An emerging group of professionals, most often RNs, work across the care continuum to provide ongoing, proactive help at a lower cost to patients with high risk or complex needs.
Healthcare organizations have strict mandates to reduce readmissions, to divert care from the ER to less-expensive settings when possible, and to address population health.
But who takes on these responsibilities when physicians already have too much on their plates?
"I think that, at least for certain groups or pieces of our population, there is a greater need for hands-on support of the patient above and beyond what physicians are prepared for or educated to do, and what office staff can do in the course of the day," says Nancy Myers, PhD, former vice president of population health strategy at NewHealth Collaborative, an accountable care organization formed by Summa Health—a patient-centered population health management organization based in Akron, Ohio.
Enter care coordinators, also referred to as care managers.
Care coordinators, most often RNs, are emerging as the go-to individuals to work across sites—including hospitals, primary care, specialties, and postacute care—to provide proactive help and continuity to patients who are high-risk or have complex needs beyond a single episode of care.
In the first half of 2016, NewHealth Collaborative avoided 300 ED visits and more than 250 hospital admissions as patients were restabilized in their homes by care coordinators, Myers says. By comparison, 370 ED visits and 300 hospital admissions were avoided in 2015.
NewHealth Collaborative, which today has 90,000 members, began its care coordination initiative in 2012 as an effort to contain costs.
The ACO used EMR and claims data to identify the patients with the most hospitalizations, ER visits, and diagnoses of multiple chronic conditions. "These were our highest-cost and most fragile patients that we could help by intervening and very quickly getting them stabilized," Myers says.
The care team also talked to physicians to find out who they thought would benefit from care coordination. "Claims-based data is old data. By getting out into the offices, we could work with the staff to identify patients who needed extra assistance and get to them early," she says.
Myers hired an all-RN staff that could operate independently and with authority.
Care coordinators must have a broad base of experience across care settings and a breadth of life experience as well to help connect with patients, she says. "While it would be great if they had experience in care management, you just don't find that. We choose RNs who can manage complex medical conditions, understanding that sometimes a social issue is the linchpin. We don't want to be focused on prescribing insulin when what they really need are groceries."
NewHealth Collaborative's care coordinators are embedded in the primary care practices to act as both members of the care team and patient advocates to help develop and carry out a patient's care plan according to his or her life goals.
"The care coordinators marry what the doctor is going to do with what the patient can commit to," Myers says.
The care coordinator stays close to the patient, checking in by phone and in person, until the point where the patient's goals and the medical goals are achieved.
Each of the 13 care coordinators at NewHealth Collaborative has between 100 and 120 open cases. They are funded in part by payer contracts such as the Medicare Shared Savings Program.
"The care coordinators marry what the doctor is going to do with what the patient can commit to."
"We have achieved enough savings to get a portion of payer savings," she says.
The care coordinator program also gets a portion of the stipend that nearly 200 providers pay to be part of the ACO and receive these types of services.
Coordinated coordinators
Mercy Health, a Catholic healthcare ministry serving Ohio and Kentucky, embedded its care coordinators into 125 physician practices (including 429 primary care providers) and located care transition coordinators in the acute care facilities.
This began with the Cincinnati and Metro Toledo facilities and recently expanded to Lorain, Youngstown, Lima, and Springfield.
Catherine Follmer, RN, BSN, MBA/HCM, vice president of care continuum at Mercy, and Lisa Cobb, RN, BSN, director of ambulatory care coordinators, have meshed the care transition coordinators and ambulatory care coordination teams to utilize nursing resources and to create a longitudinal care program.
The two programs screen and monitor rising risk and complex patients, including those having joint replacement surgery, to create their panels.
They also take anecdotal referrals from providers, payers, and the ER, which identifies high-frequency users. Hospital care transition coordinators, which follow patients for 30 days, handle approximately 65 patients at a time. After 30 days, the patients are handed off to ambulatory care coordinators, whose present goal is a patient caseload of 150.
"We average roughly 150 patients in 52 skilled nursing facilities in Cincinnati alone," Follmer says. The care transition coordinators follow the skilled nursing facility patients with a goal of efficiently identifying the next lower level of care and decreasing unnecessary lengths of stay, she adds.
The first 24 hours are most critical, according to Follmer.
In one case, an elderly patient wasn't taking her medication properly because she couldn't read the instructions on the bottle. "We only found that out because of the 24-hour call, and we were able to set her up with home care to assist," she says.
Like NewHealth Collaborative, Mercy hires RNs to be care coordinators. "Nurses are able to do the assessment piece that nonclinical, non-licensed individuals aren't able to do," Follmer says.
For example, RNs can assess a COPD patient's breathing over the phone, determine if he or she is using an oxygen tank correctly, and help with breathing techniques.
Cobb searches for RNs with experience in home care, the ICU, or ER, as well as with critical-thinking skills. Candidates should be confident and articulate as well. "Ambulatory care coordinators have to think on their feet and develop relationships with their patients. If they sound the least bit uncertain, the only place that patient is going to go is the ER," she says.
Follmer measures the success of the program by "providing the most appropriate care at the most appropriate time," which can result in decreased readmissions and ER utilization.
For example, the care coordinators can connect a patient with congestive heart failure to a physician's office for a dose of Lasix or a breathing treatment rather than sending the patient to the ER.
"We look at every case that's been readmitted to see if the patient could have been diverted elsewhere," Follmer says. In fact, the care transition coordinator team follows the patient to see what treatment readmitted patients required, and if that care could have been provided elsewhere.
'An optimum level of wellness'
At Sharp Rees-Stealy Medical Centers, a multispecialty medical group of more than 500 physicians at 22 locations in San Diego County, "the goal [of the care coordinator] is to bring the individual to an optimum level of wellness and functional capability," says Janet Appel, RN, MSN, director of population health and informatics.
Sharp Rees-Stealy is highly capitated and receives prepayment for more than 70% of its patient population. The medical group started its care coordination journey five years ago to address the problem of physicians not being able to provide care coordination alone.
Vicki DeBaca, DNS, RN, vice president of health and provider services at Sharp Rees-Stealy, first identified an area in need of care coordination—diabetes, a condition affecting between 10% and 20% of the patient population—and then inventoried the resources at hand.
