Hospitals Rethink the Service Line

This article appears in the March issue of HealthLeaders magazine.

See Also: The Cardio Service Line, Rebooted

Amid economic turbulence and regulatory changes, service lines are becoming more integrated into hospital strategic plans, where these areas of specialization can thrive—although many healthcare leaders are checking the vitals of their service lines to see what treatment may be needed.

While general surgery, cardiovascular care, and orthopedics still head the list of service lines with strong positive margins, more areas of specialization are popping up or expanding, such as geriatrics or plastic surgery, depending on the demographics and needs of a region. Hospitals large and small are reviewing their service lines, with some leaders feeling the need to revisit these programs to take advantage of multidisciplinary approaches, subspecialties, or technological advances.

Various models are being implemented to improve coordination and data collection that allow hospital and health system leaders to scrutinize the direction of their service lines for greater ROI. Throughout the country, leaders have been retooling their service lines by changing strategic plans and evaluating demographic and coordination needs while using technology to eliminate waste and improve patient engagement.

Officials of Allina Health—a Minneapolis-based nonprofit that serves Minnesota and western Wisconsin and includes 11 hospitals, 42 clinics, and 1,677 beds—began revamping clinical service lines several years ago to overcome what they called "fragmented care delivery" in the programs, says Penny Wheeler, MD, chief clinical officer for Allina Health.

Using a medical process to align physicians and facilities, Allina Health has imposed changes leading to cost savings—millions of dollars over the past three years—while reducing length of stay and readmissions. In its revamped structures, Allina worked to coordinate programs from wellness to palliative care, Wheeler says.

Leaders at Indianapolis-based Indiana University Health, a nonprofit organization with 3,326 licensed beds, also thought they had a disjointed system. They consolidated oversight of 19 hospitals—each with its own institutional board. The prior lack of full systemwide integration shortchanged delivery and income, says Doug Schwartzentruber, MD, system medical director for cancer services and associate director of clinical affairs for IU Health's Melvin and Bren Simon Cancer Center.

The demographics of a market also are a driving force for strategy, physician alignment, and growth, says Mark Loos, system vice president for clinical services at the 1,138-licensed-bed nonprofit Palmetto Health in Columbia, S.C. To accommodate the needs of an older population, for instance, the importance of working with employed and independent physician groups to provide appropriate access to care has never been greater, Loos says.

Organizations are finding that technology can play a critical role in improving service line care. Hackensack (N.J.) University Medical Center relies on technology to improve patient engagement with its cardiology service line, which helped prevent hospital readmissions and improved patient satisfaction, says Louis E. Teichholz, MD, chief of cardiology at the 775-licensed-bed hospital.

Despite the complexities, the potential for service lines is enormous, especially with the need to eliminate wasteful spending, says Peggy L. Naas, MD, MBA, vice president of physician strategies for VHA Inc. based in Irving, Texas. VHA includes more than 1,400 not-for-profit hospitals and 25,500 nonacute healthcare organizations.

Service lines can overcome work flow waste and unexplained variations in clinical processes and operations, Naas says. Even service lines that may have originated from a marketing and sales inspiration can tell a community, "Look! Our hospital specializes in this area," according to Naas. Now, she sees more hospitals being concerned about service line care delivery and tightening their organizational structures and management.

"Much of healthcare happens outside the hospital; a real unmet opportunity point is in the transition and in the continuum of care," says Naas.

Revised strategic vision

Allina Health, Indiana University Health, and The Christ Hospital, a 555-bed not-for-profit acute hospital in Cincinnati, are among the healthcare organizations that found it necessary to revamp their clinical service lines to overcome inconsistency of care by changing their strategic vision.

Over the years, Allina Health tried repeatedly to make changes to its service lines, and each time, it was unsuccessful. "Four times it was tried in our organization and it failed," recalls Wheeler. The clinical service lines were based primarily on operational and business practices but failed to improve coordination of clinical programs, she adds.

