Reduced inpatient admissions and readmissions are having a corresponding effect on hospital and health system revenues, with question marks over reimbursements. Hospitals are bracing for impact.
This article appears in the March 2014 issue of HealthLeaders magazine.
That rumbling sound you hear is the seismic shift of patient volumes for hospitals. Inpatient volumes and readmissions are shrinking. Newly insured are knocking at the door. A bundle of contradictions is at hand. Hospitals are bracing for the possibilities and the what-ifs.
At the Beaumont Health System, officials are working hard to anticipate shifting patient populations. Beaumont is a regional healthcare system with 1,728 licensed beds at three locations in the metropolitan Detroit area. Because it is an integrated system, Beaumont's leaders are confident they can move ahead effectively in the coming patient population environment, says Nick Vitale, executive vice president and CFO. Still, there are always wrinkles in the planning process.
Several months ago, Beaumont opened a 12-bed physical and occupational rehabilitation unit at its Troy Hospital because, without such a facility, Beaumont found itself sending patients to competing facilities.
What surprised hospital officials, Vitale says, was that "it filled up so quickly, in a couple of months." Essentially, "we look to see where there's a need and use our limited resources."
Across Detroit, Henry Ford Health System's top officials also were having plenty of meetings about the future and thinking about the flip side of their success in recent years of reducng readmissions and having fewer patients in their hospital beds. That effort worked. Now what? To improve its market share, Henry Ford is looking to collaborate with postacute care providers and planning on improved care for the aged and chronically ill.
Henry Ford is a comprehensive, integrated, nonprofit healthcare organization that includes six hospitals. Since early 2013, the number of admissions to Henry Ford hospitals has declined 6% and readmissions decreased about 19%. The overall admissions rate has hovered around 40,000 annually, according to William Conway, MD, the health system's executive vice president and chief quality officer, who also serves as CEO of the Henry Ford Medical Group.
Those figures are all good news; that's where healthcare is headed, toward value-based care, says Conway. But that success doesn't mean Conway or the other Henry Ford officials are resting easy.
"The scary part and the hardest thing is nobody really knows what consumers are going to do," says Conway. "Efficient patient management should suggest there would be less need for hospitalization and maybe fewer encounters for patients and the hospital. Yet with healthcare reform, these forces aren't perfectly aligned." Henry Ford is maintaining the course and is "not planning for a large influx of any ambulatory setting and not bulking it up," he says.
The shifting patient patterns and projections are giving healthcare leaders headaches. The reduced inpatient admissions and readmissions in some markets have a corresponding impact on hospital and health system revenues, with question marks over reimbursements. At the same time, healthcare organizations are bracing for an influx of new patients under the Patient Protection and Affordable Care Act.
Integrated systems and hospitals agree that they need to aim for comprehensive care that targets the shifting patient populations—especially the projected increase of chronically ill patients and the aging. And as organizations try to prevent readmissions and move toward preventive care in a population health model, they will be focusing on post-discharge care, ensuring prescriptions are filled, and making follow-up appointments.
To carry out their mission, leaders believe they must strengthen their provider base and make doctors more readily available via advanced technology or even simple phone call appointments. Ultimately, coordinated care with fully engaged communities is the best answer toward the shifting patient volumes, though not something easily accomplished.
Uncertain scenarios
Although predicting patient populations can be complicated and uncertain, hospital admission rates in the United States have been on a long-term decline, often due to better treatments. The reasons for many admissions today are different than they were 30 or 40 years ago because of improvements in care, says Lloyd Michener, MD, chairman of the department of community medicine at the 957-licensed-bed Duke University Medical Center in Durham, N.C. For example, while pneumonia was a key reason for admissions decades ago, that is no longer the case. Yet hospitals are predicting an increasing need for hospitalization from a growing aging and chronically ill population, he says.
Among the unresolved areas of shifting patient populations is the estimated 14 million people who are expected to join the ranks of the newly insured this year and the expansion of Medicaid eligibility. That got off to a complicated start last year when there were flaws in the computer systems at HealthCare.gov and state-based insurance exchanges.
Then, there is the question about the potential impact of the young population that is expected to go into the system, ostensibly to offset the costs of the elderly and the chronically ill. Is the potential dramatic or will it be a bust? These issues are bound to complicate hospital finances and will play a role in how leaders adjust to shifting patient populations.
"It's hard to model what's going to happen, with the expansion of Medicaid and those who are becoming eligible," says Vitale of Beaumont. While there was confusion stemming from computer glitches in the sign-up process for the uninsured last November, Vitale says he is concerned about "added costs going forward."
Like many hospital executives, Vitale is uncertain about how many of the young uninsured will sign up for care. "They view themselves essentially as bulletproof, and they go bare until they have an issue. They'll have this huge bill that will have to be settled; a lot of it will become bad debt," he says.
One certainty is that there will be winners and losers. Some hospital executives are moving cautiously, waiting for any more legislative changes. Others believe there is no time to waste and are heading rapidly toward their chosen plan.
For those moving ahead, they are forming medical homes, patient-centered care models, and population health centers through accountable care organizations; they are expanding outpatient facilities, enhancing specialized care, and focusing on forming community teams, especially with a revamped primary care base, to better address avoidable admissions, readmissions, preventive care, and risk-based contracts, says Michener.
A major area of concern is not only for the welfare of patients but for the economic consequences as hospitals focus on readmissions. As part of the national Hospital Readmissions Reduction Program, established by the PPACA, the Centers for Medicare & Medicaid Services began to reduce payments to hospitals with excessive readmissions, effective October 2012.
Targeting readmissions
Henry Ford Health System took specific steps that led to patient readmission reductions, and hopes to set the stage for improved coordination not only among its own healthcare team but also outside hospital walls through medical homes and population health management, Conway says.
One of the major focus areas involves decreasing 30-day readmissions for heart failure patients. The cardiac telemetry unit at Henry Ford Hospital uses a patient education program about heart failure and a postdischarge phone interview program for patients within 24–72 hours of discharge to verify that medications are being taken and a physician follow-up is scheduled.
In a review last year of 185 patients over a 5-month period, the hospital found that 77.3%, or 143, were admitted with the primary diagnosis of heart failure. The 30-day readmission rate was 10.5%, and the home care referrals rate was 72.8%, according to hospital reports.
Conway says hospital officials have been aggressively focusing on care coordination. To address the "medical, social, and financial aspects" of hospital readmission issues, the system leadership established the care coordination initiative in 2012. The purpose was to standardize care coordination and transitions throughout the Henry Ford Health System to "provide seamless care to each patient at every stage and point of care."
The initiative involves projects and teams that focus on specific disease states and "crucial points" of patient care transition. It includes transition nurse coordinators to focus on patients with a high risk of readmissions, and a heart failure readmissions team—including cardiologists, nursing staff, case managers, and pharmacists—that conducts heart failure classes for inpatients and discharged patients, makes phone calls to patients after discharge, schedules primary care physician appointments within 7 days of discharge, and provides educational materials and home care referrals with telehealth monitoring.
Henry Ford Hospital has gradually reduced all-cause readmissions from 2011 through 2013. Its readmission rate was 15.6% in 2011, 15.1% in 2012, and an unofficial 12.9% during 2013, while figures were still being tabulated. Its 2013 target was 14.2%.
For the entire Henry Ford Health System, it reports that the readmission rate dropped from 13.1% in January 2011 to 11.2% in June 2013, well below the 2012 average national rate of 18.4%.
Even as HFHS has reduced readmissions, it still has been hit by CMS penalties. But those penalties are decreasing steadily, Conway says. A hospital system report shows that penalty fees for federal fiscal year 2013 totaled $2.2 million, but the hospital system had reduced penalty fees slightly for fiscal year 2014 at three hospitals, to less than 1%. The CMS penalty fees for 2014 applied to excessive readmissions for acute myocardial infarction, heart failure, and pneumonia.
"Those steps will continue," Conway says of the efforts to reduce readmissions. He cites especially important steps: "more aggressive internal screening of admittance requests to avoid insurer rejections" and deploying "30 nurse case managers to our primary care practices for the medical home model. They closely monitor patients at high risk for admission to keep them out of the hospital."
ACO focus: Population health
The 1,321-licensed-bed WellStar Health System based in Marietta, Ga., is a large integrated system with five hospitals and seven urgent care centers and plenty of competition. The 169-bed Cheshire Medical Center/Dartmouth-Hitchcock Keene is a smaller organization that includes a community hospital and medical practice associated with Lebanon, N.H.–based Dartmouth-Hitchcock Medical Center.
At both WellStar and Cheshire Medical Center, leadership focuses on physician involvement, controlling readmissions, and using the ACO model. In WellStar's case, inpatient discharges remained flat (down 0.5%) between fiscal year 2010 and fiscal year 2013. At Cheshire, inpatient volume has been down significantly, about one-third over the past few years.
"Managing the readmission rate is a key priority," says Chris Kane, senior vice president of strategic business development for WellStar. He says there has been an 8% readmission rate for all causes, which has been a target. Overall, he says, the nonprofit system had inpatient volumes that were "flat" from 2012 to 2013, although observation cases increased 9%.
With the ACO, it has focused on managing its service lines to allow physician leadership and managers to design clinical plans for each area, Kane says. By "having formalized 11 clinical service lines, our physician leaders are literally at the table when opportunities are evaluated," which is integral to overall patient growth, he adds.
"In metro Atlanta's competitive market, we have learned that sustained growth only occurs with flawless tactical execution," Kane says. "Now success demands a precise plan about the market segment, the basis for differentiation, and the economics. Although health systems have always had a planning process in place, the stakes are higher now because of margin pressures."
The organization has 500 primary care providers, specialists, and advanced practitioners in its WellStar Medical Group's 100 locations. WellStar's outpatient services have accounted for a growing percentage of its revenue, up to 54%.
"A broader definition of primary care is also essential for the execution of the strategy. We have added urgent care centers, developed a partnership with Walgreens, and evaluated other business models," Kane says.
As system officials review technological improvements, "the difference in the decision-making about technology is the expanded role of physicians," he says.
A significant element in WellStar's planning involves different ways of allocating its resources, and that's where the ACO model is effective, Kane adds. WellStar has a partnership with Piedmont Healthcare to better coordinate care. "We want to be in the fast lane in health management." WellStar and Piedmont have created the Georgia Health Collaborative, which may expand delivery systems. WellStar has an ACO with nearly 40,000 Medicare lives.
"The objective was not to receive an ACO T-shirt from CMS. Rather, the ACO designation forces an organization to allocate resources to learn a new approach," Kane says. "All of these strategies underscore a commitment to management of the health of a defined population.
"Aligned physician incentives are a central theme in our strategy. Physician employment continues to grow for multiple reasons. Although employment permits the highest level of alignment, few health systems can rely entirely on employed physicians to succeed," Kane says. "At WellStar, we focus on creating parity between our employed physicians and affiliated independent physicians. All physicians are involved in our service lines and have a voice."
WellStar's health strategy is focused on outpatient care; the organization has committed nearly $200 million to a "health parks" concept, which would feature several 200,000-square-foot outpatient campuses in the community. Several were in the planning stages in 2013. "Patients are looking for the three C's: clinical excellence, convenience, and coordination. Our health parks are designed to meet these expectations," Kane says.
Kane foresees a healthcare landscape that will involve more partnerships and mergers. As the health system moves forward, "in many respects healthcare is like a middle school dance. The music is playing and you are nervously looking for a partner," he says. "It may be one dance or a long-term relationship, but either way, you feel compelled to do something."
ACO focus: Reducing admissions, costs
In New Hampshire, Cheshire Medical Center/Dartmouth- Hitchcock Keene has been caught in the wave of shifting patient volumes and has seen inpatient admissions drop by about one-third over the past several years, says Art Nichols, the president and CEO. And that, he says, isn't such a bad thing.
"Between the hospital and our physicians, we took a hit that already hit our census: It has declined," Nichols says. "From around 2009 to now, our inpatient census is down about one-third, maybe slightly more than that. That's what happens when you have a group of physicians trying to keep people out of the hospital."
Physicians have been working closely with healthcare leaders to reduce the amount of time people are spending in the hospital. In 2007, the organization was involved in a pilot physician group practice demonstration that Nichols describes as a "precursor to accountable care."
