Besides relying on walk-in traffic from patients, clinic leaders are also exploring new medical services to differentiate themselves and to better coordinate care.

This article appears in the September 2015 issue of HealthLeaders magazine.

It is hard to get a firm count on the number of urgent care centers in the United States. The Urgent Care Association of America says there are more than 6,400, while the American Academy of Urgent Care Medicine puts the number as high as 9,300. What is clear, though, is the growth of this care model. As hospitals and health system leaders evaluate the risks and rewards of urgent care, there are strategic considerations that may seem unimportant on the surface, but can lead to complications later on.

Take, for example, the difficulty in determining the number of urgent care centers. It stems from the lack of standardization in states' regulation of urgent care facilities. Generally, most states view urgent care centers as a physician office with extended hours. A few states, such as Arizona, attempt to regulate urgent care clinics through licensure. And some states require a certificate of need for urgent care centers. The differences in state regulations are an important issue, especially if a healthcare organization's footprint extends across state lines.

Another issue to consider is whether an urgent care center perpetuates the fragmented nature of healthcare. Hospital and health system leaders have repeatedly said that care coordination is imperative to achieve better quality, cost, and outcomes. Will patients, who are in a hurry, especially when seeking an urgent care center, get so used to the easy access and quick service that they forgo seeing or keeping their primary care physician in the loop?

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Besides relying on walk-in traffic from patients, clinic leaders are also exploring new medical services to differentiate themselves and to better coordinate care.

This article appears in the September 2015 issue of HealthLeaders magazine.

It is hard to get a firm count on the number of urgent care centers in the United States. The Urgent Care Association of America says there are more than 6,400, while the American Academy of Urgent Care Medicine puts the number as high as 9,300. What is clear, though, is the growth of this care model. As hospitals and health system leaders evaluate the risks and rewards of urgent care, there are strategic considerations that may seem unimportant on the surface, but can lead to complications later on.

Robert Rankins, MD

Take, for example, the difficulty in determining the number of urgent care centers. It stems from the lack of standardization in states' regulation of urgent care facilities. Generally, most states view urgent care centers as a physician office with extended hours. A few states, such as Arizona, attempt to regulate urgent care clinics through licensure. And some states require a certificate of need for urgent care centers. The differences in state regulations are an important issue, especially if a healthcare organization's footprint extends across state lines.

Another issue to consider is whether an urgent care center perpetuates the fragmented nature of healthcare. Hospital and health system leaders have repeatedly said that care coordination is imperative to achieve better quality, cost, and outcomes. Will patients, who are in a hurry, especially when seeking an urgent care center, get so used to the easy access and quick service that they forgo seeing or keeping their primary care physician in the loop?

"We tell patients that we do not want to be their primary care doctor," says Robert Rankins, MD, founder of E-Care Emergency Centers, a McKinney, Texas–based network of four for-profit freestanding emergency and urgent care centers that also provide urgent care services in the Dallas suburbs. "I don't want to see them for their high blood pressure and diabetes. We try to get patients who come in here for a primary care reason hooked up with a primary care physician. If they come in with a sore throat and they couldn't get in to see their regular doctor, we tell them to follow up with their primary care doctor because that is not what we want to compete with. We try to make that very clear."

Success key No. 1: Understand regulatory environment

The urgent care business model that Rankins developed—a facility that can treat urgent care and emergency patients—is both a cautionary tale and success story. Rankins says early on he learned that to minimize patient confusion and maximize volume, he needed to deliver what patients wanted and needed.

"What we're doing is a cost-savings for the consumer," says Rankins, who is a board-certified emergency physician. "Our facility is a one-stop shop," he says, noting that patients should be able to come here, receive the care they need, and not worry if they should have gone to an ER or an urgent care center. "We're trying to bring them both under one roof."

Rankins originally opened up E-Care as an urgent care center, but in 2010 when Texas began licensing freestanding emergency departments (FED), the state treated E-Care as a FED only, so Rankins switched gears to offer just emergency care. He says the effect was confusing for patients, payers, and even for him.

"We had some insurance companies who would pay us for emergency care and some would not," says Rankins. "I had a Blue Cross Blue Shield patient with chest pain, and we did a complete cardiac workup and billed it as an ER visit. They denied us, so we rebilled the visit as an urgent care one because we had to get paid something. The insurance company said, 'You're not urgent care,' and that was the impetus for me to become both."

Rankins says patient volumes are still recovering from the confusion, but being able to treat urgent care cases has helped keep his combination model sustainable. Prior to the 2010 FED rules, he says E-Care was seeing 70 patients per day at each location. But then that number dropped sharply, and the centers are now up to 30 patients per day.