In those attempts, Allina initiated changes to service lines to cut costs and make them "more efficient in terms of resource use." That was a mistake because "there was very limited engagement of those who made care decisions—the patients, the doctors, and other caregivers," Wheeler says. "While well-intended, it did not get directly to the real mission of the organization—providing exceptional care—and so didn't speak to the true interests and motivation of the clinical community."

So the healthcare system conducted a strategic review of clinical service lines. A 2010 Allina blueprint dubbed "clinical service lines" addressed the way the organization planned to improve. It said that employed and independent physician partners would be involved in a leadership structure, along with "active involvement" of patients in advisory committees. In the meantime, it adopted "deliberate implementation of processes that first and foremost facilitate improvements in clinical care." From the C-suite to the emergency department, Allina officials reviewed many systems throughout the country to study ways to improve its service lines.

"Like most U.S. healthcare organizations, Allina's current delivery model is based largely on location of services," the blueprint states. "Care processes, quality outcomes and operational efficiency vary across providers and sites of care. This variation may not serve patient or community need. Clinical service lines offer a foundation for a more fully integrated care delivery model that serves patient and community needs across the continuum of care by improving clinical quality, patient experience, and operational efficiency, and reducing total cost of care."

Allina took significant steps to change the focus of its service lines via the strategic plan, Wheeler says. "Fortunately, if you have the clinical folks define with the patients the best care, efficiencies follow through by reducing unhelpful treatments and costs are reduced. We focused on building the clinical service lines around care conditions of the patients."

Allina Health began to concentrate on high-volume service lines, such as cancer, neuroscience, spine care, women's health, and mental health, and in the past year added gastrointestinal care because of a growing need. The oncology programs focused on breast and lung care. The provider also developed programs focusing on underserved populations, through its Allina Mental Health system and Sister Kenny Rehabilitation Institute.

The health system revised its organizational leadership team over service lines with a physician governance committee that reports to the Allina board of directors. It also improved alignment of physicians through a physician network. "We continue to build these service lines and balance them as rapidly as possible to benefit more patients, while focusing on building them incrementally to focus and do the programs well," Wheeler says.

With this transformation, Allina sees service lines as core areas of hospital care that could flourish. Service lines have the potential to "increase the value of care, provide better outcomes and experiences for patients," Wheeler says. "I think you will not only see service lines surviving nationally, but they are representative of a structure that everyone is going to need."

The Christ Hospital initiated Vision 2020, a strategic plan that includes revamping its overall service line structure with designs on greater efficiency for inpatient as well as outpatient needs. Part of the plan includes clinical service portfolio and medical staff development, says Herb Caillouet, MS, PT, executive director of the musculoskeletal services for the hospital.

Under Vision 2020, hospital officials evaluated various practice models, in part by looking at how service line physician groups and organizational staff "relate to one another and the hospital." In addition, the hospital leadership stated in the plan that the "acute care hospital should no longer be the center of the health system, but rather part of a coordinated continuum of care delivery to serve people through the illness, healing, and wellness phases of life."

Indiana University Health made a strategic decision about how to deliver services as a large system, according to Schwartzentruber, noting that the system's oncology service line, for instance, "had been functioning as a bunch of independent components" at its various hospitals. The components were not coordinated. As they developed the strategic plan, leaders examined other facilities within the Indiana University Health system to determine how best to proceed.

About 18 months ago, the IUH officials examined their hospitals' experiences to review the quality of service lines and get tips whenever and wherever they could. "We were charged with putting together the service line and basically we traveled the state. We created a vision for what the service line would be like," Schwartzentruber recalls.

Dealing with demographics

Depending on regional needs, one service line may be important for a hospital or healthcare facility, while it is a losing proposition for another. One factor that could have an impact on individual service lines is the healthcare needs of those who may be among the 32 million people to be insured within the next two years under the Patient Protection and Affordable Care Act.

The Christ Hospital initiated a new musculoskeletal program geared toward the elderly population and younger baby boomers who are now reaching age 50. The hospital chose musculoskeletal services to form a "market-leading program," Caillouet says.