Cheshire Medical Center/Dartmouth-Hitchcock Keene is among 32 groups selected by the Centers for Medicare & Medicaid Services' Innovation Center to participate in the Pioneer ACO model. The program, which began in 2012, identifies whether improving care in a "proactive and coordinated manner" also reduces costs. In 2012, the Dartmouth-Hitchcock project generated approximately $2.5 million in savings as part of the Pioneer model.
"We got a jump on the whole notion of accountable care and because of that our physicians have developed some skills to keep people well and keep them out of the hospital," he says. "We've been about 50% below the national average for Medicare readmissions for many years now."
In particular, patients with coronary disease and diabetes were among those who "tended to be admitted over and over again, and those are the ones that we've tried hard to keep out when not necessary," Nichols says. "We already have risk-based contracts with many of our insurance companies, and it begins to make a difference when you bring the commercial piece into the equation and you reach a point where a higher census is not necessarily a good thing for the hospital. You are being paid a fixed fee for care for patients, not quite capitation, not far from it. It's very hard for a hospital to get over the idea that fee-for-service is not forever. I know it's a hard thing to get over."
Cooperative agreements have opened the door for the hospital to expand its reach into the community and improve its population health. In fact, the hospital is encouraging people who live within the area of 3,165-foot Mount Monadnock, through an initiative with its physicians group dubbed Healthy Monadnock 2020, to help Cheshire County become the healthiest community in the United States by 2020. The county has 23 towns and 76,851 residents.
The plan, years in the making, includes government and civic policy changes that officials hope will prompt its schools, workplaces, and towns to make healthy choices about how they eat, exercise, and take care of themselves. Thousands of people are involved in keeping track of their own health by measuring their commitment to lose weight and get fit. While schools are revamping their menus to maintain nutritious dining fare, local planners are drawing up sketches for sidewalks and parks to encourage residents to walk and run.
Ultimately, Cheshire Medical Center/Dartmouth-Hitchcock Keene and local physicians are helping people "create an awareness" of their own health, says Nichols.
"We're not unlike a lot of other communities; we are the only hospital in our county," Nichols says. "When you are the only hospital in the market and are a significant provider, I feel there's a responsibility to that market. We don't want to wait for people to get sick and show up in our offices or emergency room. That's not enough to do our jobs."
Nichols says the hospital also is developing more medical home models in the community with primary care physicians. By reaching out to government agencies and civic groups, the hospital is making integral steps to touch each person's health. He says the hospital worked with local providers—from general practitioners to dermatologists—to encourage local residents to measure and reduce their blood pressure. Within six months, 68% of residents achieved goals, and that has since increased to 84%, Nichols says.
A primary focus on ambulatory care
The push toward outpatient care reflects one of the most significant shifts of patient volumes. In 2012, outpatient volume continued to "grow at a robust pace" while per beneficiary inpatient admissions continued to decline, according to a 2013 MedPac report to Congress. Inpatient admissions per fee-for-service beneficiaries declined 1% per year from 2004 to 2010. The volume of hospital outpatient services per Medicare FFS beneficiary grew on average by 4.2% per year from 2004 to 2010.
Government incentives "to keep people out of the hospital will have a dramatic impact on inpatient volumes," says Sang-ick Chang, MD, assistant dean for clinical affairs and clinical professor at the 613-bed Stanford University School of Medicine in California.
Stanford's new primary care system has an emphasis on patients with chronic diseases, such as lung disease, asthma, and diabetes, Chang says. The hospital is focusing on ambulatory intensive care for people at high risk for hospitalization." The ambulatory intensive care unit includes providers, social workers, and mental healthcare to give patients the resources they need to keep them out of the hospital, he says.
Often, the patients who are treated have multiple hospitalizations. "We find the reasons often have to do with patients' social circumstances, their family support, and the patients' motivation" for care, he says.
Unlike some areas of the country, Stanford's patient population includes many who are insured and have their own primary care doctors. Located 35 miles south of San Francisco, Stanford is in the heart of Silicon Valley. Too often, Chang says, many patients simply see specialists or subspecialists directly for their care. Increasing patients' access to primary care physicians "helps avoid duplication and unnecessary or unwanted treatment, and helps patients navigate multiple specialists," he adds.
To improve its primary care base, Chang says the hospital is planning various "medium-sized community-based primary care practice" centers throughout the area. "The ambulatory capacity has resulted in growing demand for primary care," he says.
"To meet the demand, the providers will be closer to patients' homes rather than being at the medical center," Chang says. "We understand that as much as patients value the name Stanford, they also value time and convenience. The hospital also has opened the door for after-hours in an office setting," he says.
Across San Francisco Bay, Kaiser Permanente, based in Oakland, has been considered one of the leaders in integrated systems and aligning incentives in shared-savings plans and coordination with physician groups. Kaiser includes the Kaiser Foundation Health Plan and Kaiser Foundation Hospitals.
Kaiser, too, has looked closely at "upstream ambulatory care prevention," and such programs are important in reducing hospital admissions and lengths of stay, says Jed Weissberg, MD, FACP, senior vice president for hospitals, quality, and care delivery excellence.
Kaiser focuses on risk-factor management for heart, kidney, and stroke patients. Its home health programs have had a major impact on hospitalizations, Weissberg says. "We continue to see the readmission rate drop and the overall day rate decline. The overall Medicare inpatient day rate declined over the past three years from 1,000 to 700 days per 1,000 members," Weissberg says, "which was beyond what we thought was achievable."
Kaiser also is evaluating needs for more focused care for the elderly that it hopes will result in "better attention to the general needs of the frail and sick," Weissberg says. For instance, Kaiser physicians are stepping up coordination with other caregivers to deter fall prevention, improve osteoporosis diagnosis, and evaluate dementia and delirium, he says.
Kaiser Permanente's Transition in Care program was initiated to target readmissions and is designed to meet the principles of a complex adaptive system, such as stratifying patients by risk of readmission, creating a standard discharge summary, and reconciling medications across the continuum of care.
In addition, the program calls for a posthospital discharge hotline, scheduling a patient to see a doctor within seven days of discharge ordering a palliative care consultation for high-risk patients as appropriate, and conducting a case conference if a patient has a complex disease. A Kaiser report indicates that since the program was implemented in 2012, its absolute readmission rates declined by 3%.
Kaiser also is focusing on improved community and social care, determining whether patients need transportation or nutrition services. Medicine is not always the answer for care, Weissberg says. "We have to look at lifestyle and environmental factors, as well as what we think about medication adherence."
Confidence and challenges
Beaumont Health System is a perfect example of a system that is confident it can handle the shifting patient volumes but faces additional challenges based on an uncertain future. Its Royal Oak, Mich., hospital is a 1,070-staffed-bed major academic and referral center, its Troy hospital has 418 staffed beds, and its Grosse Point hospital has 250 staffed beds. The hospitals' medical staffs have more than 3,100 physicians. The system has ambulatory surgery centers, physician office buildings, and a home care division. Its postacute management has been growing.
"We can really take care of a full spectrum of a patient's experience for episode care management," Vitale says. He points to the organization's nimbleness when it needed to make the acute rehabilitation changes at its Troy facility: "For managing a population, we are positioned quite nicely."
And Beaumont is doing something else to help in its value-based care, such as reducing the number of readmissions, but Vitale says, "there are other factors working against us at the same time."
As Beaumont begins to prepare for the shifting volumes, one of the first things it will be looking at is dealing with potential reductions in admissions, with issues inside and outside the hospital walls. "We've taken our best stab at estimating what the impact and the shifts will be, and factored into long-range planning how we can offset losses. We will need to adjust estimates and see in reality what's going to happen."
Beaumont and other hospitals are facing regulatory issues involving observation units that have an impact on how they are caring for patients. Such units have increased significantly, as hospitals hope to improve their patient flow and reduce costs. Beaumont Health has been adding them through much of its system, with 50% more patients classified as observation over the past three years, according to the hospital.
Many healthcare leaders are concerned that CMS is revising guidelines for what can be classified as inpatient admissions. "CMS and other payers are making it harder and harder to classify inpatients coming in the door; they are changing the criteria of allowable inpatient admissions," Vitale says. "CMS continues to change the rules, and it is difficult to stay up to date." Under a new policy, if a patient is not in bed two consecutive midnights, he or she would automatically be considered outpatient, Vitale says.
"That will hurt most providers significantly, because we get paid about three times as much for an inpatient than we do for an outpatient stay."
The observation issue is among the challenges hospitals are trying to address as they confront the impact of shifting patient volumes, Vitale says. There is much uncertainty, he says. "I think most folks are like we are; we don't see anybody building new bed towers or things like that."
Reprint HLR0314-2
This article appears in the March 2014 issue of HealthLeaders magazine.
Diabetes is a potentially significant area for other hospital service lines, such as cardiovascular or oncology programs. So hospitals are teaming up with insurers, tapping into technology, and intensifying follow-up care for diabetic patients.
This article appears in the January/February 2014 issue of HealthLeaders magazine.
In 1999, Saint Mary's Hospital in Grand Rapids, Mich., opened a diabetes center. Little did hospital officials know then, but they were ahead of their time and today are confronting a disease that affects about 8.3% of the U.S. population.
Other healthcare leaders are responding, too, devoting resources to help overcome a disease that some view as rampant or out of control. To try to stem the increasing incidence, education programs are booming. Electronic medical records are in demand. Physician groups and hospitals are using apps to engage in patients in the moment. Physicians and pharmacists are teaming up to ensure patients know about their medications.
In 2011, Saint Mary's Health Care was renamed Mercy Health Saint Mary's, as part of Saint Mary's in Grand Rapids and Mercy Health Partners in Muskegon. The regional system includes five hospital campuses with 800 total beds. It is part of Trinity Health, the national Catholic hospital system based in Livonia, Mich.
Mercy Health Saint Mary's original diabetes center merged with Thyroid Specialists of West Michigan to become what it is today, Mercy Health Physician Partners Diabetes & Endocrine Center in Grand Rapids. The organization's diabetic care framework is much more sophisticated today, as a multidisciplinary team evaluates patients and coordinates care for a growing patient population.
"Diabetes is a dynamic disease that is always changing, and we look to be on the cutting edge," says Mary Harnish, RN, clinical nurse leader who oversees the inpatient diabetes program at Mercy Health Saint Mary's, which in 2011 received inpatient diabetes certification from The Joint Commission.
"We expect to see increases across the nation, not only because of an increase of obesity but also because we are doing a better job of catching diabetes. Primary care physicians are doing a good job of screening," Harnish says. "People are coming to the hospital who may not have a primary care doctor, and those who are seeking care are so sick they are coming to the emergency room. That's always a challenge and shows how important it is to have early detection by primary care doctors."
Diabetes requires continuing medical care, plus ongoing patient self-management and education to prevent acute and long-term complications. Some patients "have a passion about taking care of themselves, while other are less attentive to the self-care of their disease," says Harnish.
For hospitals, focusing on diabetes is a potentially significant area for other service lines, such as cardiovascular or oncology programs. Hospitals are launching specific diabetes-focused efforts and teaming up with other facilities and insurers, initiating education programs, tapping into technology, and intensifying follow-up care.
The diabetes patients are at higher risk than other patients for complications, falls, and longer lengths of stay, which can have economic implications. Starting in fiscal year 2015, hospitals that have high healthcare-acquired complication rates will see their Medicare payments cut 1%. Hospitals targeted for such cuts would be in the top quarter for the rate of hospital-acquired conditions, such as infections or falls, as compared to the national average, according to the Association of American Medical Colleges.
Deebeanne M. Tavani, DO, chief of the division of endocrinology at Main Line Health System, which serves Philadelphia and several suburbs, keeps tabs of the numbers. "Another 12 million people actually walk the streets of America meeting the criteria of diabetes and don't even know it," says Tavani. About one in 10 have diabetes now, she says. Main Line Health includes 331-bed Lankenau Medical Center, 319-bed Bryn Mawr Hospital, 231-bed Paoli Hospital, and 204-bed Riddle Hospital.
When diabetes strikes during childhood, it is often assumed to be type 1 or juvenile-onset diabetes, but children are now being diagnosed with type 2 diabetes, formerly known as adult-onset.
