimore's Johns Hopkins Medicine, a $7 billion integrated global health enterprise, and Chicago-based drugstore giant Walgreens is aimed at simplifying and operationalizing the coordination necessary to deliver the right care in the right place at the right time. In essence, the two organizations are doing clinical and economic research and development in Baltimore to create clinical pathways that can be effective on a national scale, which Walgreens can provide with more than 8,200 stores in all 50 states and fiscal 2014 sales of more than $76 billion.

At the core of the pilot program in development is the attempt to route patients to the most appropriate site for their condition and, in particular, to move patients who require nonemergent care out of the emergency department and into lower-cost, more coordinated sites.

From the ED to the corner drugstore

Where much of the program takes place is at the Walgreens store that opened in late 2013, adjacent to the Johns Hopkins Medicine campus. The facility is not just a drugstore; it's also a training site. This is the tangible result of an idea that an acute-focused major academic medical center can work in the nonacute setting to develop new models for improving patient care and making it more efficient, says Jeanne M. Clark, MD, director of Johns Hopkins' division of general internal medicine and a professor of medicine at the medical school.

"The store was an outcropping of the idea of how to partner together, but a lot of it had to do with research incubation," she says. "Because the Walgreens is a provider of a number of clinical services, we review protocols on whether they are using the right research to develop educational programs for their workforce, including pharmacists and nurses."

Clark says the collaboration will develop efficient best practices and educate the public, providers, and policymakers about how to implement some clinical care to lower-acuity sites.

"If you have a rare condition, there are probably only a few places to have your care," she says. "But a lot of other care—like where people get their flu shots—that doesn't need to be in Johns Hopkins."

She says that Johns Hopkins is partnering with Walgreens simply because "there are a lot of issues they can and should be addressing."

Types of care

Clark says much care can be done cost-effectively outside the hospital, or even outside the physician's office. Flu shots are an example, but there are more. For example, within the store, Walgreens and Johns Hopkins have focused on developing and implementing novel clinical programs. Two of the most developed examples focus on rabies vaccinations and some treatment of sexually transmitted diseases.

The need for a rabies vaccination is uncommon, Clark notes, but there's no clinical reason to administer it in the emergency room, which, at the moment, is the only place in Maryland where the vaccine is stocked and administered. And it's a multiple-visit treatment, requiring follow-up injections after the initial evaluation and shot. "After the initial shot, really, anyone who gives shots could give the additional shots." Clark says.

The program being developed at the store encourages patients to get follow-up care at Walgreens after initial treatment in the ED. "If this works here, Walgreens could partner with other hospitals to do this in other areas," she says.

Another example of the partnership is that both organizations are involved in shifting the handling of patients with sexually transmitted infections from the ED to the Walgreens.

"There's no need for someone with high clinical knowledge to do this," says Clark. "And the health department is overrun and not open on evenings and weekends. They could get this treatment right there in Walgreens. It doesn't need to be in ER or the health department. Things like this are a part of why other countries have higher quality and lower cost than the U.S."

Developing joint programs with Walgreens dovetails with the health system's mission of improving the health of the community and finding ways to do it outside the walls of the hospital. The program also serves its mission to try to reduce the cost of care when possible. "That's is what I find compelling about a partnership like this," she says. "It's why I get up every morning and come to work."

Walgreens' bet on services

Harry Leider, MD, Walgreens' chief medical officer, says the implications for cost savings across Walgreens on a national scale are enormous.

"Now with nurse practitioners and digital tools, we're interacting with 8 to 9 million people a day," he says. "Hopkins is, of course, a world-renowned health system and research center but is still limited to a geographic region, even though they have some international sites. The idea here is to leverage this incredible intellectual capital around clinical innovation."

The store allows testing and learning on a small scale, but that can quickly be ramped up, as Leider says is happening with the STD and rabies examples, which are the farthest along in testing.

"We're still in the pilot and exploration phase around the STD example, but we can offer treatments right there in the store that are much more cost-effective and quicker than if you received them at a hospital."

The joint effort is investigating a range of other programs around services such as hepatitis C treatments, and an innovative way to use computer technology for smoking cessation, although those collaborations are farther down the road.

Richard Grossi, Johns Hopkins' senior vice president and chief financial officer, boils down the attractiveness of the partnership for both sides.

"Walgreens wants to be seen as an attractive place for patients," he says. "So from their point of view, they get the value of more foot traffic, and they're sort of feeding their patient care delivery model."

From Johns Hopkins' point of view, he says, "readmissions cost money, and they're going to cost more money in the future. We have a new reimbursement system in Maryland, and we have more at risk here than anyplace else in the country. Maryland has a high readmission rate, so focus is imperative."

Grossi says he thinks of the Walgreens partnership as a way of addressing some of the issues hospitals and health systems are going to face in the near future, including capacity issues in the acute care setting due in part to Medicaid expansion. "If we're taking care of more people, we are going to need greater capacity, and we already have some shortages," he says.

Utilizing nurse practitioners and changing the role of pharmacists to a more interactive and consultative one with the patient is a way to do it.

Walgreens is providing the initial funding to expand on what the partners have developed already through the on-campus store by establishing with Johns Hopkins the Brancati Center for the Advancement of Community Care. Named after the late director of Hopkins' division of internal medicine, the center will aggregate the care model research under one organization.

Grossi and Clark both envision the Brancati Center as a place where healthcare leaders can come to see and train on certain protocols they develop, and where Hopkins and Walgreens can assist in evaluations on whether such innovations can be integrated into other hospitals and health systems in a high-quality fashion.

"We can't be everything to everyone in this new healthcare marketplace," Grossi says, "but within our sphere we have to be able offer everything. Wherever there's a responsible partner, we're interested in talking to them."

As for what might come of the partnership eventually, in terms of cannibalization of traditional hospital-provided services, Grossi is philosophical about the financial impact to hospitals and health systems.

"We don't know who's going to win or lose in this. This is more a learning experience," he says. "Walgreens is trying to get as close to our operations as possible and we to theirs to understand where there is a meaningful opportunity to support the patient care mission. This is the only joint venture between a large medical center and a drugstore company that I'm aware of, and their new leadership team is as committed as we are to live in each other's worlds as much as possible."

Reprint HLR0815-6