She found that numerous physician offices and other sites had diabetes care coordination activities in place, but they weren't publicized, centralized, or standardized.
She brought these activities together and gave them structure as a comprehensive professional care coordinator program.
Today, the Sharp Rees-Stealy program has a pool of more than 25 case managers who serve as care coordinators. These managers are RNs with three to five years of acute care experience and know how to navigate the healthcare system. They work with patients to avoid inappropriate admissions and readmissions.
The care coordinators also identify opportunities for care outside hospitals as well as alternative treatments to avoid hospitalization, according to DeBaca.
High-risk or complex-care patients are identified in multiple ways, including:
Self-enrollment through targeted wellness and education programs, such as smoking cessation, weight loss, and asthma control
A data team that analyzes key metrics such as medications, diagnoses, ER visits, and hospitalizations
Physicians, nurses, and other healthcare workers who recommend patients to the program
DeBaca and Appel work together to ensure the proper caseload for each care coordinator, which currently is between 100 and 125 patients.
Metrics to gauge care coordination effectiveness include reductions in admissions and readmissions, timely access to care, medication adherence, lab value normalization, and appropriate use of Sharp Rees-Stealy services.
"We are constantly slicing and dicing the data and working with everything we have to take the appropriate actions for the patient's care plan," Appel says.
Results are shared daily among the staff and leadership to quickly identify opportunities for improvement. "We focus on whether the engagement with the patient has been successful," she says.
Using real-time clinical data, the team can see if engaging a patient and building a relationship helped improve A1C levels, renal function, and eye health—deterioration in any of these areas could cause a patient to be labeled high risk and to receive higher attention.
Appel says one way to justify the cost of case managers is to map that cost against known disease progression costs—such as the cost of care for strokes, blindness, and limb loss—over the lifetime of the patient.
Using technology, including texting and automated vital sign collection, Sharp Rees-Stealy has been able to increase nursing panels. Patients use at-home monitors to transmit their vital signs for asthma, COPD, hypertension, and other chronic conditions directly into a centralized application.
If data is missing, staff at Sharp Rees-Stealy Medical Centers are alerted via a dashboard and can contact the patient to troubleshoot issues such as a disconnected device.
Also, rather than calling patients and waiting for them to call back, care coordinators can use texting to conveniently connect with them and share information.
Technology has helped the organization reach its goal to engage 5% of the population—or nearly 10,000 patients—through care coordination. "That would be hard to do without
creative resources," Appel says.
Healthcare providers are working to improve diagnostic accuracy. Here are five tips from four experts.
This is an excerpt of an article thatfirst appeared in the October 2016 issue ofHealthLeadersmagazine.
Diagnostic errors, no matter their origin, are costly.
The National Academies of Sciences, Engineering, and Medicine—Health and Medicine Division found that 5% of U.S. adults who seek outpatient care each year experience a diagnostic error.
Diagnosis-related payments, Johns Hopkins researchers found, amounted to $38.8 billion between 1986 and 2010.
But there are things physicians and care teams can do to improve diagnostic accuracy.
1. Expand Your View
Through his work in ambulatory care clinics, Mikael Jones, PharmD, BCPS, clinical associate professor at the University of Kentucky College of Pharmacy, says he has realized that an efficient way to decrease diagnostic error rates is to form cohesive care teams.
He points to the case of an elderly patient he consulted on five years ago. The woman presented to the clinic with severe diarrhea and generally wasn't feeling well. Her history showed a recent course of antibiotics, and the nurse practitioner was worried about Clostridium difficile colitis or C. diff, which would be catastrophic in a patient her age.
Before concluding that diagnosis, Jones asked about other medications she was taking. The woman had been consuming a dietary herbal supplement, which Jones found to have a high likelihood of causing diarrhea.
"I suggested taking a step back and seeing if stopping the supplement would make a difference, and it did," he says. Ultimately, the woman did not have to undergo taxing C. diff treatment.
Jones learned from that experience to make the diagnostic process a team sport and to be more specific in patient questioning. "Don't just ask about medications; ask them about prescription, non-prescription, and supplements," he says.
2. Follow the Data
Information flow has to improve, too, he says. For instance, while e-prescribing has made it easier to get prescriptions to pharmacies, the information flow back to the prescriber about whether a patient has filled the prescription is lacking.
Knowing how soon the prescription was picked up also is important because some medications, to be effective, have to be taken in a certain time frame.
He also believes provider notes should be looked at as a way to reduce diagnostic errors. "The notes are getting longer and longer and a lot of information is being imported. One incorrect fact can be easily propagated," he says.
"I make sure to look at all medication notes and reconcile them with what the patient is saying and what was intended by the healthcare provider."
3. Insist on Report Clarity
Poor documentation can also flummox radiologists, according to Joseph Glaser, MD, at Middletown, New York-based Radiologic Associates, PC. He says more attention has to be paid to basics such as systematic reporting.
"In communicating results, you not only have to report what's urgent and important, but also secondary findings," says Glaser, a nuclear medicine physician.
For instance, if a patient comes in for a chest x-ray with a presumed diagnosis of pneumonia, the report must not only describe whether there are clear lungs, but also the observation of a broken rib. "We may find a surprise that can change patient management," he says.
And how these findings are relayed to the doctor is equally important. While new technology has helped tremendously, he says, there are still times when a simple phone call is the most effective way to ensure timely and clear communication. This can also help on the incoming end as well.
He encourages imaging physicians to learn how referring doctors receive information and incorporate those preferences into their reporting. "Doctors on both ends can suffer from information overload, so it's better to know what findings they want about certain conditions," he says.
4. Go Slowly and Stay Steady
Don Goldmann, MD, chief medical and scientific officer at the Institute for Healthcare Improvement, agrees that clinicians are moving too fast these days, leaving the opportunity for diagnostic errors.
"Physicians used to take the time for careful observation, but now we think everything has to be solved right away," he says, adding "not all diagnoses are evident right away."
This hurry extends to direct patient interaction. "Physicians don't tend to wait for patients to answer questions. If there's any pause, they fill it with the next question or their opinion," he says.