"It was important to develop a strategic network of care—similar to what we had in successful heart and vascular programs—for musculoskeletal," he says. The Christ Hospital musculoskeletal service line includes surgical and nonsurgical spine, total joint replacement, sports medicine, and general orthopedic services. The program was added to the hospital's other service lines: heart and vascular, oncology, women's health, and geriatrics. Other hospital departments fall into either "specialized surgical care" or "integrated medical management" categories, Caillouet says.

"The ortho community here was quite fragmented and so we believed there were great opportunities," Caillouet says. Recruiting and realigning physicians was essential, with "surgeons and nonsurgeons working together to streamline the service," as well as improving relationships with primary care, rehab, and neurology physicians, he adds.

With a better-aligned and -positioned service line, The Christ Hospital had 7,100 orthopedic surgical cases in 2012—a 9% increase over 2011, which had 6,500 cases. In addition, the hospital led the tristate area with 24% share in spine surgery. Surgical complications rates decreased to 24% last year. In the meantime, inpatient direct variable cost per case in the 2012 fiscal year decreased by 8% compared to the same period the previous year, Caillouet says.

The hospital is coordinating the new musculoskeletal program with The Christ Hospital Spine Surgery Center, a freestanding facility for outpatient spine surgeries and pain management procedures. The surgery center is included in a partnership among The Christ Hospital, spine specialists from the Mayfield Clinic in Cincinnati, and United Surgical Partners International, a Dallas-based for-profit that owns and operates surgery centers and private surgical hospitals in the United States and the United Kingdom.

Keeping an eye on competition is critical, says Loos of Palmetto Health. "You don't want to be a patient and wait six months to see a specialist." If they faced that kind of wait, "patients may choose to go to Charleston or Greenville to competing hospitals," he says. So Palmetto is examining potential shortages in key medical and surgical positions or subspecialties that it may need to buttress to maintain or expand patient access. Service lines are being designed not only for improved clinical care and outcomes, but also with an eye to the manner in which the organization can attract them into the system, he adds.

Patients' expectations for care are changing how orthopedic, cardiac, and oncology services are delivered, as a more educated patient population is increasingly active and engaged in the care process. "They are ready to participate in their care. They are doing research online and asking questions and using social media," Loos adds.

Coordination of cancer care

Oncology service lines are among the most popular and the most important for hospital revenues. As a disease with a single name but thousands of variations, cancer requires many treatments, as well as types of care. That is just one of the facts that can make running a high-functioning oncology service line complex.

At Indiana University Health System's cancer centers, leaders identified inconsistent levels of cancer care through the system and determined that they needed a more coordinated service line, says Schwartzentruber. Before IUH moved ahead, hospital officials identified several key goals: Achieve buy-in from internal stakeholders, create benchmarks to measure progress in the system, and compare its plan with other systems, he says.

The numbers alone were telling the story of the need to improve an oncology service line, says Holly Goe, RN, MSN, vice president of cancer services at IUH.

"Obviously we have a lot more cancer survivors than we did 10 or 20 years ago. We're making sure that we continue to provide what care survivors need, treating [cancer] more as a chronic disease than we have in the past," says Goe. "One of the first things we had to do was integrate all the sites and create buy-in. We brought all the leaders together [to decide] how we should move the service line forward."

As leaders developed the program, they did so with the recognition that cancer patients need a comprehensive model of care, Schwartzentruber says. All employed and independent oncology practice sites were to include patient navigation, use of clinical pathways to drive treatment decisions, plans of care and treatment summaries for each patient, and the multidisciplinary approach to care, including access to a broad array of cancer clinical trials, he says.

"When the vision was created, we realized we needed to be comprehensive throughout the cancer journey, from diagnosis through survivorship," Goe adds. In addition, the hospital created outpatient programs for palliative care and survivorship programs for cancer care.