Main Line Health has a diabetes process improvement team centered at Lankenau. The group includes endocrinologists, nutritionists, certified diabetes educators, nurse managers, and pharmacists. This team reviews order sets and disseminates guidelines to other campuses. It is important to evaluate prediabetes conditions, especially because of growing obesity rates in the country, and the team works on that, says Tavani.
Prediabetes is a condition in which blood sugar levels are higher than normal but not high enough to be considered type 2 diabetes.
Janet Wendle, RN, BSN, CDE, director of Main Line's education program, says she and other educators focus on encouraging patients to make lifestyle changes and keep up with their medications. The Centers for Disease Control and Prevention monitors records of obesity rates, and the states with the highest obesity rates also have the highest rates of diabetes, says Wendle.
Another factor in the increase of diabetic patients is because, in part, "this is a social issue, too. Patients are losing jobs and have no healthcare," says Tavani. "We are seeing an indigent population, and they repeatedly come to the hospital every couple of months. They run out of their diabetes medicine. We don't know if this is going to change," she says.
Main Line Health has a diabetes management program that includes individual consultations with a diabetes nurse specialist or diabetes dietician specialist, a 10-hour course in diabetes management, plus support groups and other resources.
At educational meetings with people with diabetes, Wendle says, "We talk about prediabetes, and when I ask them, 'How many of you have prediabetes?' usually more than half the hands go up." She warns them that they need to make changes, but understands that, for many, to make "behavioral changes, it's really tough."
Physician referrals for education are especially important. In a recent review of the system's program, of 100 people who were asked how they found out about the Main Line program, Wendle says 95 found out about it from primary care physicians.
Often, diabetes patients have comorbidities. Diabetes as a principal or secondary diagnosis can increase patient lengths of stay, which can decrease hospital revenue.
Success key No. 1: Multidisciplinary teams
As Mercy Saint Mary's Hospital developed its diabetes program, one of the first things officials did was to target efforts at admissions for those who knew they had diabetes and those who didn't.
The effort is a focus of Mercy Saint Mary's multidisciplinary diabetes operations team, the overriding team that focuses on inpatient and outpatient care. There are other teams that focus on diabetes as part of the hospital system, too, says Harnish.
Physicians, nurses, dieticians, and social workers comprise the operations team, which works with primary care physicians. "We invited the primary care physicians to come on the team so we're all talking the same language to the patient," says Harnish, the clinical nurse leader who oversees the inpatient diabetes program.
Mercy Saint Mary's also assembled a glycemic control team that works with other physicians in various service lines, such as cardiology and oncology, to coordinate care with respect to national protocols. The team includes specialists such as neurologists and vascular, cardiothoracic, gastrointestinal, and bariatric surgeons. The diabetes operations team handles blood sugar management protocols and education for patients.
"We work on diabetes or prediabetes throughout our healthcare system in a coordinated manner and ask 'How can we fill in any gaps we may have found?' " Harnish says. "A primary care physician may not know what to do further, having done all he or she can to help patients deal with their diabetes. They need to see a specialist."
To address such cases, the hospital works with healthcare coaches in primary care offices "to keep people on task to make sure they are following through with diet and exercise goals and to help keep them motivated," Harnish says. They particularly monitor those with prediabetes and in follow-up care make clear to patients: "You are heading toward diabetes. You're in the prediabetes stage."
Mercy Saint Mary's team focus also has steered the hospital toward continual innovations in diabetes care, she says. Several years ago the hospital improved physician protocols for diabetes control by implementing a basal-bolus regimen for glycemic control.
The hospital found the treatment better than what it had been using, a sliding-scale regular insulin practice. Some studies have shown the basal-bolus regimen has resulted in less treatment failure. The hospital uses electronic medical records to monitor blood glucose readings directly from meters for bedside testing, Harnish says, "which was a huge improvement" in patient care.
Success key No. 2: Partnerships with pharmacists
In Ohio and elsewhere around the country, physicians and pharmacists are simultaneously seeing diabetic inpatients to improve care. Both can answer the patients' questions, and the dual effort "allows a more comprehensive understanding of diabetes by the patient and more patient-specific therapy changes," says Stuart J. Beatty, PharmD, BCPS, CDE, assistant professor of clinical pharmacy at the Ohio State University College of Pharmacy.
The coordination continues after the patient visit: A note is shared electronically with the primary care physician, which improves efficiency during the next office visit, says Michael S. Langan, MD, FACP, director of the primary care track, at OSU CarePoint East, an outpatient clinic in Columbus that is part of the 976-licensed-bed Ohio State University Wexner Medical Center. The note can lead to improved clinical care because the primary care physician can follow up on any acute issues regarding diabetes, he says.
"Additionally, the pharmacists often call the patients in between office visits to check in on diabetes treatment adjustments and/or goals. The calls are documented within the EMR and shared with the primary care team," Beatty says. "Changes made at diabetes clinics are communicated with the community pharmacy through either a telephone call or through electronic prescribing, as appropriate."
OSU CarePoint East uses a patient-centered medical home model and includes attending physicians, resident physicians, pharmacy faculty, pharmacy residents, nurse practitioners, registered nurses, medical assistants, and social workers in the same office. CarePoint is a community outreach location of Ohio State University Wexner Medical Center. Each CarePoint location provides routine and specialty care, such as diabetes, cardiology, orthopedics, radiology, and primary care. The same EMR that is used at the medical center is used at this and other outpatient facilities so that information from both inpatient and outpatient procedures is included in the documentation, says Beatty.
"If we have a patient who has been hospitalized at OSU, we can look through the hospital-stay labs, procedures, medication changes, and documentation very easily because we are in the same EMR," says Langan.
The OSU College of Pharmacy has been involved in a program known as Project IMPACT: Diabetes, which includes clinicians and about 2,000 patients in 25 communities across the country focusing on improving the health of patients who are diabetic. According to six months of data collected from the program in 2012, there was a 0.7-point reduction in A1C levels, from 9.0% to 8.3%, and a reduction in LDL cholesterol from 99.5 mg/dL to 92.2 mg/dL.
Pharmacists collaborate and refer patients to other healthcare providers to ensure that patients receive comprehensive care, says Benjamin Bluml, senior vice president for research and innovation at the American Pharmacists Association Foundation, who designed and is leading Project IMPACT: Diabetes.
"A lot of people are challenged in their lives and may not be coming to appointments," Bluml says. "We've heard amazing stories: Patients have really gotten their diabetes under control and are trying to do the right thing with food choices; they are also making sure they are taking their medications. It's an inspiring thing that you are helping people in some portion of their lives through a team-based process."
The care features one-on-one patient consultations, group educational classes, grocery food tours in conjunction with certain markets, and exercise programs. Some of the patients also receive discounted or free healthy lunches at employer worksites and discounted copayments for medication and supplies.
Despite the promising results, a significant problem is the lack of reimbursements.
"We feel very strongly that our model works and have data to show that patients are healthier once enrolled in our program," Beatty says. "Unfortunately, there is not a reimbursement structure available to pay pharmacists to provide these services alone or any additional reimbursement from a standard office visit with a physician by having a team of healthcare professionals involved.
"This makes it very difficult to hire healthcare providers, such as pharmacists, even though it has been shown that patients are healthier when providers are working together as a team to care for the patient. This has been a limitation to expansion of our model to more patients with diabetes or other disease states," he adds.
Success key No. 3: Overcoming nonadherence
Providers are working to overcome a significant obstacle to improving the condition of diabetic patients: nonadherence to medication prescriptions.
"Nonadherence is probably the most common barrier we observe that leads to poorly controlled diabetes," Beatty says.
The Ohio State University Medical Center was involved in a study presented during the American Diabetes Association scientific sessions in 2013 that showed disease education programs can have a positive impact on hospitalizations. Sara J. Healy, MD, a soon-to-be endocrinology fellow at the medical center, presented data on patients hospitalized from 2008, with a discharge diagnosis of diabetes and glycated hemoglobin (HbA1c) levels greater than 9%. There was a 30-day analysis of 2,265 patients and a 180-day analysis of 2,069 patients. According to the study, readmission rates were 5 percentage points lower for those who received the education (11%), than those who didn't (16%).
Wendle, head of Main Line Health's education program, says medication adherence is an important concern. Years ago, she says, physicians would tell patients they had a slight case of diabetes or were borderline: "That means nothing. The statement now is prediabetes. I had a woman who came into the program, and she had taken it four years ago and had fallen off the wagon and came back. Some prediabetics have warning signs, while there others who don't have any symptoms and become complacent."
The availability and convenience of some smartphone apps allows patients to "have information at their fingertips when they are going to a restaurant and have a GPS for walking. These can be extraordinary motivators to see cause and effect," she says.
One patient came in for education counseling because she heard Tom Hanks announced he had type 2 diabetes, Wendle says, noting "whatever it takes."
As Beatty sees it, there are ways hospitals and physicians can overcome barriers that keep patients from controlling their diabetes, such as areas involving cost, motivation, diet, nutrition, and follow-up care.
Cost: If patients believe they have problems meeting expenses associated with improving care, they can work closely with the OSUWMC Department of Pharmacy medication assistance program technicians and pharmacists, who will help patients with the paperwork for the program at no cost. "This has a significant impact on patient access to treatment, in particular insulin and supplies," which can cost as much as $300 per month for patients, Beatty says.
Motivation: It's not easy to get patients to make lifestyle changes, such as increasing physical activity—what Beatty calls a "limiting step." To help, OSU provides patients with pedometers and instructs them on how to track their daily steps. "This gives us and the patient an objective number of how active the patient is and allows us to make measurable goals to improve activity," she says. "This also helps patients to see that when we discuss physical activity, any activity is good; it doesn't have to be lifting weights or jogging 3 miles a day."
Diet and nutrition: OSU educates patients about basic nutrients, especially carbohydrates. Diet and nutrition are among the "hardest components to overcome" for patients trying to control their diabetes. Among other things, the team teaches portion control and how to make healthier choices in meals, and provides cookbooks designed for diabetes patients.
Follow-up care: Proper follow-up is among the measures physicians and hospitals can take that have the "biggest impact on adherence," Beatty says. "In the office, many patients commit to making a change, but once they are home, it is easy to say, 'I'll start my exercise tomorrow.' " At OSU, the physician office contacts patients between visits and "holds them accountable to making a lifestyle change," Beatty says. "A call coming from a physician's office carries a lot of weight to patients in showing that we care and we want to help them get better. There are some patients we call every week to keep them on the path toward better health."
Success key No. 4: Text reminders
For many people, getting text messages consistently from someone may be annoying. But Sanjay Arora, MD, of the Keck School of Medicine at the University of Southern California in Los Angeles, found something else among diabetic patients treated in emergency departments. Not only did the patients like receiving the daily text messages he and his team sent as reminders to improve their control of diabetes and medication adherence but the patients also did a better job of improving their health.
Arora is an emergency department physician at the 600-bed Los Angeles County Hospital of the University of Southern California Medical Center. Patients overwhelmingly liked the messages, in part because they felt the physicians cared about them, Arora says.
The messages were simple and to the point: "Having diabetes can lead to a heart attack or stroke—but it doesn't have to" and "Eat more fruits, vegetables, beans, and whole grains, and less salt and fat."
The patients who received text messages for six months improved enough to reduce their dependence on the emergency department in their care for diabetes, Arora says. He and colleagues wrote about their findings in the Annals of Emergency Medicine. The study was dubbed "TExT-MED."
Text messaging is effective, low-cost, and widely available for patients who often see themselves as having no other source of medical care than the ED, he says.
The study focused on adult patients with poorly controlled diabetes who visited an urban, public emergency department. They received two daily text messages for 6 months. For patients who received text messages, blood glucose levels decreased by 1.05%, compared with a decrease of 0.60% in the control group. Self-reported medication adherence improved from 4.5 to 5.4 on an 8-point scale, compared with a net decrease of 0.1 points in the control group.
"The study population has very little access to regular primary care and very limited time, and they weren't getting the education they needed or the personalized level of care," he says.
The proportion of patients who visited the emergency department over the 6-month period was lower among the text-messaging group, 35.9%, than in the control group, 51.6%.