By slowing down, he says, physicians can gain tremendous insight on issues such as family problems that are causing stress. Knowing this might avoid needless tests looking for very unlikely chronic conditions.
"The worst thing to do is to order a bunch of tests to cover yourself because you're worried you'll miss something. Every test has a margin of error, so they will likely lead to more tests," he says, which, in turn, "will do more harm than good."
He says physicians who do order tests must get better about closing the loop on delivering results to patients. "Misdiagnoses can be made simply because the referral loop isn't closed and assumptions are made about who knows what," he says.
5. Close the Loop
Closing the loop is a mission for Johns Hopkins Community Physicians, a network that includes internal medicine, family practice and pediatrics, and specialty services with locations in Virginia, Maryland, and the District of Columbia.
Johns Hopkins Community Physicians has created redundant processes in the EMR system to ensure that physicians are alerted in a reasonable time when tests they've ordered have been completed, says President Steven Kravet, MD, MBA, FACP. The system also alerts physicians when they haven't been received in a reasonable amount of time so they can be checked on.
"I don't believe no news is good news," Kravet says. The goal is to avoid results falling off the map like an abnormal Pap smear that gets sent to the wrong doctor and the patient is never called.
The network now labels certain tests "critical" so physicians can run reports and quickly track down missing results. Even noncritical tests are reported on so that all results make their way into the system.
With skilled nursing facilities spread thin and under value-based performance pressure, hospital systems are testing new approaches to prevent readmissions.
This article first appeared in the April 2017 issue of HealthLeaders magazine.
Intermountain Healthcare, a Salt Lake City nonprofit health system with 22 hospitals and a broad range of clinics and services, found that ambulation was a key component to reducing readmission rates for complex abdominal and orthopedic surgeries. The problem was ensuring that the postacute care setting, including skilled nursing facilities (SNF) and home health agencies, would enact the ambulation protocol, says Mark Ott, MD, surgeon and chief medical director for the health system's central region, which has five hospitals in Salt Lake Valley.
"Complex abdominal surgeries such as colectomies and pancreatic resections have a high rate of readmissions because of the high-risk nature of some of these patients and the complexity of their surgical operations," Ott says. "With the ambulation protocol, we were able to cut readmissions from 15% to 7%."
Intermountain Healthcare found that patients who walked more after surgery would get out of the hospital sooner; preliminary results are that each additional walk decreased the hospital length of stay by approximately 0.17 days, and lowered rates of readmission to the emergency room or hospital by 50%, Ott says.
However, ambulating patients is a labor-intensive process, and the workload was more than the hospital nurses could handle, says Ott. He and his team worried that if hospital nurses were struggling, SNFs and patients and families at home certainly would not be able to fulfill the protocol without additional resources and help.
To shift the burden off nurses and other staff, Intermountain supplied 1,300 patients with a smartphone, loaded with an activity tracker app the health system developed with Savvysherpa, an ambulation and healthcare analytics company in Minneapolis. Patients are given ambulation goals based on their previous day's ambulation efforts. They also receive an alert when it is time to walk around, and data surrounding the activity is logged and shared with clinicians.
"The patients are given the devices and education at no cost to them. They receive in-person and online education. They also have a call-in number for questions. The patients feel empowered to actively participate in their care and recovery. Whether they go home or to a skilled nursing facility, the program is there to remind them," he says. "And if a patient doesn't follow it, they receive a call from support staff to help get them back on track."
The device approach, Ott says, helps supplement skilled nursing with family and friends or the patient independently to achieve a more consistent outcome.
"Intermountain Healthcare can show a 40% reduction in total cost of the hospitalization for several of our patient populations that participated in the ambulation and enhanced recovery after surgery program, and believes, that the cost savings more than offset the cost of the program. That along with the improved outcomes and patient engagement are why we keep doing this," says Ott.
External forces at work
Intermountain is not alone in trying creative approaches to ward off readmissions.
There are a lot of admissions—and readmissions—from SNFs to Sharp Grossmont Hospital, says Scott Evans, CEO and senior vice president of the 485-staffed-bed facility in La Mesa, California, which is one of four hospitals in the San Diego–based nonprofit Sharp HealthCare system. "Patients are brought in when they are in acute crisis, and then transferred back to their facility once they are stable and well enough to return," Evans says.
Before the organization could reduce those readmissions, it had to study the quality of the care at the facilities. Evans and other leaders started a dialogue among acute and postacute settings to better understand care plans for patients.
"We talked to several nursing home administrators and nursing home organizations to gauge their processing practices. We wanted to better understand how they manage their patients," says Evans.
The team focused on advanced illness management where patients do not want life-saving measures put in place.
"We see patients show up at the hospital in an ambulance from the facility, only to discover that the patient's advanced illness is progressing in a manner that was previously anticipated," Evans says, making the visit potentially unwarranted. "Rather than triaging acute problems, we need to get all parties together to understand the patient's plan, the disease burden, and the likely progression.
"The reality is that some patients will die in a nursing home, and sending them back and forth to an acute care facility may not be aligned with their expressed wishes," he adds.
Sharp Grossmont is in the early stages of addressing this issue and does not yet have data to gauge the pilot program's success, according to Evans.
"We are measuring readmission within 30 days, and tracking information about the care received outside of our hospital: from the time of discharge to readmission, as well as assessing the continuity of care in between that time," he says.
The hospital is now considering the benefits of sending a hospital medical team to a facility when a patient runs into an acute situation.
A 'readmission bundle'
Banner Health, a Phoenix-based integrated health system with 29 hospitals, including three academic medical centers and other related health entities and services in seven states, found that each of its hospitals were trying different things to reduce readmissions. "This led to a chaotic picture that impaired our ability to see what really works," says David Edwards, MD, FACP, chief medical officer for post acute care services at Banner Health.
To better analyze the impact of its disparate interventions, Banner Health suspended all new programs and standardized what would be called "a readmission bundle," says Edwards, a colead on Banner Health's Readmission Initiative. The bundle encompasses core processes that must be done with high reliability.