"It's been a challenge, but we're getting there," he says.

A significant obstacle is the overhead a FED incurs without the patient volume to go along with it. FEDs have the same requirements as a hospital-based EDs: Have at least one ambulance bay, be open 24/7, have emergency-trained physicians and nurses on site, and have appropriate diagnostic equipment. But what's not coming through E-Care's doors quick enough are ambulances with patients who need emergent treatment but not a hospital admission.

Rankins says that's because there is no statute that requires emergency medical service crews to use FEDs, which are in direct competition with area hospital–operated EDs and want the admissions.

"It's not fair, in my opinion, to be prepared for emergency traffic but not require the other team to play with us," he says. "We need to be able to downsize our staff at night and cut expenses. It's not right to say, 'You have to be ready to play, but we're not going to force them to throw the ball to you.' We want emergency cases, we have to be prepared for them, and it costs us the same to staff. What's happened is FEDs have the same expense and overhead as a hospital-based ED but nothing coming in."

Beverly Bokovitz, MSN, RN, NEA-BC

Right now, Rankins estimates that, depending on the time of year, between 190 and 273 patients per month per location are true emergency cases at E-Care facilities. That represents between 20% and 30% of E-Care's patient volume. He'd like to increase that volume, but by having a combination urgent care and FED, Rankins can afford to ride out state healthcare regulations. Rankins is on the board of directors of SAFER-Texas (State Association of Freestanding ERs), an organization made up of FEDs that advocates for its members. As vice president of advocacy for SAFER-Texas, he is actively involved in state legislation that can hinder or help FEDs.

Success key No. 2: Align urgent care with emergent care

In St. Louis, competition for urgent care patients is fierce, says Beverly Bokovitz, MSN, RN, NEA-BC, chief nursing officer at St. Anthony's Medical Center, a 550-staffed-bed nonprofit Catholic hospital that has four urgent care centers. Bokovitz is also part of the four-member St. Anthony's Office of the President, which includes new CEO David Sindelar, a unique leadership structure that complements the traditional and singular CEO role.

Bokovitz says St. Anthony's urgent care centers are strategically placed in locations surrounding the hospital. The busiest center is Lemay Urgent Care, serving 20,000 patients annually. It is about 5 miles from the hospital.

"We're in a very competitive market, and looking geographically at locations made sure our strategy is in alignment with our demographic studies," says Bokovitz, noting that there are 45 urgent care centers in metro St. Louis, including a competitor directly across the street from St. Anthony's Medical Center.

St. Anthony's total urgent care volume for all four centers in 2014 was 77,357, and brought in $28 million in revenue. Bokovitz says so far in 2015, volumes are up by 10%, primarily because the urgent care centers are doing more than seeing patients with a cough, sore throat, or broken bone.

"Urgent care allows you to have another healthcare setting in a different location," she says. "If you put yourself in the box of 'You're just an urgent care,' I think that's probably a mistake. The best strategy is to think about what other types of services you can offer if you have multiple locations."

The biggest contributor to the urgent care patient volume increase this year is occupational medicine. In 2014, the hospital's ED was reorganized to improve wait times, and in the process, urgent care was reorganized, too, because the urgent care centers were a main source of ED patients. That prompted a new organizational chart that combined occupational medicine, urgent care, and community health and wellness (including employees) under ambulatory care.

Charles J. Lewis, MSN, RN

Charles J. Lewis, MSN, RN, is the executive director of emergency services and ambulatory care at St. Anthony's Medical Center. Lewis says when the system did its operational assessment of ED and urgent care services, it was clear that the occupational medicine work was siloed, resulting in operational inefficiency. Before the reorganization, patients who came in for occupational medicine needs followed a different workflow because not everyone was trained to perform a blood alcohol test or other tests needed in order to be cleared for employment. It fostered an us-versus-them attitude among staff, he says.

"We have varying levels of service and offerings within occupational medicine that includes worker injury and population health preventive-type services, like community wellness and fitness," says Lewis. "Blending occupational medicine with urgent care was a natural fit. We have to see those patients in a brick-and-mortar setting, and we had those resources available through the four urgent care locations, so why not blend the staff and resources together?"

Now, all four urgent care centers can see an initial worker injury; the longer-term follow-up is done at two of St. Anthony's urgent centers.

"We have occupational medicine care at every location," says Lewis, who also says that ability to provide occupational medicine is an opportunity to differentiate St. Anthony's from the crowded urgent care market in St. Louis.