Arora says if someone sent him a text message two or three times a day, "I would think, 'Enough.' " But the patients felt different. To them, it "wasn't annoying; it felt like the first time a doctor really cared for them. That was the most surprising for me."
Reprint HLR0214-9
This article appears in the January/February 2014 issue of HealthLeaders magazine.
When Laurent Gueris noticed how the environmental services staff he manages at a California medical center was interacting with patients, he wasn't pleased. His work with his 45-member team has turned things around and had a profound impact on patient satisfaction.
This profile was published in the December, 2013 issue of HealthLeaders magazine.
Laurent Gueris, as manager of environmental services, oversees cleaning and sanitation at the 283-staffed-bed Providence Little Company of Mary Medical Center in San Pedro, Calif. But a few years ago, Gueris noticed his staff walking in and out of patient rooms, quietly moving throughout the hospital while not making eye contact with the patients, barely looking at them. No "hello." No "how-are-you?"
Gueris wasn't happy about it. "When it comes to being courteous in a hospital by staff, there's no excuse. This is not a courthouse," he says.
Gueris tapped into that invisible presence, that silence, and wondered about its impact on patient satisfaction, one the measurements used by the government for hospital payments. Over time, he has worked with his 45-member staff to improve their interactions with patients, which he says had a surprising, yet profound impact on patient satisfaction.
Using role-playing, he "play-acted" staffers' interactions with patients and even videotaped their sessions. Those exercises brought out hospital employees' innate compassion and gave them confidence to open up to patients, Gueris says. "They could see themselves in a more powerful way," he says. "It's very powerful when you look in your own mirror," he says.
Patients have responded, dramatically improving Providence Little Company of Mary Medical Center's patient satisfaction scores, Gueris says. Over a three-year period, patient satisfaction involving housekeeping improved from 60% the first year to 70% the second and 90% the third, according to the hospital's latest figures in 2012.
Not only that, patients sent personal notes to the housekeeping staff, thanking them, mentioning them by name. Pretty unusual, Gueris says.
The satisfaction scores are included under the Hospital Consumer Assessment of Healthcare Providers and Systems survey, which asks patients about their satisfaction during their hospital. The survey mentions communications with doctors, staff responsiveness, hospital cleanliness and quietness, and overall rating of the hospital.
When the HCAHPS first asked patients about how their room was clean, and their satisfaction involving communication with staff, "That was always one of my goals, to shine" on those HCAHPS measurements about clean lines and communication with staff, Gueris says.
Before Gueris embarked on his venture to change housekeeping attitudes about patients—and their attitudes about housekeepers—the patient rooms may have seemed unnaturally quiet.
Gueris met every morning with his staff, and discussed their interaction—or lack thereof—with patients. He offered guidelines to how they could improve their interactions. Using a script, Gueris went over what the housekeeper should do and say: they should knock on the door, ask permission to come in, and introduce themselves as representatives from housekeeping. Gueris explained the importance of maintaining eye contact with the patients, flashing a smile, and talking to them.
Gueris sat down in a room and made believe he was a patient. He took on their persona, if necessary: He was angry. He was flirtatious. Some on his staff were taken aback, but Gueris explained that the practice sessions had to reflect reality.
"We did basic scripting," Gueris says. "We put on paper what they should say; every day each employee would practice that. As weeks went by, they were becoming more comfortable. I started to challenge them and ask questions and try to push buttons with facial expressions and body language, being extremely rude or flirty, asking for a phone number, just to embarrass them, put them on the spot."
After visiting his mother in a hospital in France, Gueris came home, and worked with the staff to videotape them in the playacting. After initially expressing concern, "they came on board and loved it," he says. The video was important because it allowed the housekeepers to see themselves in action. Some realized that, yes, they did have a smirk or a frown, and that, no, they didn't make eye contact like they thought they did.
Nancy Carlson, the CEO of Providence Little Company of Mary Medical Center, says she would stop by and marvel at the change in behaviors and attitudes among housekeeping staff. While Gueris has a heavy French accent, most of the housekeepers spoke Spanish. "They were afraid of interacting with patients and had no confidence in their ability to communicate," Carlson says. "They went to clean the room, and he saw this as an opportunity to help us with our patient experience. They've really taken off with this."
Carlson says she's thinking about extending the program that Gueris started to other parts of the hospital.
Gueris says he's thankful about the turnaround for the hospital staff and the patient satisfaction scores. Mostly, the idea is to help patients. "You don't come to the hospital by choice," Gueris says. "I've been a patient, and it's a very scary experience."
Developing heart centers that specialize in women's cardiology care is of growing importance, not only for women's health, but for hospitals seeking improved economic returns.
This article appears in the December issue of HealthLeaders magazine.
Confusion and uncertainty cloud the issue of women's heart disease, and perhaps surprisingly that lack of clarity is even evident among physicians—or at least among those who aren't cardiologists.
Heart disease is the leading cause of death in females, but this fact is not understood universally by the general population. Many people also fail to realize that the symptoms of heart disease in women can be dramatically different than those for the same ailment in men.
Many hospitals are deciding the time is right to focus on women's cardiac health. While women's health programs have been part of hospital service lines for years and are showing steady growth, some healthcare providers are creating special centers that address women's cardiac health specifically. They tailor care for patients to focus on heart disease risk factors, with education a key component in delivering preventive strategies. That education is beginning to pay off.
"We're seeing an increase in recognition by women that heart disease is something that is much more likely to occur than any other form of disease, such as cancer," says Gretchen L. Wells, MD, PhD, who is director of the women's heart center at 885-licensed-bed Wake Forest Baptist Medical Center in Winston-Salem, N.C. "It's nice to see awareness increasing, but there are definitely gaps in knowledge among age groups and ethnicity of patients."
The lack of awareness includes patients and physicians, points out Kimberly A. Skelding, MD, director of women's heart and vascular health for Geisinger Health System in Danville, Pa. "After I spoke to a group of women on the topic, one woman came up to me and said, 'Oh my goodness, I have these complications you spoke of.' Light bulbs went off," recalls Skelding.
The Geisinger system includes the 545-bed Geisinger Medical Center campus in Danville, 547 beds at two other acute hospitals, and a rehab and nursing facility. "Women's cardiac problems present differently than [they do in] men, and it's not even known extensively in the cardiology community," Skelding says. "I'm only 15 years out of my general cardiology training, and I didn't have women's cardiac care as part of my training. This is something everyone needs to know about."
The most common heart attack symptom in women is chest pain or discomfort similar to what men experience, but women can have other symptoms, such as nausea, shortness of breath, and back or jaw pain, according to the American Heart Association.
The AHA has been pivotal in trying to change the conversation around women's heart health. Although much progress has been made in the "awareness, treatment, and prevention" of cardiovascular disease in women since the organization published its first clinical guidelines in 1999, the AHA states that "considerable challenges remain." Heart disease remains a major killer of women and, reversing a trend of the past four decades, death rates of women 35–54 years of age in the United States appear to be increasing, likely because of the impact of the obesity epidemic.
"Among our priorities is to provide comprehensive cardiovascular care and early identification of cardiac disease," says Indu Poornima, MD, director of the women's heart center at the 661-licensed-bed Allegheny General Hospital in Pittsburgh, part of the 1,200-bed West Penn Allegheny Health System, which includes five western Pennsylvania–based acute care hospitals. "Comprehensive care for women is offered at the center before an event occurs because the heart conditions of women present differently, and specialty care in cases such as hypertension can manage symptoms."
Over time, physicians and academics have continually found differences in what men and women need in cardiac care. Some reports are contradictory, puzzling, and still being sorted out. For instance, women's risk of heart disease appears to increase as their estrogen levels decrease during menopause, but the link is not clear.
In addition, postmenopausal women undergoing hormonal modulation may have greater risks of heart disease, and pregnant women with certain conditions may be susceptible to more cardiology ailments. Most baffling of all, nearly two-thirds of the deaths from heart attacks in women occur among those who have no history of chest pain. Other studies also have raised growing concerns about atrial fibrillation among women.
Developing a heart center that specializes in women's cardiology care is of growing importance for institutions, not only for improving care for women but also for hospital ROI, says David X. Zhao, MD, FSCAI, FACC, chief of cardiology and director of the heart and vascular center for excellence at Wake Forest Baptist Medical Center.
Within months of his arrival in July, Zhao restructured the hospital's cardiology team to also ensure a focus on women's cardiac issues and appointed Wells to head the women's heart program. Previously, "we didn't have a lot of interaction" with women cardiac patients, says Zhao. The new program is part of an evolving "cohesive service line," including a physician champion for women's health and prevention programs to address patient weight management, risk stratification, and hypertension.
Developing such a women's heart program was "critical from an institutional standpoint and for patients," Zhao adds. The program "creates a specific health structure using a platform to educate the public" and a streamlined approach for primary care physicians who refer cardiac patients to the hospital, he says.
Having a specific heart center that focuses on women's cardiac issues also opens the door for improved economic returns for the hospital, says Zhao.
"You capture those referral volumes from physicians by having a heart center for women," says Zhao. "From a business standpoint, you are increasing patient visits from women. It's the woman who makes a lot of the healthcare decisions in a family. If you provide good service, they tell their husband or father, and we triple, quadruple the service from the hospital's standpoint if the entire family comes in."
The Center for Women's Heart Care at the 957-licensed-bed Duke University Medical Center is not located in a separate facility, but within the cardiac division on the main Durham, N.C., campus. It's what L. Kristin Newby, MD, MHS, a cardiologist at DUMC calls a "virtual" program.
It works this way, she says: "We have our physicians declare their interest or special interest in heart disease in women, and our communications center aligns patients when they call in—asking for specific services—with those physicians."
That, Newby says, helps patients feel more comfortable: knowing they have a women's cardiac program to address their needs.
Success key No. 1: Specialized centers
Cardiac care centers for women often target subspecialties of need. For instance, Allegheny General Hospital is putting a concentrated effort on pulmonary hypertension and follow-up care for patients. The 664-bed Rush University Medical Center's Rush Heart Center for Women in Chicago is examining atrial fibrillation and its impact on women.
While these centers have a different focus, they incorporate a multidisciplinary team to ensure a coordinated framework with primary care and other specialists.
At Rush Medical Center, the multi-disciplinary teams include psychologists because many women who have had heart attacks experience stress and anxiety as they fear having another cardiac episode, says Annabelle Volgman, MD, FACC, medical director of the Rush Heart Center for Women. The center includes mostly women cardiologists and nutritionists in its programs. Female patients often feel more comfortable with physicians of the same sex, although not exclusively, Volgman says. One reason is that for too long, women were not treated in care as aggressively as men, she says.
Rush Heart Center's conce tration on atrial fibrillation issues reflects increasing concerns among women about the most common type of arrhythmia, an abnormal heart rhythm. An estimated 2.6 million people had atrial fibrillation in 2010, and about 12 million may have the condition by 2050.
Volgman says the Rush Heart Center is exploring not only a host of therapeutic procedures to prevent atrial fibrillation but also ways to ensure safe management of the disease once it is diagnosed.
Among the therapies being used: adding blood thinners for women, sometimes as often as men receive them, and consistently monitoring anticoagulation therapy to avoid excessive bleeding, Volgman explains. Prescribing a blood thinner also has been effective in stroke care, she says. The hospital determined that while older women were twice as likely to receive aspirin as the blood thinner warfarin in treatment, warfarin reduced stroke risk by 84% in women and 60% in men, she adds. They adjusted treatment accordingly.
Those continued evaluations of medications are important as the heart center assesses women's cardiac care, Volgman says.
Today, Volgman reports seeing more female cardiac patients coming through the hospital's doors. "A decade ago, I was only seeing patients one half day a week, and now I have to limit my time to see patients to three full days a week," Volgman says of her clinical practice. "I also now have two other female cardiologists helping to see women patients interested in being seen in the center."
In Pittsburgh, Allegheny General Hospital is focusing on a different aspect of women's cardiac care: pulmonary hypertension, or high blood pressure in the arteries that affect the lungs or the right side of the heart. The condition can be easily missed in women, who may not understand why they have shortness of breath, says Poornima, director of the women's heart center.
Pulmonary hypertension "specifically impacts more women than men and can present itself quite differently," Poornima says. "Sometimes, it is not diagnosed until it becomes quite severe. You definitely need a full spectrum of experts to treat and monitor the condition."