"The board of directors chooses a limited number of initiatives to focus high-level leaders' attention on by tying management incentives to performance on these initiatives. In 2014 and 2015, there was an initiative to focus on decreasing preventable readmissions by focusing on creating a reliable process for patients at high risk for readmissions. In patients identified as high risk for readmission, we focused on medication reconciliation, setting up an appointment within seven days of discharge, and teaching the patient about their disease process utilizing the teach-back method. We measured our performance in each of the areas and were able to improve the reliability to do this," Edwards says.
In addition, Banner is developing a program to predict which patients are at highest risk for readmissions, how to prepare patients best for discharge, and how to transition patients to the correct next level of care with expectations for that level.
"The key for us is to transition high-risk patients to the right level of care and have that level of care performed well rather than focusing on a readmission number," he says.
Banner owns a home health agency, a home-based palliative care program, ambulatory case management, and iCare—a remote, patient home–monitoring program—and works with these affiliated programs to better patient transitions and to identify improvement opportunities. Some examples include reviewing readmissions between hospitals and the postacute entity and improving communication between Banner ER staff members and the medical directors of SNFs.
"We have measured critical factors in transitioning patients, making meaningful contact within 72 hours, medication history within 72 hours, and having a care conference for patients on service 30 days or more. We worked to improve our performance in those areas. Additionally, we have developed aligned postacute providers—SNFs, SNFists, home health agencies—with whom we have quarterly or more frequent meetings to review data, readmissions, and other quality issues identified. We have worked to identify areas of improvement in a collaborative manner with them," says Edwards.
Banner uses its telehealth program, eSNF, to enable communication between SNF nurses and nurse practitioners at Banner's eICU to potentially prevent readmission.
"eSNF allows a nurse in a SNF to connect with a nurse practitioner working in our eICU for questions or evaluations. The NP can evaluate patients who are deteriorating or have fallen, or ones that they have questions on. The NP can place orders on patients in the SNF, make recommendations for transfer to the ER, or have the patient be evaluated the next day by a physician. In addition, the NP is able to access the SNF chart to see clinical information recorded there," says Edwards.
Kim Henrichsen, RN, MSN, vice president of clinical operations and chief nursing officer at Intermountain Healthcare, says Intermountain readmission rates are low; however, administrators think there is still opportunity to further reduce avoidable readmissions by collaborating with providers such as SNFs in the postacute care settings.
A little over two years ago, Intermountain invited nearly 100 SNFs across Utah to apply to collaborate with the health system through its health plan. Intermountain informed the facilities that to be considered as a preferred postacute collaborator, they would need to maintain high quality ratings, be willing to share their quality data, adopt appropriate Intermountain evidence-based clinical protocols, and be willing to accept patients from all payer sources—at any time of day or night—as well as being willing to develop expertise in caring for certain clinical conditions.
Henrichsen and the team realized the initial group of SNFs was too broad and narrowed the network for the second year of the collaboration to 52. Selection criteria included but was not limited to the number of Intermountain patients cared for in the clinics, clinical quality based on CMS Star Ratings, patient satisfaction reported by CMS, and staffing levels. Each SNF was evaluated on over 80 criteria to determine which of them would be selected to participate in the Quality Improvement Initiative with Intermountain and SelectHealth.
Once the field was winnowed down, Intermountain selected a few of the participating SNFs and began working with them to improve care specifically for heart failure patients as a pilot project.
"Skilled nursing facilities are doing the best they can with the amount of resources they have. It's a daunting task for them to deliver that care, so we have to partner with them."
Like Sharp Grossmont, Intermountain recognized the need for SNFs to have more access to medical providers to prevent avoidable complications and readmissions. "In most cases where patients were readmitted to the hospital, the skilled nursing facility may not have identified the deteriorating patient soon enough, or felt they didn't have timely access to the medical providers who could manage the situation," Henrichsen says.
The Southwest region of the system is testing the impact of having health system advanced practice nurses round at the SNFs on Intermountain patients, and early results show a reduction in readmissions. In the Central region, neurologists—who have been skeptical about stroke patients going to SNFs because they don't think these patients get the rehabilitation or interaction they need to regain function—are working with a small number of SNFs to lift their expertise.
"Skilled nursing facilities are doing the best they can with the amount of resources they have. It's a daunting task for them to deliver that care, so we have to partner with them," Intermountain's Ott says. "If we want patients who come through the hospital to do well, we need to invest in devices, follow-up calls, and visits to stay connected to them so that issues get detected early."
Henrichsen adds, "We have assumed risk as a delivery system, and we believe that by working collaboratively with skilled nursing facilities, we'll improve care for our patients and members, reduce hospital readmissions, reduce complications, and reduce length of stay, which all contribute to decreased healthcare costs."
Based on provider and payer feedback, the revised program will feature annual check-ins and reporting instead of the current program's three-year recognition cycle.
When the National Committee for Quality Assurance (NCQA) releases the 2017 iteration of its Patient-Centered Medical Home (PCMH) recognition standard in April, Marc Mayer, DO, president and medical director at Avenel-Iselin Medical Group, a multispecialty healthcare practice with more than 12 physicians in Iselin, New Jersey, will be excited to see major changes.
Mayer's practice first received NCQA PCMH recognition in 2011 and re-upped its status to Level 3 in 2014. He calls both experiences "pretty intense" and hopes the adjustments in 2017 will provide consistency and clarity that the application submission and review process currently lack, he says.
NCQA's PCMH is one of several PCMH recognition programs in the country to ensure primary care practices live up to the promise of the patient-centered medical home. For NCQA, that means inspiring quality in care, cultivating more engaging patient relationships, and capturing savings through expanded access and delivery options that align patient preferences with payer and provider capabilities.
Today, 17% of primary care practices, or 55,000 clinicians, carry NCQA's PCMH designation, according to NCQA, an increase from 100 when it was first introduced in 2008.
NCQA's intent in creating the standard, which can take three months to a year to meet through documentation, was to "acknowledge a need to elevate the status of primary care in this country to make it more attractive for professionals to go into and to make it a more joyful practice," says Patricia Barrett, vice president of product design and support at NCQA.