"You have to do it very well and have a high level of customer service for the clients," he says.

Reorganizing emergency medicine and urgent care under one leader has helped the system align its goals, says Lewis, especially because of the historically rocky relationship between EDs and urgent care centers.

"The ED physicians work closely with our urgent care physicians," says Lewis. "And I meet regularly with senior leaders of our physician group, and we talk about access. We share EMRs, so if a patient is seen in urgent care, it's very easy for the primary care or the ED physician to be able to see what care has been provided and what the plan was for that patient."

Care coordination is a key issue for healthcare executives. Poor postacute care can lead to readmissions penalties, lapses in quality, and lackluster patient satisfaction evaluations. If a patient seeks care in an urgent care center, that episode may or may not make it back to the patient's PCP.

In 2013, a brief developed by the Center for Studying Health System Change noted that among the 30 urgent care, hospital-based ED, and health plan executives it interviewed, urgent care centers weren't major disruptors to the coordination of patient care, but it also was not a big priority, especially for the urgent care centers that were not affiliated with a hospital or health system.

Steve Sellars, MBA, is CEO of Premier Health Urgent Care based in Baton Rouge, Louisiana, which sets up joint ventures with hospitals to own and operate urgent care centers; he says coordinating care is an important issue that operators shouldn't overlook.

Steve Sellars, MBA

"We see a lot of different things going on in urgent care centers," says Sellars, an Urgent Care Association of America board member since 2011. "It is an access point to care within the health system, and our partners typically have a family of services, so it's about getting the patient into the right level of care. The UC industry is committed to making sure that communication between primary care, urgent care, and specialists happens."

St. Anthony's shared EMR helps the system keep a patient's care coordinated. There are no more repeated studies if a patient is transferred from an urgent care center to St. Anthony's Medical Center ED, and there are no more duplicate copays. Lewis says that a patient's urgent care copay will be applied to the ED copay or inpatient bill, if that care also is required. The EMR allows the urgent care centers to note that the patient is an urgent care transfer, which prompts the ED physician to look into the record to find completed labs and tests.

Another improvement from the reorganization that benefits urgent care and emergency patients is the direct-to-ED-bed policy. If a patient is seen in a St. Anthony's urgent care facility but needs to transfer to the ED, St. Anthony's Medical Center will hold an open ED bed for 30 minutes.

"We script what urgent care will say," says Lewis. "The urgent care staff are trained to say, 'Mr. Smith, if you go now, the ER is holding a bed for you.' And when the patient gets to the ER, we have a script there as well: 'We've been expecting you,' and we place them directly into their ED bed. Their wait time starts as soon as they're seen in urgent care."

This direct-to-ED process also is available to St. Anthony's Medical Center patients. Bokovitz says the new process, developed by both ED and urgent care physicians, improved wait times tremendously. In 2013, the average amount of time an urgent care patient waited for an ED bed was 125 minutes. In 2014, that was reduced to 19 minutes.

In addition to supplementing urgent care offerings with occupational medicine, Bokovitz also says St. Anthony's Medical Center is exploring the possibility of offering primary care services, telemedicine, and a partnership with retailer CVS.

"We're in the midst of change with urgent care, and you really have to start thinking out of the box: What are other ways we can use urgent care centers?" says Bokovitz. "We're in a competitive market. If we were the only people in town, we'd have less to worry about, but we're not, so we need to think about the other ways we can serve patients."

Success key No. 3: Trending the future

Torrance, California–based HealthCare Partners, a division of DaVita HealthCare Partners, which operates and manages medical groups and urgent care centers in California, Florida, Arizona, Nevada, and New Mexico, is also experimenting with diversifying its urgent care services.

For example, its urgent care center in Pasadena, California—HealthCare Partners' largest urgent care center in California, where physicians see 5,000 patients a month—has added two specialty care clinics within the past year based on the needs of patients it was seeing.

"Cardiology is a new department we added in the last year," explains Claudia Pfeil, MD, one of two lead physicians who oversee the Pasadena urgent care center site, and chair of the HealthCare Partners urgent care center steering committee, a group of administrators, nurse leaders, and lead clinicians from other urgent care centers who meet to share best practices.

"The cardiologist works synergistically with the urgent care doctors to treat chest pain and other chronic cardiac conditions in the urgent care. The cardiologist actually can perform on-site stress testing for patients as well, so that's been an exciting area of development."

Pfeil says another specialty clinic at the Pasadena site is whole-body wound care.

"These specialty departments have evolved either out of the urgent care, based on the need of the patients that we're seeing here, or we've brought them in because the department, such as cardiology, will work synergistically with what we're doing."