Moreover, the prevalence of a related disease, pulmonary arterial hypertension, is twice as common in women than in men, according to Allegheny Health Network's Srinivas Murali, MD, FACC, director of the division of cardiovascular medicine and medical director of the Cardiovascular Institute. "Pulmonary hypertension" describes high blood pressure in the arteries of the lungs. Pulmonary arterial hypertension is one form of pulmonary hypertension.
The Allegheny Health Network's program features a multidisciplinary team that includes pulmonary, rheumatology, and imaging specialists who conduct a comprehensive review of each patient with pulmonary hypertension. Once a patient is diagnosed, the team evaluates the severity of the condition, prescribes treatment, offers educational programs, and coordinates care with referring physicians, Poornima says.
"Our goal is preventive treatment, and we see patients early—before they develop their heart attacks, strokes, symptoms of congestive heart failure, and other cardiovascular risk," she says. "We're seeing increased awareness—not only in referrals from other physicians but also in self-referrals from patients who would like to know more about their disease."
Success key No 2: Using electronic records
While women of child-bearing age may gravitate toward their OB-GYNs for care, they sometimes neglect checkups with primary care physicians after giving birth and may miss some nonobstetrical health issues, says Geisinger's Skelding. Studies have shown a link between certain pregnancy-related complications for women in their 20s through 40s and "having a higher risk of cardiovascular events later in life," she says.
Yet new mothers may not think of the potential problems ahead. "After her delivery, a patient's pregnancy-related issues vanish and she goes on her way, not realizing that she's at risk in the next 20 years for heart disease," says Skelding. "A woman may not see an internist for primary care until
middle age," she adds.
Through electronic health records and community involvement programs, Geisinger is focusing on improving cardiovascular care for women who have complications during pregnancy and may have a greater risk for cardiovascular disease, Skelding says.
"We and other centers around the country are attempting to engage these women early on, after their pregnancy and get them engaged in their health for life," Skelding says. "We try to work with them, to keep their risk factors in check, and have a basic awareness of the risks."
Geisinger has begun using its ProvenCare program, supported by the electronic medical records, to treat pregnant women. This will allow Geisinger to identify women with pregnancy-related complications and direct them to healthcare providers to lower their risk of cardiovascular disease later in life. Geisinger has used the program for perinatal care and surgical procedures such as coronary artery bypass grafts.
Overall, the program has shown steady improvements in clinical and financial areas, according to Geisinger officials. In 2012, the hospital reported an 80% improvement in reduced inhospital mortality rates and a 29% decrease in pulmonary complications, through the use of coronary artery bypass grafts since ProvenCare was initiated. The hospital's data was the result of reviews of 132 patients before the use of the ProvenCare and 321 afterward. An earlier Geisinger report showed ProvenCare reduced the length of patient stays from 6.2 to 5.7 days, with a 30-day readmission rate that fell 44%, from 6.9% to 3.8% between 2005 and 2009
The total inpatient profit per coronary artery bypass graft case increased by $1,946, according to the 2012 report.
Using the ProvenCare program, "we have a link between the OB-GYN navigator and the cardiology navigator, and we have ready access—in real time—to these pregnancy-related complications that are known to increase cardiovascular problems," Skelding adds. "This continually identifies these women and brings them to our attention."
The idea is to develop educational materials targeting women who might not have picked up a packet in the OB-GYN clinic or hadn't read about it on the Internet, she says. "We can focus our educational efforts toward them … offering them screening programs, as well as further educational material, to help keep them healthy for years to come."
Coordination is important with specialties and evaluation by primary care providers, Skelding says. There are OB-GYN partners "who are also very interested and motivated to identify these women and get them to us for screening, prevention, and treatment if needed," she adds.
Success key No. 3: Facing care discrepancies
While healthcare leaders are working to improve treatment equity for cardiovascular disease that impacts women, they are also looking at the demographics of subgroups of women, especially among African-American and Hispanic populations.
A 2012 study by the American Heart Association noted that education campaigns helped white women become more aware of heart disease risks, but those efforts did not have an apparent impact in minority communities.
The study of trends among racial and ethnic groups showed that from 1997 to 2010, the rate of awareness among whites of cardiovascular disease as a leading cause of death increased from 30% to 56%. Yet awareness in 2012 was only 36% among black women and 34% among Hispanics—at levels similar to those of white women in 1997.
The AHA report noted, "Awareness of cardiovascular disease among women has improved in the past 15 years, but a significant racial/ethnic minority gap persists." It added, "Continued effort is needed to reach at-risk populations."
Findings like that have prompted officials of Baltimore's 372-licensed-bed St. Agnes Hospital's women's heart center to initiate a community outreach program to improve awareness.
African-Americans and Hispanics have "some of the highest rates of cardiovascular disease in the city, and the gap is even greater among women," says Shannon Winakur, MD, medical director of the St. Agnes Hospital women's heart center.
Heart disease and stroke are the leading cause of death in Baltimore. African-American men die 6.7 years earlier than white men, and African-American women die 4.2 years earlier than white women there, according to a 2011 report from the Johns Hopkins Center to Eliminate Cardiovascular Health Disparities.
To overcome the challenges, St. Agnes Hospital has initiated a Heart to Heart initiative that includes partnerships with churches in the region to screen African-American women for cardiovascular disease.
If patients are found to have risk factors such as diabetes, hypertension, high blood pressure, or other symptoms of heart disease, they can receive follow-up screenings. As of October 29, 222 women have been screened, with 160 of them qualifying for the intervention, which included participating in St. Agnes' well4life program with four months of exercise and educational classes, plus access to a lifestyle coach and support groups, she says.
St. Agnes has conducted screenings at four churches so far. "For the first three screenings, we are in the process of conducting the follow-up visits for postintervention after four months," she says.
The follow-up visits repeat first-round biometrics, such as weight, blood pressure, and waist circumference, as well as blood work for cholesterol and blood glucose, to follow the women's progress after the intervention.
The hospital also conducts a heart health assessment in an hour-long program that costs patients $60 each. Patients complete a comprehensive risk assessment and can receive a personalized education program based on the results.
St. Agnes wants to keep up the drumbeat for women's cardiac care. The hospital sponsors seminars, meetings, and educational events. While there is often great interest among women in the topic around Valentine's Day—with American Heart month and AHA Go Red for Women activities—sometimes interest drops off afterward. That shouldn't happen, Winakur says. It's a year-round, day-to-day effort, and women "need to be aware of the risk factors."
Reprint HLR1213-6
This article appears in the December issue of HealthLeaders magazine.
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 Laurent Gueris.
This profile was published in the December, 2013 issue of HealthLeaders magazine.
"When it comes to being courteous in a hospital by staff, there's no excuse. This is not a courthouse."
Laurent Gueris, as manager of environmental services, oversees cleaning and sanitation at the 283-staffed-bed Providence Little Company of Mary Medical Center in San Pedro, Calif. But a few years ago, Gueris noticed his staff walking in and out of patient rooms, quietly moving throughout the hospital while not making eye contact with the patients, barely looking at them. No "hello." No "how-are-you?"
Gueris wasn't happy about it. "When it comes to being courteous in a hospital by staff, there's no excuse. This is not a courthouse," he says.
Gueris tapped into that invisible presence, that silence, and wondered about its impact on patient satisfaction, one the measurements used by the government for hospital payments. Over time, he has worked with his 45-member staff to improve their interactions with patients, which he says had a surprising, yet profound impact on patient satisfaction.
Using role-playing, he "play-acted" staffers' interactions with patients and even videotaped their sessions. Those exercises brought out hospital employees' innate compassion and gave them confidence to open up to patients, Gueris says. "They could see themselves in a more powerful way," he says. "It's very powerful when you look in your own mirror," he says.
Patients have responded, dramatically improving Providence Little Company of Mary Medical Center's patient satisfaction scores, Gueris says. Over a three-year period, patient satisfaction involving housekeeping improved from 60% the first year to 70% the second and 90% the third, according to the hospital's latest figures in 2012.
Not only that, patients sent personal notes to the housekeeping staff, thanking them, mentioning them by name. Pretty unusual, Gueris says.
The satisfaction scores are included under the Hospital Consumer Assessment of Healthcare Providers and Systems survey, which asks patients about their satisfaction during their hospital. The survey mentions communications with doctors, staff responsiveness, hospital cleanliness and quietness, and overall rating of the hospital.
When the HCAHPS first asked patients about how their room was clean, and their satisfaction involving communication with staff, "That was always one of my goals, to shine" on those HCAHPS measurements about clean lines and communication with staff, Gueris says.
Before Gueris embarked on his venture to change housekeeping attitudes about patients—and their attitudes about housekeepers—the patient rooms may have seemed unnaturally quiet.
Gueris met every morning with his staff, and discussed their interaction—or lack thereof—with patients. He offered guidelines to how they could improve their interactions. Using a script, Gueris went over what the housekeeper should do and say: they should knock on the door, ask permission to come in, and introduce themselves as representatives from housekeeping. Gueris explained the importance of maintaining eye contact with the patients, flashing a smile, and talking to them.
Gueris sat down in a room and made believe he was a patient. He took on their persona, if necessary: He was angry. He was flirtatious. Some on his staff were taken aback, but Gueris explained that the practice sessions had to reflect reality.
"We did basic scripting," Gueris says. "We put on paper what they should say; every day each employee would practice that. As weeks went by, they were becoming more comfortable. I started to challenge them and ask questions and try to push buttons with facial expressions and body language, being extremely rude or flirty, asking for a phone number, just to embarrass them, put them on the spot."
After visiting his mother in a hospital in France, Gueris came home, and worked with the staff to videotape them in the playacting. After initially expressing concern, "they came on board and loved it," he says. The video was important because it allowed the housekeepers to see themselves in action. Some realized that, yes, they did have a smirk or a frown, and that, no, they didn't make eye contact like they thought they did.
Nancy Carlson, the CEO of Providence Little Company of Mary Medical Center, says she would stop by and marvel at the change in behaviors and attitudes among housekeeping staff. While Gueris has a heavy French accent, most of the housekeepers spoke Spanish. "They were afraid of interacting with patients and had no confidence in their ability to communicate," Carlson says. "They went to clean the room, and he saw this as an opportunity to help us with our patient experience. They've really taken off with this."
Carlson says she's thinking about extending the program that Gueris started to other parts of the hospital.
Gueris says he's thankful about the turnaround for the hospital staff and the patient satisfaction scores. Mostly, the idea is to help patients. "You don't come to the hospital by choice," Gueris says. "I've been a patient, and it's a very scary experience."
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 Brad Stuart, MD.
This profile was published in the December, 2013 issue of HealthLeaders magazine.
"This is advanced care: helping people live the best they can and stay out of the hospital."
Nearly four decades ago, as a third-year medical student in California, Brad Stuart, MD, didn't want to give more chemotherapy to a dying patient who had bone marrow cancer. Stuart argued against the care plan, pleading with his superiors: Please talk to the patient and his family to determine "what was in store for them."
His bosses rejected Stuart's suggestion, saying they should finish the research protocol and not discuss the patient's status or treatment with him. Just give him the chemo, they told Stuart. Two days later, the patient died, sooner and with less comfort, Stuart believed, than if he had not given the chemo.
" 'I killed him,' I said to myself. 'I am never going to forget this. There's got to be a better way,' " Stuart recalls.
The incident was a turning point in a new doctor's life. Over the next decades, Stuart turned to hospice and palliative care to treat very sick patients, people who didn't want more tests or more procedures, but just sought peace.
Until recently, Stuart was CMO at Sutter Care at Home, part of Sutter Health system's network in Fairfield, Calif. He left Sutter in October to start Advanced Care Innovation Strategies, an Alamo, Calif.–based firm that will consult for hospitals, health systems, and medical groups on advanced illness–related issues, and increase the quality of care for advanced chronic illness and reduce its cost by promoting the dignity, choice, and responsibility. Such programs are meant to partner with families and patients for better coordinating care for those who are very sick, have chronic conditions, or who are dying.
Under Stuart's leadership, Sutter has been demonstrating success in its palliative care program for years.