In summer 2016, NCQA called for input on the next version of the standard and received 3,000 comments from participating organizations. Although they were "generally positive," Barrett says they proved a need to redesign the process, including how applications are reviewed, the availability of submission assistance, and more clarity in expectations.
Barrett expects the 2017 recognition program to eliminate the guesswork and confusion from the submission and review process. For example, multisite healthcare facility applicants will be assigned a relationship manager whom they can interact with via WebEx to ask questions and double-check requirements. Also, instead of a single review, the process will comprise three check-ins that afford applicants an opportunity to correct items and receive credits. "Recognition will no longer be one and done; it will be more of an ongoing evaluation process," she says.
Another notable change will be the flattening of levels from three to one, Barrett says, enabling a much clearer delineation between practices that are recognized by the NCQA and those that aren't. "Our goal is to get back to the core concepts of the medical home and make sure what we are asking for truly reflects those concepts," she says.
"I didn't agree with the levels in the first place," Mayer says; adding that it takes time to transform a practice, making Level 3 difficult to achieve. However, he is committed to pursuing 2017 certification. "We decided a long time ago that PCMH was the way we were going to get the practice in line for the future."
Getting Recognized
About 15 years ago, Avenel-Iselin began adding specialty care, including cardiology, podiatry, gastroenterology, urology, and nephrology. "We've grown from just a primary care provider to a primary care–based practice," he says, making the practice far more conducive to the recognition requirements of collaborative and coordinated care.
Mayer first applied for recognition knowing "insurance companies and Medicare were going to go toward this type of practice transformation for primary care," he says. "We wanted to be forward-thinking."
A clinical manager and an administrator head up the application submission and review process. "While it wasn't difficult to make the transformation to PCMH internally, we spent a lot of time documenting what we were doing," he says.
One area that Mayer has seen improvement in due to the NCQA PCMH process is team-based care. "We had it, but we weren't maximizing it," he says, adding everyone now works to the highest level of their degrees, including medical assistants, nurses, and front desk personnel.
"Nurses used to just take vital signs and put people in a room," he says. "Now they look for gaps in care, such as patients being due for mammograms, colonoscopies, and vaccines. In the past it was my job as the doctor, but on a busy day, I didn't always ask."
As the medical team starts to gather metrics on these coordinated care efforts, they are noticing significant improvements. For example, only half the patients who should have been getting colonoscopies were, and now that number has increased to 85%, Mayer says. "The nurse makes one click in the EMR system and the front desk personnel know to schedule the procedure," he says.
Getting Buy-in
Ann D. Brown, MD, FACP, vice president of practice transformation and innovation, Physician Alignment, at Methodist Le Bonheur Healthcare, which has more than two dozen primary care locations in the Memphis area, first started working with a subset of 11 practices to gain NCQA PCMH recognition in 2013.
"We looked at trying to transform all the practices at once," Brown says, but she found it more practical to hand-select and target practices familiar with population health. She persuaded physicians to participate by explaining PCMH as a tool that would help them remain in practice and help them enjoy practicing. She added that PCMH would spread some of the patient's care to the entire medical team with proper education, training, and participation.
To assist the primary care group practices, Physician Alignment hired an IT director for its EMR platform with the focus of creating reproducible and trusted data in line with NCQA PCMH requirements. "For primary care groups, we've had internal quality measures for more than three years. Our IT director was instrumental in creating the trust for our doctors in our data being valid. We also have a Quality Committee of primary care physicians who have a voice in measure performance review and measure development."
But as streamlined as internal data-gathering has become, Brown sees room for improvement on NCQA's part and is encouraged with the recognition redesign process NCQA is initiating this year. The primary care group practices received recognition under the more-difficult 2014 standards, and Brown is expecting that practices participating in NCQA recognition will be able to maintain their recognition after 2017 more easily, she says.
Brown says that the PCMH recognition process can be costly in terms of training and support, including employment of quality improvement coaches, and that the return on investment possibly won't be recognized for three to five years. However, CMS' Quality Payment Program may reward certain PCMH-recognized practices with favorable Merit-based Incentive Payment System scoring, including NCQA, she says. For these reasons, the practice transformation has to be about improving patient care, "not financially focused. It's the right thing to do," she says.
A Group Effort
Randy Pritza, MD, MMM, chief medical officer at Omaha, Nebraska–based CHI Health Clinic, a network of primary care and specialty services with 100 locations in Nebraska and southwest Iowa, has collaborated with other CHI providers on NCQA PCMH recognition, including Barry Hoover, MD, MBA, FACEP, vice president and chief medical officer at The Physician Network, a wholly owned subsidiary of CHI with 50 primary, specialty, and urgent care practice sites throughout Nebraska.
Pritza started the PCMH recognition journey in 2012 by creating a pilot clinic at one site. That site achieved Level 3 recognition in 2013, and it was just re-upped for the 2014 standard. He created a learning lab on how to get certified and on the benefits of the NCQA PCMH recognition. Likewise, The Physician Network was able to get eight clinics certified in 2015 and 2016. Both organizations have been working to expand their recognition pool and continue to share their transformation best practices with the greater CHI collaborative.
"We have an aggressive timeline to have the majority of our clinics certified," Pritza says, but had run into roadblocks each time NCQA updated guidelines for each of the levels. "It makes the bar more complicated and forces us to think how we're going to achieve our goals," he says.
Hoover says organizations should realize that the process could take longer and require more human resources than expected. "Make sure you've resourced the efforts around this journey well," he says. "It's more a long-distance race than a sprint."
"You definitely won't be able to turn it around in 30, 60, or even 90 days," Pritza says. "You're dealing with a culture change on how you deliver care that a lot of doctors just aren't ready for."
As for NCQA's PCMH evolution, Hoover is hopeful. "My personal sense is it's evolving in the right direction," he says. "However, it would serve them well to focus on things that have positive patient impact, more so than process issues."
A look at how healthcare organizations are working to improve diagnostic accuracy.
This article first appeared in the October 2016 issue of HealthLeaders magazine.
Children's Hospital Colorado, University of Colorado Hospital, and the University of Colorado School of Medicine are collaborating on an initiative to better understand and address the problem of diagnostic errors across their organizations. In addition to addressing the first-stage remedies of better communication of results and better handoffs in transition of care, the three institutions are now focusing on the issue of cognitive bias.