The Pasadena urgent care location is one of eight urgent care centers owned by HealthCare Partners. In June, it marked its one-year anniversary at a new location. According to the Urgent Care Association of America's benchmarking report, expansion is a trend: 60% of urgent care centers accommodated growth by buying another practice, adding space, or building a new location.

The Pasadena location's new space expanded from 25 treatment rooms to 40; it also has nine observation units. It is open 24-hours a day, 365 days a year, and the observation rooms function the same as a traditional hospital.

"It was one of the main incentives to move to a larger site," says Pfeil. "It doubled our observation capacity."

HealthCare Partners Pasadena urgent care center has not always been open 24/7, but the impetus to expand its hours seven years ago was because Pfeil says its patients are older and sicker, and were staying in the urgent care center longer.

"Prior to going 24/7, by 10 or 11 o'clock at night, we were scrambling to try to transfer patients out," says Pfeil. "Typically they would end up going to the ED. This way, we have more time to really provide better care and get them directly admitted to the hospital or into a skilled nursing facility."

HealthCare Partners also has a shared EMR system that connects patients to its employed hospitalists at area hospitals and to its primary care physicians. HealthCare Partners also can provide a heightened level of coordinated care.

"About 60% of our patients are with HealthCare Partners' HMO, and about 40% are PPO," she says. "Having an integrated EMR makes a huge difference. It's critical for us to provide that coordinated care."

The issue of educating patients on the difference between emergent and urgent care is something that is ongoing with aggressive marketing campaigns, but Pfeil says she also makes sure that referring providers know the difference, too.

"The majority of primary care doctors will actually come through and meet with me," says Pfeil. "I give them an overview of what we can do here in urgent care, what kind of services we have, so they have a mental image of what our clinic looks like."

Urgent care centers have an opportunity to meet patient access needs and coordinate care, but it must be done thoughtfully, says Sellars.

"We have an aging population, a looming shortage of primary care physicians, and more insured people in the marketplace. When you lump all that together with what urgent care provides, it's safe to say that urgent care will play an important role in the healthcare system going forward."

Reprint HLR0915-8

Despite strides in neuroscience and stroke care, leading organizations are finding there are still improvements that can be made.

This article first appeared in the April 2015 issue of HealthLeaders magazine.

Peter Rasmussen, MD

Hospitals and health systems have increased their focus on stroke care over the years, which in turn has helped contribute to reducing stroke deaths as well as improving outcomes for stroke patients; however, there are still significant gains that some hospital-based neuroscience leaders say can be made.

"We feel attention to stroke care is underrated," says Peter Rasmussen, MD, director of Cleveland Clinic's Cerebrovascular Center. "Proper stroke care is not universally available. Generally in the United States, it is not what it should be or could be."

In January, the American Heart Association released its annual update on heart disease and stroke data showing that, from 2000 to 2010, the annual stroke death rate decreased 35.8% and the actual number of stroke deaths declined 22.8%. That's a noteworthy drop, but, on average, someone dies from a stroke every four minutes. Getting to the patient quickly to diagnose what type of stroke is occurring is key, and the phrase many in neurology use is, "Time is brain."

Indeed. Strokes injure the brain, and the severity of the damage depends almost completely on time. Ischemic strokes, caused by a clot that blocks blood from getting to the brain, occur the most. In fact 87% of strokes are ischemic; 10% are classified as intracerebral hemorrhage (bleeding within the brain), and 3% are subarachnoid hemorrhagic (bleeding just outside the brain). When treated quickly, it means better outcomes for patients. For hospitals, it means shorter lengths of stay, and lower rehab costs.

The gold standard of clot-busting drugs, tissue plasminogen activator (tPA), is the key factor in timely treatment of stroke. The FDA-approved drug dissolves clots blocking blood to the brain, reducing what doctors call "door-to-needle time," which is the primary measure hospital leaders use to determine stroke care progress. Despite its effectiveness, tPA is used in less than 10% of ischemic stroke cases, and when it is used, most hospitals administer it outside the recommended 60-minute window. The drug is effective up to 4.5 hours after stroke onset, but the sooner it is given, the better the outcome.

To help improve their stroke measures, many hospitals have become certified by The Joint Commission as either primary or comprehensive stroke centers. The Joint Commission began its primary certification program in 2003. Hospitals must meet eight core measures every two years to receive primary certification. Hospitals took the stroke program seriously and, by 2007, the AHA and American Stroke Association recommended taking stroke patients to the nearest stroke center instead of just the nearest hospital.