As part of the change, hospital officials created a service line administrative and clinical management team to ensure all operations carried out at network sites are consistent with tactical goals. That leadership at the IUH system includes the medical director, the leadership council, and Goe as vice president of cancer services. Each facility within IUH has an operational leader and medical director. The oncology leadership council includes physician leadership and administrative leaders responsible for all representatives of the practices and sites.

Importance of data

Data improvements have been necessary to keep track of potential problem areas in service lines. Allina Health's enterprise data warehouse has the ability to track, report, and analyze care over time to allow the health system to understand clinical outcomes, utilization, and costs, according to Wheeler. A financial officer and a physician leader have been assigned to each clinical service line as part of the data warehouse oversight. They report to an executive committee, which includes presidents from each of the hospitals.

"The data infrastructure is one of the keys to all we do, with the other being the engagement of caregivers and patients," she says. "The EDW continues to expand and gives those in a position to improve care information on the greatest opportunities to do so.

"It does so from an aggregate population level all the way down to an individual level," she adds. "We would not be able to understand our outcomes improvement without the integrated data warehouse. It is vital to our future of demonstrating quality and value to all we serve."

Technology also can play a role in improving patient engagement. Leaders at Hackensack University Medical Center discovered a need to better the cardiovascular service line to help prevent hospital readmissions and enhance patient satisfaction.

The University Health Network is the nonprofit New Jersey–based parent company of HackensackUMC and corporate joint venture partners with LHP Hospital Group, a Plano, Texas–based for-profit organization in ownership of two hospitals: HackensackUMC at Pascack Valley and HackensackUMC Mountainside.

As hospitals move from volume- to value-based healthcare programs, "interacting with our patient more often and more effectively" is a key to better outcomes and reduced readmissions, says Teichholz, the medical director for cardiac services at HackensackUMC.

 "When you look at the statistics for congestive heart failure and heart attacks, we give excellent care. Our mortality rate is very low, but our readmission rate has not been at the top and is something we wanted to improve on," Teichholz says. "We were very concerned about moving that forward and, of course, the government will be penalizing hospitals for readmission rates."

Indeed, in 2012 HackensackUMC reported a 26.7% all-cause heart failure readmission rate for 1,889 patients, compared to 24.7% for the national average, according to the Centers for Medicare & Medicaid Services' Hospital Compare website. Within the past year, however, HackensackUMC decreased the all-cause heart failure readmission rate to about 21%–23%, Teichholz says.

HackensackUMC, as part of its effort to reduce readmissions, was among four
hospitals to participate in a pilot program designed to follow up with congestive heart failure patients after discharge. The hospital uses EmmiTransition—an automated, interactive system of outreach tools—to call patients for 45 straight days after discharge, reminding them when to schedule an appointment with their primary care doctor, take their medication, or complete other actions.

The voice response system asks patients questions, such as their weight, and reports the information to the hospital. The pilot program saved an estimated 600 hours and found more than 313 red flags—recognition of a possible risk factor, such as weight gain—that otherwise may not have been captured, according to Teichholz.

"Through at least one initial telephone call to every patient from our nursing staff, improvement in postdischarge instructions for all patients, and the use of Emmi, we have met our goal of decreasing all-cause CHF readmissions," Teichholz says.

"It did make a substantial difference compared to usual care. For congestive heart failure patients, the communication program has shown to be more effective than not using it, based on a comparative review." The program enabled the hospital to decrease readmissions of more than 60 patients by 20%–25%, he says. Total CHF readmissions are now 7% with a readmission diagnosis of CHF, Teichholz says.

"The key to preventing readmission is the engagement of patients," Teichholz says. "What we've learned is that trying to educate patients before they leave the hospital doesn't always work. They just want to go home. In this way, we're getting patients involved as a partner in their care and making sure that they make an appointment to see their primary care physician, making sure they get their medication and continue with the medication."

Joe Cantlupe is senior editor for physicians and service lines for HealthLeaders Media. He may be contacted at jcantlupe@healthleadersmedia.com.

Reprint HLR0313-2

This article appears in the March 2013 issue of HealthLeaders magazine.