From 2009 to 2011, Sutter reported a 54% reduction in hospital admissions and readmissions, an 80% reduction in intensive care unit days, and a 26% reduction in hospital lengths of stay. There were reduced visits to physician offices and clinics, too, Stuart says.
Sutter received $13 million from the Centers for Medicare & Medicaid Services' Innovation Center under a three-year grant for advanced illness management for patients with late stage chronic illness. The money came after Sutter's Sacramento region showed positive outcomes from its AIM program, such as reduced hospitalizations and improved care transitions
"In our program we deal with patients who are as sick as they possibly can be," Stuart says. "They can't be sicker than this, yet we've reduced hospitalizations. We are enabling people to stay at home, where they can be comfortable and nonstressed. This is advanced care: helping people live the best they can and stay out of the hospital."
Through palliative and advanced care planning programs, patient care is often focused on pain, symptoms, and the stress of serious illness, or even spiritual assistance, if wanted. One of the major hallmarks of advanced care is that it is not seen as a failure when patients say they have grown tired of treatments and want comfort for their chronic illness as they see the end of life near.
As the U.S. population ages, with the probability of more chronically ill patients in hospitals, more physicians should get acquainted with advanced care, not only for quality reasons but also as an improved economic tool, Stuart says.
"In our way of thinking, we are reducing costs the right way," Stuart adds. "You are preventing readmissions, having incredible savings, and letting patients say what they want, and make sure they get that. I made the mistake for so many years just assuming my job was to diagnose and treat the patient."
Like many physicians, Stuart says that was part of his medical training. During his first two years at Stanford Medical School, he says it was thrilling, with Nobel Prize winners as teachers, and he studied internal medicine, clinical psychology, and neurology.
"It was very intoxicating, but then I went into the wards and immediately realized we were doing something very wrong," Stuart recalls. "We were literally treating people to death. I was horrified." He saw that many procedures were done on patients with devastating illness, yet they still died "pretty quickly."
At the beginning his career in palliative care, there were only a few hospital programs in the country, and some hospital officials maligned them as not being cost effective, Stuart says. Just being in such programs made him and others feel as if there were a lack of support as time passed and they pushed for greater support for advanced care. "Developing advanced care as a step beyond palliative care was like pushing a rock uphill," Stuart says. He kept at working for palliative care. "It just stubbornness."
Over time, palliative care programs have grown markedly, with the number of palliative care programs in U.S. hospitals showing "a rapidly rising trend," says the Center to Advance Palliative Care. According to its most recent data analysis in 2011, 1,568, or 63%, of U.S. hospitals with more than 50 beds have a palliative care program—an increase of 138.3% between 2000 to 2009, according to the Center to Advance Palliative Care's most recent survey.
Even though more hospitals are developing such programs, the need may be greater in the years ahead, considering the growth of the U.S. aging population, Stuart says.
By 2030, the number of people in this country over the age 85 is expected to double to 8.5 million.
"The pace of progress for palliative care was definitely glacial; it was worse than glacial," Stuart says of the beginning of the movement. "But we've hit one of those tipping points and things have really taken off in the past year or two, the most that I've seen in the 20 years. "I've never seen in my lifetime this much enthusiasm [and] supporting innovation for this."
Despite the advances in palliative care and related programs, the government has been slow in widespread reimbursements for such care, Stuart says.
"Right now the bottom line economically is for places like Sutter Health spending their own money and using grants to put teams to provide care, but the savings are going to the payers," he says. "We're saving Medicare a lot of money. The goal is to have much less hospital-based care and more home- and community-based. And then we can have care management reimbursed. The savings can be shared and the quality can be increased at the same time."
"We want to change the standard of care for advanced illness across the U.S., for the clinical and reimbursement structure, so this kind of care management is paid for, through any new mechanisms or bundled payments, or something else," he adds.
With the government's efforts to reduce readmissions and reduce costs, palliative and advanced life programs fit nicely into healthcare planning, Stuart says.
Stuart says he wants to spread the message about palliative care and advanced care planning. He is developing a strategies company around such programs and is a member of the board of the Coalition to Transform Advanced Care based in Washington, D.C.
"My personal aspiration is to develop a national initiative that can help change the game for this population," Stuart says of patients facing chronic and life threatening illnesses.
"I've gone from being a naïve medical student back in the day to having a platform to stand on, and some data to back it up," Stuart says of his mission. "It's taken 40 years, but I'm very grateful to the way it is turning out."
Frustrated and noncompliant patients can lead to increased healthcare costs. Through remote monitoring, video conferencing, and nurse navigators, health systems and hospitals are tapping into the needs of patients facing an array of chronic conditions – and lowering their cost of care.
This article appears in the November issue of HealthLeaders magazine.
Emily Lieb, MD, medical director of Bon Secours Health System's Care-A-Van program regularly goes into the community to connect with patients. She and a nurse colleague and medical assistants drive to sites in Virginia on scheduled days in the hospital's mobile health clinic to provide free, urgent, and preventive care to patients who are uninsured and might not have seen a family doctor for a while. Their patients have chronic conditions and have lost track of their own medical history.
A typical patient is one who steps inside the van with a nagging cough and asks to be checked for bronchitis. After an initial examination is done, the diagnosis of bronchitis is confirmed, much as the patient suspected. But there's more to it than the patient realized. "Did you know your blood pressure is high? And you may have other complications?" The patient is surprised but agrees to follow-up care with a primary care physician.
By providing that convenient and unassuming healthcare presence in the van, "you can work hard to reverse their problems," Lieb says. "You have dodged a bullet. The patient is empowered in that situation to change things and is very happy about it."
The health provider's van makes at least 400 visits a month in remote areas of Virginia where the patients may lack transportation. Bon Secours is a $3.3 billon not-for-profit Catholic health system based in Marriottsville, Md., that has 4,400 beds among 19 acute care hospitals in six states.
The medical director of the Carolina Advanced Health medical practice in Chapel Hill, N.C.,Thomas Warcup, MD, DO, FAOBFP, looks at a monitoring screen and listens to a patient's rundown of ailments. The doctor is glad to hear from the patient because, like many who call in through the practice's telemonitoring system, this patient was expressing frustration with his previous experiences in healthcare and hadn't seen a doctor for a while. To engage such patients, the Carolina Advanced Health program is involved in a care partnership with BlueCross BlueShield of North Carolina and the University of North Carolina Health Care.
After months of telehealth talks, and tapping into self-monitoring programs through the practice's advanced technology, these patients are finding something unusual in the sometimes arduous journey of taking care of themselves: They are actually enjoying it, Warcup says.
Lieb and Warcup, in different ways, are making inroads in the care of patients with chronic conditions who have been among the most reluctant partakers in healthcare. Ironically, they are among those most in need. In the process, these providers are developing improved engagement, loyalty, and satisfaction among the most disenfranchised patients.
Patients with chronic condition are the "heaviest users" of healthcare services, according to Medicare studies.
In a report this year, the Centers for Medicare & Medicaid Services stated that about one in five Medicare beneficiaries was admitted to a hospital in 2010, resulting in costs of more than $100 billion. Chronic care is the crushing fiscal blow: Among the 14% of beneficiaries with six or more chronic conditions, more than 60% were hospitalized and accounted for 55% of total Medicare spending for hospitalizations.
"Beneficiaries with multiple chronic conditions were more likely to be hospitalized and had more hospitalizations during the year," according to CMS.
Yet these patients are often frustrated with their healthcare or are noncompliant, leading to increased costs.
"Some people are just dissatisfied with the throughput process; some are unhappy with their providers, have a misunderstanding of their disease, and just haven't been able to break through their static inertia," says Warcup. "Certainly, when they come to see us in our practice, maybe they haven't seen anybody in a while."
A major focus for his practice, says Warcup, is to help patients "get motivated, or stay motivated, when they hadn't been before. Sometimes they had felt dictated to, or never understood their disease well enough to stay motivated."
Physician practices and healthcare systems are focusing on various engagement strategies to help patients become more empowered in their care and also leading them toward greater patient satisfaction through technology or improved communication in chronic care management.
Through remote monitoring, video conferencing, nurse navigators, coaches, and various educational programs, healthcare systems and hospitals are tapping into the needs of patients facing an array of chronic conditions, from high cholesterol, asthma, and diabetes to congestive heart failure and depression. That's not all: They are using remote apps for "real-time" care so they can adjust medication when needed, schedule appointments quickly, and effectively monitor their patients, ease their concerns, and thwart potential hospital admissions or readmissions.
Medical groups and hospitals are asking patients not only about their clinical needs, but also about their social and economic conditions—beyond the scope of their disease—to tap into potential care needs. Physicians are changing their schedules to make it more convenient for patients to see them. Hospitals are also talking to patients about follow-up care, well before they are discharged from their rooms.
With a growing older population and those with chronic diseases, hospitals have little choice but to improve coordination of care for chronic ailments, says Don Bignotti, MD, senior vice president and CMO of CHE Trinity Health based in Livonia, Mich. Like other healthcare systems, CHE Trinity Health is concentrating on "chronic disease management to provide for the needs of the community," he says.
CHE Trinity Health is forming an "intense cardiac improvement program" and a "diabetes collaborative" that are included in a medical home care structure, Bignotti explains. In late 2012, Trinity merged with Catholic Health East, creating a health system with 84 hospitals, 89 continuing care facilities, plus home health and hospice programs serving residents of 21 states.
He says it's important that patients are engaged to improve their chronic conditions, and patient satisfaction also plays a role. "If patients are engaged and moving forward and their quality of life improves, we also believe they will become more satisfied in their care."
Improving patient engagement and loyalty is naturally linked with enhanced hospital processes of care, Bignotti says. By focusing on heart failure, for instance, Trinity, prior to the merger, reported a reduction of 30-day Medicare all-cause heart failure readmissions from 19% to fewer than 16.2% in a six-month period. Essentially, technology sometimes takes a back seat to improvising a care path. "It's about teamwork and a lot of interventions," Bignotti says. A major impact results from a simple formula: hospitals working with primary care physicians to ensure follow-up appointments for patients, he adds.
"For the patient, it's the experience in the sense of being connected and holistically involved in care," adds Mary Ellen Benzik, MD, CMO of Physician Network Services for CHE Trinity Health. "You have to have a holistic view, having the system surround the patient in a coordinated way. The patient says it feels different."
Success key No. 1: Technology, flexibility
Warcup knows the patients he sees at Carolina Advanced Health had been reluctant to see their doctors, and many said they were dissatisfied with their care. "They never understood their disease well," he explains.
Working with BlueCross BlueShield of North Carolina and the University of North Carolina Health Care, CAH has reached out to patients who hadn't seen their primary care physicians for at least a year, asking them to give CAH a try. Within two years at CAH, Warcup has seen these patients transformed, especially in their attitudes about seeking care.
Technology and flexible staff time have improved patient engagement and satisfaction.
Warcup says he emphasizes team-based care, and "on-time" electronic information for patients, with increasing use of telehealth. The practice focuses on care for chronic conditions, such as diabetes, hypertension, high cholesterol, congestive heart failure, coronary artery disease, and obesity.
The care team is robust, and includes physicians, specialists in internal medicine, a psychiatrist, physician assistants, behavioral specialists, nutrition/health coaches, clinical nurse managers, and social workers. By concentrating on chronic disease management, the team effectively reduced the number of patients seen by each physician, from 3,000 to about 1,300, Warcup says. That focus on chronic care has led to a 10.5% reduction in hospitalizations among the group's patients.
"We use motivational type interviewing: 'What's the optimal health for you? What does it look like?' We try to spend a lot of time educating [patients] on their disease and showing them different technologies to help them manage their disease. If they say, 'The goal is to be around and see my granddaughter or daughter get married,' we turn it around and say, 'Here's your goal, not my goal. Your goal can be achieved if we do this.' It helps them stay motivated when they hadn't been before," he says.
Within one year, patient satisfaction scores reached 95% and 100%; that was especially unusual, Warcup says, because many of the group's patients weren't welcoming of medical care. More than 100 patients were polled.
"Some [patients] haven't seen anybody in a while," Warcup says of those who had stopped seeking medical attention. "We spend a lot of time educating them about their disease, and we show the different technologies we have to manage their disease. We have expectations that they are part of the team. We use that language constantly: You are part of the team."