Anthony Avellino, MD

In 2012, The Joint Commission developed its comprehensive stroke program, a tougher designation that identified hospitals that could take the most acute stroke patients and offer a broader range of services.

There are now more than 900 primary and more than 80 comprehensive stroke centers across the country, and The Joint Commission is adding another stroke designation later this year called the Acute Stroke-Ready Hospital Disease-Specific Care Advanced Certification program. It's meant to better prepare rural and community hospitals that are close to stroke patients but do not or cannot reach the primary or comprehensive stroke thresholds. It sets standards for giving an initial stroke assessment, diagnosing with either a CT or MRI, stabilizing patients and then transferring them to a primary stroke center.

Success key No. 1: Prioritize
OSF HealthCare, a Peoria, Illinois-based nonprofit Catholic integrated healthcare system with 10 acute care hospitals, more than 600 employed multispecialty physicians, outpatient services, and two schools of nursing, has attained both the primary and comprehensive stroke center designation.

Anthony Avellino, MD, MBA, CEO of the OSF HealthCare neuroscience service line and the Illinois Neurological Institute, says the system's flagship hospital, OSF Saint Francis, was one of the first to receive The Joint Commission's comprehensive stroke designation back in 2012.

"Stroke is a top priority for us," says Avellino. "I think the next two to three years is going to be the most critical time for healthcare reform for the next 20 years. Any system that can get down cost per procedure is going to see a payment transformation."

In 2011, stroke costs in the United States were $17.5 billion; per patient, the estimate is $4,692. The opportunity for cost savings is on the front end of stroke—that is, prevention, as well as curbing length of stay and length of rehab. Preventing a stroke is an educational venture, and Avellino says OSF HealthCare is constantly educating the community about risk factors. But the benefits of education are a long-term prospect, and healthcare systems are looking for ways to get costs down now.

Avellino says his team is currently developing a standardized stroke protocol for each of its hospitals.

"We should capture the same metrics at every hospital," he says. "The challenge is in our other hospitals; some are a lot smaller than our flagship, Saint Francis."

Saint Francis is OSF HealthCare's only comprehensive stroke center, and has focused on stroke care since the late 1990s, with processes and protocols—and plenty of staff—in place with nearly two decades of practice. To push out that knowledge to its other facilities will require more staff and leadership, Avellino says.

"We have hired a clinical outcomes integration director, and this person will work collaboratively to implement the protocols for standardization."

This position won't just roll out systemwide protocols for stroke, but also for other top-priority neuroscience programs Avellino has identified for 2015: spine, neuro-oncology, epilepsy, multiple sclerosis, neuro-trauma, and sleep.

Those programs are tier 1 priorities. When Avellino arrived at OSF HealthCare last August, he did two things that set the neuroscience department on its current strategic path. First, he developed a one-page charter that outlined the purpose and mission of the neuroscience service line, and he separated the service line's priorities into three buckets, or as Avellino calls them, tiers.

"The tier 1 programs are ones we are already leading in, but want to solidify even more within a year," he says. "Tier 2 programs are one to three years out; tier 3 programs are three to five
years out."

The tier 2 programs include rehabilitation, neuromuscular, headache, movement disorders, neuro-vestibular, neuro-ophthalmology, and pain. The tier 3 priorities are building a memory and brain wellness center, developing a way to transition children with neurological disorders into adulthood, plus neuropsychiatry and complementary neuro-medicine.

"We are trying to find a way to horizontally and vertically integrate neuroscience care to produce the best possible outcomes at the lowest cost with the highest quality," he says.

Tom Tracy, MD

Performance measures are also tied to the tiered priorities. Avellino wants to see improvements in patient satisfaction, safety, outcomes, and 30-day readmissions, among other benchmarks. One of the reasons stroke remains a top priority for Avellino is because improving the door-to-needle time for patients means improving downstream costs of rehab and readmissions. It is not easy, but it can be a significant cost-containment tool.

Avellino's focus on reducing how long it takes for a patient to receive tPA therapy seems to be working. In October 2013, it took OSF Saint Francis Medical Center staff 79 minutes to administer tPA. In September 2014, it was down to 41 minutes, and there were two instances when tPA was given to a patient in just five minutes.

There are plenty of opportunities for neurology to expand its outpatient services, particularly in spine and sleep.

"Outpatient services are key as we develop population health, collaborative care models," he says. "We should be doing simple spine surgery on an outpatient basis. We're not, but it's something we're going to explore next year."

Success key No. 2: Prepare
Other hospitals are aiming to reduce their time to initiation of tPA, but they also pay attention to research that shows an even quicker alternative.