"We know that as providers, when our brains are thinking fast, we are prone to bias. Our hypothesis is that we can teach ourselves to also think slowly, and try to avoid anchoring and other cognitive biases that can lead to diagnostic errors and delays," says Daniel Hyman, MD, MMM, chief medical and patient safety officer at Children's Hospital Colorado, a private, nonprofit pediatric health network with over 3,000 pediatric specialists.
Diagnostic errors are under the microscope at many healthcare organizations following a report from the National Academies of Sciences, Engineering, and Medicine—Health and Medicine Division that found that 5% of U.S. adults who seek outpatient care each year experience a diagnostic error.
The Health and Medicine Division also found that "postmortem examination research spanning decades has shown that diagnostic errors contribute to approximately 10 percent of patient deaths, and medical record reviews suggest that they account for 6% to 17% of adverse events in hospitals."
Diagnostic errors, no matter their origin, are costly to health systems. In a news release in 2013, Johns Hopkins researchers reported that after reviewing 25 years of U.S. malpractice claim payouts "diagnostic errors—not surgical mistakes or medication overdoses—accounted for the largest fraction of claims, the most severe patient harm, and the highest total of penalty payouts." Diagnosis-related payments, the researchers found, amounted to $38.8 billion between 1986 and 2010.
To reengineer clinicians' approaches to diagnosis and to encourage them to slow down and avoid bias, Hyman is working with a group of adult and child health faculty at the three Colorado organizations to develop and introduce a curriculum that will be used at their hospitals and medical school starting in the fall. Ahead of that rollout, they will be surveying the faculty about their knowledge and attitudes about cognitive bias and incorporating the concepts into case review processes similar to other patient safety efforts.
"Physicians have the opportunity to expand the diagnostic assessment or treatment plan to include things that are less common," Hyman says. "In fact, anybody on the care team, including the patient and family, can speak up if they have a concern."
For example, a patient may present with complaints including abdominal pain, vomiting, and fever, and clinicians are likely to initially focus on gastrointestinal causes of the symptoms. They may even become "anchored" in an abdominally focused list of possible causes. "Until the caregivers expand their thinking, they may not consider the diagnosis of pneumonia," he says.
Slowing down and being more efficient in diagnosing patients also aligns well with the new world of value-based payments, Hyman says. "In a capitation model, the sooner we make the right diagnosis and provide appropriate treatment, the greater the cost efficiency," he says, contrasting it to fee-for-service where physicians are reimbursed for every visit and every test.
Understanding diagnostic error rates can be tricky, though. "You can't run a report on how many patients had a diagnostic error," he says. "But you can run a report on patients whose diagnoses changed from one visit to another and analyze those." What providers might uncover, for example, are patients who were treated for a viral illness but actually had leukemia, or were treated for a headache when they had a brain tumor.
Expanding the traditional care team
Through his work in ambulatory care clinics, Mikael Jones, PharmD, BCPS, clinical associate professor at the University of Kentucky College of Pharmacy, says he has realized that an efficient way to decrease diagnostic error rates is to form cohesive care teams.
He points to the case of an elderly patient he consulted on five years ago. The woman presented to the clinic with severe diarrhea and generally wasn't feeling well. Her history showed a recent course of antibiotics, and the nurse practitioner was worried about Clostridium difficile colitis or C. diff, which would be catastrophic in a patient her age.
Before concluding that diagnosis, Jones asked about other medications she was taking. The woman had been consuming a dietary herbal supplement, which Jones found to have a high likelihood of causing diarrhea.
"I suggested taking a step back and seeing if stopping the supplement would make a difference, and it did," he says, adding the woman did not have to undergo taxing C. diff treatment.
Jones learned from that experience to make the diagnostic process a team sport and to be more specific in patient questioning. "Don't just ask about medications; ask them about prescription, non-prescription, and supplements," he says.
Information flow has to improve, too, he says. For instance, while e-prescribing has made it easier to get prescriptions to pharmacies, the information flow back to the prescriber about whether a patient has filled the prescription is lacking. "In the clinic, we have to play detective to see if they filled the prescription or not," he says.
Jones adds that knowing how soon the prescription was picked up also is important because some medications, to be effective, have to be taken in a certain time frame.
He also believes provider notes should be looked at as a way to reduce diagnostic errors. "The notes are getting longer and longer and a lot of information is being imported. One incorrect fact can be easily propagated," he says. "I make sure to look at all medication notes and reconcile them with what the patient is saying and what was intended by the healthcare provider."
Clarity in reporting
Poor documentation can also flummox radiologists, according to Joseph Glaser, MD, at Middletown, New York–based Radiologic Associates, PC, who says more attention has to be paid to basics such as systematic reporting.
"In communicating results, you not only have to report what's urgent and important but also secondary findings," says Glaser, a nuclear medicine physician.
For instance, if a patient comes in for a chest x-ray with a presumed diagnosis of pneumonia, the report must not only describe whether there are clear lungs, but also the observation of a broken rib. "We may find a surprise that can change patient management," he says.
And how these findings are relayed to the doctor is equally important. While new technology has helped tremendously, he says, there are still times when a simple phone call is the most effective way to ensure timely and clear communication. This can also help on the incoming end as well.
"While some incoming documentation is concise and clearly states what is being evaluated, there are also occasions when incoming documentation contains a great deal of additional material—often automatically generated—that may make it difficult for the physician to find what they need," he says.
He encourages imaging physicians to learn how referring doctors receive information and incorporate those preferences into their reporting. "Doctors on both ends can suffer from information overload, so it's better to know what findings they want about certain conditions," he says.
Slow and steady
Don Goldmann, MD, chief medical and scientific officer at the Institute for Healthcare Improvement, agrees that clinicians are moving too fast these days, leaving the opportunity for diagnostic errors.
"Physicians used to take the time for careful observation, but now we think everything has to be solved right away," he says, adding "not all diagnoses are evident right away."
This hurry extends to direct patient interaction. "Physicians don't tend to wait for patients to answer questions. If there's any pause, they fill it with the next question or their opinion," he says.