Carolina Health Alliance also relies on an electronic medical system that gives its physician an accurate real-time view of patients' conditions. The system checks on the current status of patients using a color-based system. For instance, diabetics' color coding might be graduated by intensity of need with red, yellow, or green defining the severity of their current condition.
On-site lab testing is available and on-site pharmacists work with patients to review medication. The practice also uses smartphone and Web-based programs that allow patients to monitor their diabetes, so "we are engaged, not intrusive," he says.
As they evaluate patients' chronic conditions, Carolina Health Alliance looks at patient psychological and social conditions as effects on their care. It doesn't stop at the doorstep of clinical needs. "With our patient connect surveys, in the comfort of their own home, they can respond to screenings for depression, tobacco and alcohol abuse, and domestic violence," Warcup says.
Flexibility in hours also figures prominently in patient satisfaction. The medical offices open at 7 a.m., stay open at lunchtime, and include two nights with evening hours and half days on Saturdays. Appointments can be scheduled within 48 hours.
Overall, Warcup says that the "patient has a real appetite to understand why we do the things we do." And the message to patients is: "Ultimately, it's your decision and what we do is based on your goals."
Success key No. 2: Constant reminders
Usually, patients are given instructions about medication and taking care of themselves as reminders before being discharged from hospitals. The 174-bed Florida Hospital Celebration Health in Celebration, Fla., doesn't just ask questions or give reminders to patients when they are leaving.
At FHCH, the scenario seems more proactive: Patients are given reminders about their follow-up care while they are still in the hospital, days before discharge. The reminders are shared with friends and family members, too, with the approval of the patients. The staff asks patients questions about areas related to the Hospital Consumer Assessment of Healthcare Providers and Systems.
It is important that discharge planning begins early, says Monica Reed, MD, CEO of FHCH, which is part of Florida Hospital, a system that includes eight campuses serving the greater Orlando area. Nurses work with patients days before discharge to go over their care plans, medications, and what's needed for follow-up care, Reed says. Too often, "patients don't know what their medical diagnosis is, they don't understand the medication they are using, they don't make it to the next doctor's appointment after discharge. And then they end up back in the hospital with the same problem," Reed says.
The hospital ensures that patients receive educational plans gradually, says Patty Jo Toor, RN, OCN, MSN, the chief nursing officer for FHCH. "We want to be sure that patients aren't bombarded," she says. Hospital officials want the patient to have enough educational material to begin taking control of their care. Heart failure patients, for instance, are taught generally about the disease and what it means for them personally: the foods they should eat, what kind of exercise program they should have, Toor adds. To help patients understand their medications, nurses explain the prescription regimen and give them proper dosage before discharge.
The hospital tracked HCAHPS scores between 2012 and 2013. Nurse communication increased 13%, up from 70% to 79%; communication about medication increased 8%, from 59% to 64%; and discharge information scores increased 6%, from 79% to 84%. The overall rating improved 5%, up from 73% to 77%, and willingness to recommend jumped 16%, from 69% to 80%.
For CEO Reed, patient satisfaction stems from having patients engaged in their own care. "I think patient satisfaction is the beginning, then you have activation for the patient.
"At the end of the day," Reed adds, "you want to keep patients out of the hospital. So we want them to understand their disease process and to trust their care providers to help them in their disease process. I think loyalty is a substitute for trust: Do I trust these people with my health? If patients know we see the hospital as a place of health and one of healing, then we've done a good thing."
Success key No. 3: Life coach program
The emergency department is a place in the hospital where many chronically ill patients wind up because they don't have physicians of their own. As a way to connect—and stay connected—with these patients, Bon Secours Health System initiated a life coach program in which nurses and other personnel are assigned to help patients find medical care outside of the ED.
The life coaches can include nurses, technologists, or pharmacists. Two coaches are at each hospital location, where they reported an average of as many as 200 daily ED visits by uninsured patients without a primary care doctor. The average life coach sees about 10–15 patients a day.
From the outset of the program, Bon Secours staff would see all the patients who came into the ED and determine whether they needed a primary care physician, says Pam Phillips, senior vice president of mission for Bon Secours. Many of the patients did not have insurance. In some cases, they had ailments that didn't require hospitalization.
By connecting these patients with primary care physicians, Bon Secours improved their access to appropriate medical care, she says. In the first year of the program, from September 2008 to 2009, life coaches assisted 1,000 patients who had been using the ED for primary care needs, and only 12 returned. At least 60% of those who were helped haven't returned to the ED for chronic care but are instead receiving care in other settings.
Some of the patients "have acute conditions and eventually have to be admitted because it's so serious, or they come to the ED because they have an earache and it's not emergent but there is nowhere else for them to go," Phillips explains.
When they are directed to primary care physicians, the patients are integrated into the Bon Secours primary care employed network, or connected to a free clinic partner.
Clinicians ask patients about medical issues and, more important, about their social situation, if there's an issue at home, says Phillips. For example, if their electricity was turned off, they could receive a referral to the community agency to pay electric bills. "We try to address the social needs as well as the medical needs," she says. The life coaches also help patients fill out paperwork "because a lot of the people are entitled to benefits and they don't even realize it," she says.
The Bon Secours medical community connected 3,548 patients in 2012 to social services such as food, dental care, financial assistance for rent or utilities, or medication assistance.
"When a patient leaves they actually may have an appointment with a doctor at one of the clinics. A life coach calls them at home, reminds them of an appointment. If they don't have transportation, the coaches help them get it," Phillips says. In that way, it shows that patients can feel comfortable in knowing they have access to care they didn't know they had.
After meeting with the life coaches, 2,498 patients who didn't previously have doctors were scheduled for appointments with primary care physicians in 2012. Bon Secours also does follow-up calls to check on the outcome of the doctors' visits.
"The goal of life coaches is to establish community partnerships to better serve the economically poor with respect and dignity, and to improve access to primary care," Phillips says. "Helping people who don't have a doctor get established with their own physician is the first step in securing their health and consequently the health of the community."
Success key No. 4: Cooperation with competitors
In some cases, hospitals are teaming up to focus on chronic care programs impacting vulnerable populations. The cooperative arrangements include organizations that have been competitive with each other.
By having these organizational team approaches, however, hospital officials say they can improve access to care, target chronic conditions, and open the door for primary care physician referrals. In addition, they can reduce ED use and readmissions.
The 592-staffed-bed New Hanover Regional Medical Center works with Community Care of North Carolina, a community-based physician-led program designed to improve access to primary care medical homes for needy populations, especially for chronic conditions, says Scott Whisnant, director of government relations for NHRMC in Wilmington, N.C.
The collaborative effort "is attractive to the hospital, and we are seeing a better and newer way to treat this type of chronic disease," Whisnant says of chronic conditions. The community program has opened the door for more cooperation in which hospital physicians work with specialists within CCNC to find "best practices to treat patients [and] have care management by going to the home and making sure meds are taken correctly."
The NHRMC has a network of nearly 500 physicians from various hospitals to coordinate care, and serves a population of 1.2 million. Between 2007 and 2010, Community Care of North Carolina saved Medicaid nearly $1 billion, according to an evaluation by Milliman Inc., the CCNC stated. The coordination of care has resulted in a 20% reduction in readmission, compared to clinically similar patients who receive care, says Paul J. Mahoney, vice president of communications for CCNC.
When case managers review patient files and visit them, sometimes they find the root of their physical problems don't have anything to do with clinical issues but environmental issues that the hospital may not have spotted initially, Whisnant says. "A patient may feel they can't control their child's asthma. Then you find out the patient has a dog sleeping on the bed with that child. Does that have something to do with it?" Whisnant asks.
"Maybe a baby is having trouble breathing in the home, and then you find out they are scrubbing the floor with ammonia and the window isn't being raised" for ventilation.
Patient satisfaction scores in a 2013 report show that 82% of NHRMC's discharged patients said "yes," they would definitely recommend the hospital, compared to 71% of the North Carolina average and 71% of the national average. The figures were part of a survey of at least 300 patients from October 1, 2011, to September 30, 2012, according to Hospital Compare data.
In Illinois, the Chicago Medical Home Network focuses on a remote home monitoring program to more accurately identify at-risk patients and improve patient engagement and satisfaction. The network includes hospitals and dozens of clinics and physician practices that have agreed to cooperate and improve basic care for Medicaid patients, and they are linked through an Internet portal.
The participating Chicago hospitals are the 895-bed Cook County Health and Hospital system; the 160-bed Holy Cross Hospital; the 49-bed La Rapida Children's Hospital; the 319-bed Mount Sinai Medical Center; the 664-bed Rush University Medical Center; the 395-bed Saint Anthony Hospital; and federally qualified health centers.
Like some other hospital programs, the Chicago-based Medical Home Network, a collaborative of 12 hospitals and 110 team-based primary care medical homes, uses an electronic system to alert physicians when Medicaid patients are admitted, discharged, or use an emergency department, and the reasons why. MHN's secure Web-based portal, MHN Connect, also provides access to complete patient medical history to physicians throughout the world.
MHN goes one step further, says Cheryl Lulias, its president and executive director. MHN also operates a remote home monitoring initiative for hypertension and congestive heart failure patients at seven partner clinics.
Patients receive wirelessly connected technology that transcribes their medical readings in an encrypted fashion to a secure network, which, if necessary, triggers an alert to physicians. MHN provides the equipment free of charge to the patients. The equipment includes blood pressure cuffs and scales. Each device is battery operated and equipped with Bluetooth technology, which wirelessly transmit diagnosis readings to a cellular pod than then encrypts the readings and relays them to the portal.
From there, MHN facilitates data analysis, synthesizing real-time biometrics with the wealth of data available in its MHN Connect portal, resulting in actionable tools for chronic disease management.
The technology alerts help engage patients, and they are happier about the process, Lulias says. By enabling clinicians to monitor patients in real time, for instance, doctors are able to "mitigate the 'white coat' effect on blood pressure readings that occur during office visits, a temporary condition that can confound readings and lead to mismanagement of hypertension," Lulias says.
The remote monitoring program is one part of MHN's broader mission to drive better health outcomes for its target population. One of MHN's key performance indicators is for patients to receive follow-up care in their designated medical home within seven days of being in a hospital or having an ED visit. In December 2012, MHN reported 19% of patients were routed to medical homes within a week; and in six months, it was 23.4%, which Lulias sees as good progress.
"We're trying to reduce readmission, inappropriate hospitalizations, poor chronic care management, and preventable ED visits," Lulias says.
The personal communication between staff and patients has encouraged both, she says. "Through our efforts, we are working to engage patients, support healthier behaviors, and build healthier communities.
"We have made competitors collaborators for this initiative and have organized around a shared vision and purpose," says Lulias.
Reprint HLR1113-7
This article appears in the November issue of HealthLeaders magazine.
This is a population health strategy: A plan years in the making and backed by the local medical center may make Cheshire County, NH, the healthiest community in the nation by 2020.
"Almost without interruption we had the mountain in sight before us,"-- Henry David Thoreau
wrote about 3,165-foot Mt. Monadnock in New Hampshire, a mountain that inspired him, spiritually and physically.
At the base of Mt. Monadnock where the air and water are still clear and cool , thousands of residents, with physician and hospital support, are thinking about different mountain to climb. Their goal is to become the healthiest area in America.
Do you want to talk about population health planning? Cheshire County, NH, is exploring it big time, far beyond the four walls of its lone hospital and physician offices.
The 169-bed Cheshire Medical Center/ Dartmouth Hitchcock Keene, hospital and primary care and multispecialty clinic has sparked an initiative, dubbed Healthy Monadnock, to become the healthiest community in the nation by 2020. Cheshire County has 23 towns and is located in the southwestern corner of the state. According to the census, the county has 76,851 residents within its 729 square miles.
It's no joke. There is a concerted effort to make the Monadnock area the healthiest in the nation. The plan, years in the making, includes government and civic policy changes that officials hope will prompt its community organizations, schools, workplaces and municipalities to make healthy choices about how they eat, how they exercise, and generally take care of themselves.
Thousands of people are involved in keeping track of their own health by measuring their commitment to lose weight and get fit. While schools are revamping their menus to offer reliably nutritious fare, local planners are drawing up sketches for sidewalks and parks to encourage residents to walk and run.