The Miriam Hospital, a 247-bed private nonprofit hospital in Providence, Rhode Island, may be small, but it has big resources. The hospital is part of the Lifespan Health System, a five-facility system it helped create in 1994 along with Rhode Island Hospital. The Miriam Hospital is also an academic medical center, affiliated with the Alpert Medical School of Brown University.

"The Miriam Hospital has always been a specialty-focused, academic, community, and research-focused enterprise," says Tom Tracy, MD, senior vice president of medical affairs and chief medical officer for the hospital.

The combination of being a research center and a community hospital may be paying off soon, says Tracy. That's because three trials published in the New England Journal of Medicine showed positive outcomes for some ischemic stroke patients treated with a procedure that Miriam already performs sporadically.

"A subset of patients, when examined angiographically, are found to have occlusions along their middle cerebral vasculature, and there are now approved devices that can completely open those clots," says Tracy.

The procedure is called a mechanical thrombectomy, and the device Tracy is talking about is essentially a tiny clot-retrieval tool that is inserted into the arterial system and directed to the internal carotid and middle cerebral arteries, where the clot is captured and removed. A study known as MR CLEAN was done in the Netherlands among 16 hospitals with 500 stroke patients. Of patients who had a mechanical thrombectomy, 33% were able to function independently, which was greater than the 19% associated with the other patients.

The Miriam Hospital treats about 650 stroke patients annually, and Tracy says about 25% are eligible for this type of procedure.

Tracy says he scheduled multidisciplinary meetings for the entire team in March to determine how to handle the potential uptick in using this kind of procedure. The neuroscience team has performed it on some patients and the results, says Tracy, are encouraging.

"I was on call the other night, and the neuroradiologist did one, and I asked him how the patient was, and he said the patient left the hospital the next day," says Tracy. "It's amazing."

Tracy's desire to build a focused program around this new procedure is only possible, he thinks, because the hospital is already a certified primary stroke center.

"These patients," Tracy says, "are going to need to be in a comprehensive or primary stroke center that has all the time-sensitive neuroradiology resources, and that's going to be a problem for some hospitals. We are looking at the cost, logistics, and business plan. It helps a little bit that we are ahead of the game, but to make it a big program for the region, we have to look at it thoughtfully."

Success key No. 3: Present your case
Smaller community hospitals may not have the resources to respond quickly to the newest studies, but earning a primary stroke center designation is one way that they are working to meet the needs of their stroke patients.

For example, Lake Forest Hospital, a 201-bed community hospital in Lake Forest, Illinois, that is now part of the massive Northwestern Memorial HealthCare system in Chicago, had no stroke certification and no dedicated neurologists just five years ago.

Now, in large part due to its merger with Northwestern, it is a primary stroke center and has four neurologists on staff in the hospital.

"It was a different landscape five years ago," says Michael Ankin, MD, FACP, FCCP, chief medical officer of Northwestern Medicine Lake Forest. "I remember sitting down with the chairman of the department of neurology and I said, 'Listen, I need this, and this, and this,' and he looked at me and said, 'Look, you're going to have to eat chuck before you get sirloin.' "

What Ankin wanted was at least one neurologist dedicated to the Lake Forest facility. At the time, the hospital was at the mercy of the nearby neurology groups fitting that neurologist into their schedule, along with other hospitals in the area.

"We are 25 miles from the downtown campus," says Ankin. "That's 25 miles of urban city rush-hour traffic. I needed people embedded in this hospital the majority of the time."

Ankin didn't get the four neurologists all at once. First came the work to be certified as a primary stroke center, which he describes as a good process that developed a close cross-section of team members from neuroscience, radiology, and the emergency department.

"If you aren't a certified stroke center, then the liability is that the paramedics bypass you," he says. "It was important to be certified. The number of early strokes we see has increased considerably."

Another infrastructure addition since merging with Northwestern is telestroke at a freestanding emergency room in the nearby town of Grayslake.

Telestroke, like other telemedicine efforts, is gaining popularity and is seen as a way to alleviate a shortage of physicians in rural areas while increasing access to doctors for emergencies, such as stroke. The telestroke program is relatively new to the Lake Forest campus, as are the increases to Ankin's neurology staff, but he is hopeful that it's a sign of more resources to come.

James Grotta, MD

"I think that now that the treatment of stroke is a time-limited event, the idea of developing infrastructure for a patient is really a team effort," he says. "And now I have four full-time neurologists on staff at this 200-bed hospital. I'm not quite sure where I am on the spectrum of meat, but I am well beyond the chuck stage."