He encourages doctors to really listen to patients and explore possible diagnoses with simple and open-ended questions, such as, "How long have you felt like that?" and "What do you think caused this?"
By slowing down, he says, physicians can gain tremendous insight on issues such as family problems that are causing stress. Knowing this might avoid needless tests looking for very unlikely chronic conditions.
"The worst thing to do is to order a bunch of tests to cover yourself because you're worried you'll miss something. Every test has a margin of error, so they will likely lead to more tests," he says, which, in turn, "will do more harm than good."
He says physicians who do order tests must get better about closing the loop on delivering results to patients. "Misdiagnoses can be made simply because the referral loop isn't closed and assumptions are made about who knows what," he says. "We keep holding out the dream of an integrated medical records system" where results are well communicated. The reality, though, requires physicians to reach out to referring groups to obtain results and then directly communicate those results to patients.
Reaching for the closed loop
Closing the loop is a mission for Johns Hopkins Community Physicians, a network that includes internal medicine, family practice and pediatrics, and specialty services with locations in Virginia, Maryland, and the District of Columbia.
Johns Hopkins Community Physicians has created redundant processes in the EMR system to ensure that physicians are alerted in a reasonable time when tests they've ordered have been completed, says President Steven Kravet, MD, MBA, FACP. The system also alerts physicians when they haven't been received in a reasonable amount of time so they can be checked on.
"I don't believe no news is good news," Kravet says. The goal is to avoid results falling off the map like an abnormal Pap smear that gets sent to the wrong doctor and the patient is never called.
The network now labels certain tests "critical" so physicians can run reports and quickly track down missing results. Even noncritical tests are reported on so that all results make their way into the system.
Kravet also would like to see certain testing systems rise to the level of mammography where women are told immediately whether there is cause for concern.
"This does not exist for other imaging tests such as chest x-rays," he says. If a radiologist finds a 5 mm nodule on the lung, they'll note it in the record but may not necessarily call the doctor. However, that still requires a follow-up, he says, so it's critical that the information is directed to the provider. "There's more information nowadays, and there is a higher tendency for things to get lost in a pile of paper."
Team time
Richard Friedberg, MD, PhD, FCAP, president of the College of American Pathologists, hopes new payment models will help in the fight to reduce diagnostic errors. "In a capitated system, every time you order a test, you lose a buck," he says, and, therefore, pathologists are being encouraged to set standards for appropriate usage.
Friedberg says most laboratories have become highly controlled and regulated and, therefore, highly efficient, so most of the diagnostic errors are occurring before the specimen hits the lab and after it is tested.
In pathology—as other diagnostics—it's possible to be 99% correct and 100% wrong if an error occurs, such as putting the wrong name on a tube. And as care teams grow, he says he believes so does the potential for mistakes.
"We're getting more and more people at the bedside who have less and less experience with diagnostics," he says, pointing to the influx of nurse practitioners and physician assistants to address gaps in primary care but who may not be properly trained in lab diagnostics.
Pathologists must partner with providers and other members of the care team for better training in ordering and more awareness of how to construct and communicate reports. For example, a best practice could be to put critical words such as "malignant" in bold at the top of a report.
As healthcare organizations across the country address their diagnostic error issues, Children's Hospital Colorado's Hyman is optimistic that like other challenges, healthcare will emerge victorious in solving this problem through changes such as how providers think about diagnosing patients. "I'm confident that 20 years from now people will say we used to have diagnostic errors, but now they are much less common because we implemented changes to the way we communicate and think about diagnoses," Hyman says.
"In a healthcare system's most mature state, everyone owns quality," says Baylor Scott & White Health's chief quality officer. So if everyone owns quality, why have a CQO?
This article first appeared in the May 2016 issue of HealthLeaders magazine.
When David Ballard, MD, PhD, MSPH, FACP, assumed the role of Baylor Health Care System's first chief quality officer in 1999, he says he was the second healthcare executive in the country to hold the title. Today, Ballard calls the CQO title a "must-have" for all health systems to show their commitment to quality care.
"The explicit business case for a CQO is more obvious in 2016 than it was in 1998," says Ballard, who retains the CQO title with the Texas-based organization now known as Baylor Scott & White Health, which now has 41 hospitals, more than 950 patient sites, and more than 6,600 affiliated physicians. "A key pathway to reducing per capita costs of healthcare will be to achieve continuous improvements in the health of populations while delivering effective care and reducing ineffective care, healthcare waste, and harm to patients." And he says CQO is the role necessary to lead this charge.
Ballard travels the country to teach other health systems how to structure their CQO positions, acknowledging that the approach differs based on an organization's size and priorities. "In a healthcare system's most mature state, everyone owns quality," he says.
So if everyone owns quality, why have a CQO? "Because the future of health systems rests on the ability to continually improve on the care they provide patients, and they must have someone in a leadership role to make that happen," Ballard says.
At Baylor Scott & White Health, he also serves as president and founder of the organization's STEEEP Global Institute and practices the Institute of Medicine's STEEEP concept, which he wrote about in several books, including Achieving STEEEP Health Care. STEEEP refers to safe, timely, effective, efficient, equitable, and patient-centered care. Part of Ballard's job is to ensure that all of the organization's 40,000 employees are well versed in STEEEP and consistently apply its principles.
Quality is now one of the four pillars for compensation at Baylor Scott & White Health, requiring employees to have goals and accountability in this critical area, he says.
Creating relationships
Ballard's direct reports—who include a chief patient safety officer, a chief patient experience officer, a chief health equity officer, and a chief clinical effectiveness officer—answer to the CEO and collaborate with other members of the C-suite, including the CFO, CNO, CMO, COO, and CIO. "To be effective as a CQO, you have to be a connector, relate to a whole lot of people, and be comfortable getting things done through dotted-line relationships," he says.
"You have to be able to motivate those around you to seek change and do change with the patient as the center of your work."