Cheshire Medical Center/Dartmouth Hitchcock Keene, and local physicians are helping people "create an awareness" of their own health, says Art Nichols, the hospital CEO.
"We're not unlike a lot of other communities. We are the only hospital in our county, and we have had this partnership with physicians for 15 years," Nichols says. "When you own the market and are a significant provider, I feel there's a responsibility to that market. We don't want to wait for people to get sick and show up in our offices or emergency room. That's not enough to do our jobs."
"We want to try to help our community be the healthiest it can be, and in fact, we declared we wanted it to be the healthiest community in the country," Nichols adds.
The Healthy Monadnock 2020's activities are overseen and guided by a "healthiest community advisory board," a coalition of 30 people representing schools, private business, healthcare organizations, recreational groups, non-profit agencies, municipal and state governments.
With community 'champions' designated to help residents, the group plans to measure community progress toward achieving goals. Generally, the goals encompass what officials describe as a "broad spectrum and vision of health:"
Social factors that influence health
Education and "awareness" of healthy lifestyle behaviors
Healthy eating
Active living
Social support network
The hospital will spend upwards of $200,000 for the program and Nichols says it's worth every penny. "There is no factor more important for health than [the] behaviors of an individual. At least 50% of a person's health is reliant on behavior and that's the whole notion of trying to create the healthiest community. So much happens outside the walls of a hospital, there's only so much a hospital can do."
Physicians have been working closely with healthcare leaders to reduce the amount of time people are spending in the hospital. Under its accountable care initiatives, the hospital has significantly reduced inpatient admissions, Nichols says.
"We got a jump on the whole notion of accountable care, and because of that, our physicians have developed some skills to keep people well and keep them out of the hospital," he says. "We've been about 50% below the national average for Medicare readmissions for some years now," Nichols says.
Economically, "the healthier patient is going to pay off" for the hospital, Nichols says. "This is a nice crossover for a healthier community as we enter the new world of (value-based care)."
Town leaders have written the "principals" of what they envision of a healthy community to be in their master plan. "They have developed streets that include sidewalks and bike lanes that aren't barriers to people [going out and walking]. And there is a lot of emphasis on local foods, and access to fruits and vegetables," Nichols says. "It sounds a little crunchy, but it's really not, it can be done."
For its work, Cheshire Medical Center/Dartmouth-Hitchcock Keene has been awarded the Carolyn Boone Lewis Living The Vision Award from the American Hospital Association reflecting the AHA's "vision of a society of healthy communities where all individuals reach their highest potential for health."
While the community is actively promoting its program, there's a way to go. Less than half of its residents—49%—know about the hospital's goals. "We know if we're going to be successful, we need everyone on board with Healthy Monadnock 2020," the hospital says.
It's a lofty goal, but 2020 is a long way off and Nichols is enthusiastic. In the meantime, the rest of America might consider doing what Cheshire County is actively trying to accomplish.
While the reasons for the projected doctor shortage are clear—population health issues, shrinking physician reimbursements, workforce issues, and residency training insufficiencies—the path toward a solution is not.
Perhaps you've seen reports saying that physician shortages may not be as bad as once feared. Maybe you believe that a greater push toward using mid-level providers is reason for hope among healthcare execs. It's no surprise that scope of practice laws are being challenged in several states.
Don't buy it, says Atul Grover, MD, PhD, chief public policy officer of the Association of American Medical Colleges, based in Washington D.C.
"We can live in a make-believe world or live in the world we are in. It's going to be a lot tougher to fill those gaps," Grover says of potential physician shortages. "There's cultural issues, there's reimbursement issues…. We haven't trained enough doctors… There's definitely a shortage."
Current utilization patterns suggests that by 2020 there will be a national shortage of 91,500 physicians – 45,400 primary care physicians and 46,100 subspecialists. Recent data suggest that advances in care, such as a 50% reduction in mortality for cardiovascular disease, will only expand the need for more physicians, Grover says in an article in this month's Health Affairs. Lidia M. Niecko-Najjum, a senior research and policy analyst at the AAMC, co-authored.
While there may be disagreement over numbers, there's no question that there will be a need for care, especially among an aging population and rising numbers of the chronically ill. Coupled with a physician force whose numbers are dwindling, the problem is easy to see.
Much of the need for physicians, of course, depends on healthcare workforce projections, which "have been notoriously unreliable because they are often based upon idealized future delivery systems rather than current utilization trends," Grover and Niecko-Najjum write.
Physician Attrition
Meanwhile, physicians are growing dissatisfied with their work. One in three practicing physicians older than 55 is expected to retire in the next 10 to 15 years, Grover writes.
Many are not eager to continue practicing medicine. A survey published last year by The Physicians Foundation [PDF], attracted widespread attention when it disclosed that 60% of physicians "would retire today if given the opportunity."
So at the top end of the age scale, physicians are leaving by attrition, and at the low end, younger physicians seeking better work-life balance seek to work fewer hours than their predecessors.
In upcoming years, the academic world will be working to enlist more physicians, but the political world is way behind, and that's the problem, Grover tells me. "It's kind of alarming," he says.
Residency Training
States and schools have responded to the need by increasing the number of medical students, but that alone will not increase the supply. The unwillingness of Congress to fund additional Medicare GME positions may lead to U.S. medical school graduates who lack opportunities to complete their residencies, Grover says.
Just last March, 528 qualified 2013 medical school graduates were not matched to a residency training position, 758 qualified medical doctors who had graduated prior to 2013 also failed to be matched.
"I can boost enrollment in an MD [academic] program until the cows come home. If I don't train them after they receive their degrees, it's worthless. You can't practice until you are matched into a residency as a trained and licensed physician," Grover says.
"They can go into industry, but they can't take care of patients. No physician, no MD, or DO can practice anywhere in the country without doing a residency. They can work for industry or research, but our goal is to have as many out there to take care of patients," he says.
Since 1965, Medicare has been the largest supporter of graduate medical education programs and has paid for its share of training costs. Then the Balanced Budget Act of 1997 imposed a cap on Medicare funded-GME at 1996 levels. This came at a time, he says, that managed care seemed to be the future of the healthcare systems.
That didn't happen. "The cap," Grover writes, "is still in place, limiting teaching hospitals' efforts to expand or create new programs." Medicare now pays for less than 25% of direct training costs for residents and fellows.
In the late 1990s, when Grover was a resident, there were HMOs, and predictions for the need for physicians were less dire. Then "technology helped make fatal diseases chronic diseases," he says. Now Congress needs to expand the number of federally supported residency positions, he says, noting that some legislation has been proposed.
Non-Physician Providers
Grover agrees with healthcare planning providing for physician assistants, social workers, nurses, physical therapists, and pharmacists to buttress physician work. But that only goes so far without physicians themselves, he says.
Even if current health care delivery reforms are implemented and successful, the U.S. population certainly will need a larger healthcare workforce, including more physicians. The Patient Protection and Affordable Care Act may add up to 30 million more insured to the population in the upcoming years
"I worry about giving 30 million people a card and a false promise," Grover says.
Although many bills designed to kill the sustainable growth rate formula have languished in Congress over the years, the talk these days is much more serious and physician groups have reason to be optimistic.
The government is still struggling with the fallout from the HealthCare.Gov fiasco, President Obama continues to explain to the confused masses how they will get insurance, and the U.S. is still waking up from a partial federal government shutdown.
While much is in disarray, particularly in healthcare, there is some irony here: The long-running physician payment scheme—aka the "doc fix"—might be on its way to being resolved for good (maybe).
For a decade, the SGR (sustainable growth rate formula) sets Medicare physician payment rates through a formula set in 1997. It has been the subject of an annual dance in Washington. The "doc fix," imposed by Congress to ward off potential cuts in the SGR, is scheduled to lower Medicare rates by 24.4% in 2014.
That drastic rate drop explains why when physicians are asked about one of their chief concerns and hopes in their practices, demolishing the detested SGR is virtually always at the top of their lists.
Although many bills designed to kill the SGR have languished in Congress over the years, the talk these days is much more serious. A so-called "discussion draft" released by the Senate Finance and Senate Ways and Means Committees last week would not only get rid of the SGR, but would also deliver value-based payment and delivery models to Medicare physician payment systems. It builds on a plan approved by the House Energy and Commerce committee.
As envisioned, the proposal would hold doctors' pay at current levels as other optional payment plans are developed. And it would combine some existing Medicare quality programs into an initiative that would offer doctors additional pay based on new metrics, according to the American College of Physicians.
The SGR would be eliminated and a new performance-based incentive program would be created, which would become effective in 2017.
Reviewing the Proposals
Healthcare experts are examining the proposal and are being asked by lawmakers to comment on them. Analysts who have reviewed the plan are excited about the possibilities, though there is concern that there are still not enough details in place how any payment structure would replace the SGR.
Still, elected officials are patting each other on the back because there was a bipartisan agreement among powerful Senate committees that endorsed the plan. Physician groups are applauding it, too.
"It needs to be repealed and it needs to be repeated now," Charles Cutler, MD, FACP, chair of regents for the American College of Physicians, said in a statement.
"Congress is demonstrating that they understand that ending the failed SGR this year is fiscally responsible," American Medical Association President Ardis D. Hoven said in a statement.
"Congress must ensure stability in physician reimbursement and avoid any cuts that jeopardize the nation's teaching hospitals and the ability of their physicians to provide Medicare beneficiaries with timely access to care," The Association of American Medical Colleges' President and CEO Darrell G. Kirch, MD, said in a statement.
With the actions of the Senate committees, lawmakers have shown more progress in ditching the SGR than seen in the past decade, says Anders M. Gilberg, senior VP, government affairs for the Medical Group Management Association's Washington, DC office.
"The bottom line is you can go to (Capitol) Hill any day and get unanimous support for repealing the SGR. I'm not aware of any member of Congress not opposed to repealing the SGR," Gilberg says.
Details To Work Out
So, is this for real? Yes. But…
"It's for real in the sense people have put their cards on the table with respect to the policy alternative. What's not real is how to pay for it," Gilberg says. The Congressional Budget Office has estimated it would cost at least $139 billion over the next decade to get rid of the SGR. When another House committee passed a repeal bill in July, the estimated cost was estimated at $175 billion.
"The prospects for repeal this year is largely up in the air. What's going on are a lot of political crosswinds that can derail the success of an SGR bill this year," such as budget deficits.
As Gilberg sees it, reform is possible if Congress moves quickly in the remaining two months this year, or early next year.
If Congress doesn't act early next year, that could mean trouble for any SGR changes because "next year is an election year and the closer you get to an election, the more polarizing it would be, and it would be difficult again," Gilberg said, referring to House and Senate elections. "I can't think of a more dysfunctional situation in Congress right now."
Optimism
Other experts are even more optimistic.
"This time, it looks like the effort could actually succeed," writes Bob Doherty, Sr. VP of government affairs for the American College of Physicians in a blog. (The ACP staff pointed me to Doherty's blog when asked for comment). "Never before has there been agreement between the House and Senate, Republicans and Democrats on a plan to repeal the SGR, never mind on what they would replace it with. Their goal is to get the bill enacted and signed into law before the end of the year."
According to the American College of Physicians, under the Senate committees' SGR elimination plan, physicians will have the opportunity to earn additional Medicare incentive payments, above the zero percent annual baseline updates, for participating in a new Medicare Value Based Incentive Program, which would replace the existing Medicare Physician Quality Reporting Program, Meaningful use for electronic health records, and Medicare value-based modifier program.
This creates an opportunity to develop a "simpler, more harmonized and effective reporting and incentive program," the ACP states. There are also incentives for medical homes by directing Medicare to pay for complex chronic care management services in medical homes, and giving them the highest possible performance score for clinical practice improvement activities under a new value based payments incentive program.
Still, many details have to be worked out, including the various ways that lawmakers will have to consider to pay to replace the SGR.
"The question is what would the alternative payment models look like, because even with ACOs, the Medicare shared savings program, there have yet to be results from those," says Gilberg of MGMA.
"So basically you are designing a value system for Medicare, when people have yet to figure out what are the actual mechanisms to move us away from fee for service. There's a tension there."
As for physicians, they await to see the outcomes in Congress. As one healthcare official told me, "We want to keep the momentum and enthusiasm and getting change in there and have life more predictable for physicians."