Success key No. 4: Mobile care units
Large health systems and community hospitals alike have seen the benefits of attaining The Joint Commission's stroke center designations. But what happens when a health system hits a wall?

Cleveland Clinic, the nonprofit, academic medical center that has reach in Canada and Abu Dhabi as well as expanding partnerships with medical centers across the country, maxed out at how much time it could shave off of getting tPA into a stroke patient.

"At Cleveland Clinic, we're rich in resources, and despite that, 55 minutes is about as good as we can do," says Rasmussen, the director of Cleveland Clinic's Cerebrovascular Center.

To get the door-to-needle times lower, the hospital invested about $1 million in a mobile stroke treatment unit—essentially an ambulance that's outfitted with a mobile CT scanner and a five-person team that takes the stroke treatment to the patient. Instead of waiting for the patient to come through the emergency room doors, the clot-bust shot of tPA comes through a patient's front door.

"In the mobile stroke treatment unit, our times are down to 20-25 minutes," says Rasmussen, who is heading up the mobile stroke treatment unit project. Cleveland Clinic and Memorial Hermann Texas Medical Center are using the highly specialized units.

The systems got the idea for moving stroke treatment out of the emergency room from observing a similar unit in Germany.

"I was invited to lecture in Berlin," says James Grotta, MD, director of stroke research in the Clinical Institute for Research and Innovation at Memorial Hermann Texas Medical Center based in Houston. "I took advantage of the opportunity."

He is studying the cost-effectiveness of using a mobile stroke unit to treat patients.

"We want to know if we treat patients earlier, how much better will they be?" says Grotta. "In an individual person, if it makes someone better, it's priceless, but we have to show there's enough of a widespread benefit, and we are trying to make some estimate of the reduction in cost."

Grotta's study aims to detect a 15% reduction in long-term costs, which would be a huge savings. "Similar to all other mobile stroke unit centers, we've seen substantial reductions in the time it takes to get patients treated," he says.

Cleveland Clinic's unit does not have a neurologist on board like Memorial Hermann's does. Instead, Rasmussen says it uses a telestroke unit along with a CT technician, an RN, an EMT, a paramedic, and a program manager who is cross-trained as a CT tech and EMT.

"We're not tying up a doctor resource," says Rasmussen. "We know, from prior experience, that a telestroke neurologist is 98% accurate."

It's that 2% miss rate that keeps Grotta riding in the unit with his team in Houston.

"Just last night I had a patient and he had a subdural hemorrhage in his brain," says Grotta. "The teledoc missed it, so we're measuring how often there is disagreement between the neurologist and the teledoc."

Another key difference is that Cleveland Clinic is getting reimbursed for administering tPA from its unit. Grotta isn't. The reimbursement issue will be a key factor in whether these mobile stroke units are financially viable. "Units in Berlin, Cleveland, and Houston vary in size and cost, ranging from $650,000 to more than $1 million, depending on bells and whistles," Grotta says. "Wherever the mobile stroke unit operates, local traffic patterns and geography will determine the area it can cover."

Both health systems are just getting started measuring what seems to be a promising treatment for stroke. Cleveland Clinic's mobile stroke treatment unit has transported 155 patients and Memorial Hermann's, close to 100.

Rassmussen says outcomes are positive enough and hopes mobile stroke units are part of the future of stroke care. Grotta says implementation is going smoothly, but more research is needed.

"It's not, 'What is the cost?' It's 'What is the cost to society without one of these units?' " says Rasmussen.

"The bottom line is that this will save time; it's logical that it will, therefore, improve outcomes and be cost effective," says Grotta.

Reprint HLR0415-7

Parkland Health and Hospital in Dallas is seeing such promising results from a mental health demonstration project, that it could be a model for other systems that care for a low-income, high-need population.

The stigma that mental health carries can often overwhelm a patient to inaction.

Couple that with a shortage of mental health workers, and you have a confluence of issues that perpetuate inattention to a pressing need that is not going away. Unfortunately, few hospital systems are investing in the mental and behavioral health needs of patients. The need is great for licensed clinical social workers, psychiatrists, and psychologists.

But one of the country's largest public hospital systems, Dallas-based Parkland Health and Hospital is seeing such promising results from a demonstration project, that it could be a model for other systems that care for a low-income, high-need population.

Parkland's program is aimed at identifying and treating women with postpartum depression. Instead of waiting for a patient to self-identify as possibly having PPD, each woman is screened for PPD at her two-week postpartum checkup. If the mother's PPD screening scores indicate a need for further mental health services, the patient is referred to a mental health counselor who is onsite at the clinic.

Mietra Doty, MD

Parkland has 10 women's health clinics, and there are counselors at five Parkland clinics now. By September 2016, officials say nine of the clinics will have an onsite counselor.

PPD is an issue Parkland has been paying attention to, but its previous methods just weren't working.
"We had a system of referrals to see these patients, but it wasn't very efficient" says Mietra Doty, MD, a board-certified adult psychiatrist at Parkland who sees women with PPD. "It would take a couple of months to get in, and I noticed a high rate of no shows."

Parkland officials estimate that as many as 2,000 women in its system experience PPD, which can not only endanger the health of the mother but also the health and well-being of the child.

"Babies will feel the stress of the mom," says Jackie Juarez, MSW, LSCW, a counselor at Parkland's Oak West Women's Health Center. "There may not be much eye contact, they may be fussy, or crying a lot, but once a mom starts to engage in therapy and gets help, the baby's behavior improves."

'Curbside Consults'
Juarez is also a resource for the providers at the clinic where she is co-located. She says it's not unusual for a physician to knock on her door and ask for a quick opinion on a patient mid-appointment.

"We are a resource for providers in the moment," she says. "I call them curbside consults."

These "curbside consults" have helped providers understand the unique cultural needs of patients at Oak West where Juarez estimates about half of the patients are Hispanic and often need a Spanish speaker.

All of the counselors Parkland has hired for this program are bilingual, though it is not a requirement. Still, Juarez says, understanding the Hispanic culture and being able speak their language helps overcome one of several barriers with patients.

"There is a stigma, especially within the Hispanic population, associated with counseling and medication," says Juarez.

One of Juarez's patients, 26-year old Lupe Solis, puts a finer point on it during a follow-up appointment with Juarez. "Most of them don't believe depression exists," says Solis. She has been seeing Juarez for five months for depression and anxiety. Solis was referred to Juarez after receiving a high score on her the PPD screening at her two-week PPD checkup. Solis met Juarez initially, then after an hour-long appointment, Juarez referred Solis to Doty for medication.

This new referral process—sending a patient to a mental health counselor on-site first, then having the counselor determine if a higher level of care is needed (an appointment with Doty)—has improved Doty's no-show rates and her patients' engagement with their care.

"The no-show rate is now at 50%," says Doty. It is high, but has improved significantly with only half of the mental health counselors who are slated to be hired over the next year. "When they see me, they know what to expect and what I can do for them. They're much more open to my treatment recommendations."

Solis says she's seen Doty about once a month to evaluate her medication dosage, and sees Juarez about once every two weeks. During the appointment I was generously allowed to observe, Solis told Juarez that she feels like her depression is getting worse.

"I'm really stressed out from moving. I think the pressure is coming back," she tells Juarez. "I'm always tired. I could sleep all day long."

Juarez and Solis talk for about 30-minutes, the average length of her follow-up sessions with patients. As Solis explains the stress she feels from dealing with a family member who doesn't believe her mental health issues are real, Juarez nods her head in agreement. It's a small but important gesture that shows Juarez understands the unique family dynamic.

"There is a lot of family judgment in the Hispanic culture," says Juarez. "There is also a lot of self-judgment. The patients may think, 'I'm not normal.' "

During the appointment Juarez also administers a GAD-7 (for anxiety) and a PHQ-9 (for depression) screening. Solis scores in the normal range for anxiety, but higher for depression.

The scores prompt Juarez to call Doty's office to get Solis worked in for an appointment sooner than the one Solis has scheduled for October. Doty's number is on a well-worn bright yellow sticky note taped to the bottom right of her computer screen.

While Juarez calls Doty's office, Solis waits patiently, showing me pictures of her son Andy, and her 5-year-old daughter, Jocelyn.

"Nothing is more important to me than my son's health, my daughter's health, and my health, she tells me. "I really think this program has really helped me. When I first started coming, I couldn't even stand still. I look forward to coming here. I feel more relaxed because I said everything I needed to say."

Funding and Future Plans
The PPD program at Parkland is one of 22 funded though what's known as the Section 1115 waiver, which is federal money meant to offset the costs of uncompensated care hospitals deliver and improve access to care.

The waiver expires next September, but Christina Mintner, a vice president who oversees Parkland's 1115 Waiver program, says the state of Texas, one of more than a dozen states that didn't expand Medicaid, has asked CMS for a five-year extension of the waiver..

"It's crucial to the infrastructure of our health system for Medicaid and [the] uninsured population to have the waiver extension granted," she says.