To reduce high-risk cardiac surgery mortality rates, Ballard worked closely with health system leaders, hospital leaders, cardiac surgeons, and operating room staff to institute a second-opinion rule. Together they sorted out benefits and likely risks for certain cardiac patients, ensuring clinicians could optimize a patient's functional status—such as addressing lung or kidney issues—prior to surgery. "Employees have to be empowered to prevent a surgeon from taking someone for elective cardiac surgery without a documented second opinion who has at least an 8% risk of dying," he says. "You need full alignment across the organization to achieve objectives."
At UPMC, the Pittsburgh-based health system with 20-plus hospitals and 5,100 licensed beds, CQO Tami Minnier, RN, MSN, FACHE, considers relationship-building a key factor in the success she's had in the role over the past decade. "You have to be able to motivate those around you to seek change and do change with the patient as the center of your work," she says.
Leading and supporting
Minnier, who previously served as vice president of patient care services and CNO at UPMC Shadyside, a tertiary care hospital, says promoting from within is the ideal approach. "I think there are individuals who can come in from the outside and be successful as a CQO, but in general, because this is such a relationship-based position, having internal experience gives you an advantage," she says.
Her influence in the clinical, regulatory, and safety arenas now stretches deep into UPMC. For example, when the Centers for Medicare & Medicaid Services announced it would release a sepsis management bundle, Minnier worked with ICU service line leaders across the system's hospitals to prepare for and educate everyone on the changes ahead of the new measure. She also worked with IT to insert the new protocols into the electronic health records system.
"It's one thing to hand down information on the regulation; it's another to implement it effectively," she says. After the bundle went into effect in October 2015, Minnier began gathering data and feeding it back to clinicians to determine how well the teams are performing and what protocol changes are still necessary to achieve the best possible results.
"Ultimately, the CQO is a supporting function, and the operational leaders who oversee management of clinical areas have to be the ones to drive change," she says. "We are partners in helping them achieve their goals."
An evolving role
For many years, Minnier had little guidance regarding the role of the CQO, but she sees the industry starting to come to consensus. "CQOs will be very key in the upcoming decade as healthcare moves from volume to value," she says. "We have yet to define value and quality, and the CQO can serve as an excellent resource as we navigate this transformation in healthcare."
One area where a CQO's expertise would be useful: simplifying systems. "We continue to have large, complex, and overbuilt systems, and a CQO's knowledge on the process side of quality could go a long way to solving that," she says.
While Minnier stops short of saying that CQOs should own clinical systems, instead referring to her collaborative relationship with UPMC's IT team, other organizations use a more defined approach.
J. Michael Kramer, MD, MBA, senior vice president and CQO at Spectrum Health, a 12-hospital health system in Western Michigan with 184 ambulatory and service sites, says in order to achieve highly reliable outcomes and quality goals, clinical informatics and quality teams need to be tightly aligned. "If we're going after particular quality measures, we have to know how to hardwire them into the infrastructure and processes of care," he says. "Value-based healthcare depends on it."
Kramer, who reports to the executive vice president/CMO, focuses quality on four key areas: informatics and the ability to embed quality into the systems; process improvement; transparency in analytics; and transparency in professionalism. He presents in-person quarterly reports to the board and is a member of the CEO's leadership council.
"Many of the functions I perform are delegated from the CMO," he says, calling the CQO role "forward-thinking." The CQO role must be "strategic in supporting value and triple aim, and sophisticated in developing education and board engagement. This is not feasible for the CMO alone nor is it possible for the CQO without deep partnerships with operations and clinical leaders."
Creating structure
When he became CQO three years ago, Kramer consolidated 14 disparate quality teams and elevated them to the system level. He standardized care through the electronic medical records systems. "How can you zero in on readmissions when you can't establish a true length of stay across the health system?" he says.
Kramer says the overarching responsibility of his 140-member team—which includes specialists in clinical informatics, quality improvement, and analysis and data abstraction—is to provide meaningful data to the organization. They have improved the system's dashboards for gauging quality, which were based on the Healthcare Effectiveness Data and Information Set (HEDIS), by introducing core quality measures such as mortality rates and episodes of care as well as cost and patient experience.
To that end, 23,000 employees now have access to quality, cost, and patient experience dashboards that feature data from 500 quality measures so they can analyze critical information such as catheter-associated UTI, sepsis, and venous thrombosis rates.
Kramer also centralized the majority of the registries clinicians report into across the organization "so that we understand what data is available for quality reporting as well as understand the sensitivity of that data in the context of privacy and security," he says. Information includes registries operated by the Centers for Disease Control and Prevention as well as U.S. News & World Report's pediatric rankings.
Although Kramer says he is eager to be involved early on in new initiatives, he also is content, once processes are established, to hand off projects to clinical leaders who can sustain them. For instance, his team helped build predictive analytics models for the sepsis bundles but then shifted responsibilities to a rapid response team.
Kramer says the next challenge for Spectrum Health is to standardize the health system's professional practice capabilities, aiming for a common management model across the whole system. An example of this is to have common bylaws across the medical staff, he adds.
Passing on the CQO title
While many quality leaders opt for the CQO title, Leigh Hamby, MD, MHA, chose to head up quality in 2013 from the position of CMO at Piedmont Healthcare, which has six hospitals in the Atlanta area and serves nearly 2 million patients.
Hamby, who had been CQO at Piedmont from 2007 to 2013, has corporate oversight for all safety and quality initiatives. His CMO-specific responsibilities, he says, are a small slice of what he does as CMO because Piedmont is well developed at the hospital level with respect to traditional CMO matters. "The CMO at corporate level is going to do two additional things beyond the traditional CQO: building population health and moving from volume to value," he says, noting that "ninety percent of what I do is what a CQO would do, not a traditional CMO. Quality is truly our prime directive here."
That directive was solidified in 2015 when one of the system's hospitals received a lower score than expected on the Leapfrog Hospital Survey. "Our CEO was clear that I would call the shots on devising a strategy to turn it around," he says. That clarity from the top has helped his team avoid turf wars, according to Hamby.
His goal for quality has been to steer away from what he calls "counting and measuring," to using process engineers to figure out "how to move the needle" on improvements. "I want to spend less time thinking about accrediting bodies and more time on quality improvement," he says.
As part of this information overhaul, Hamby took the opportunity of the CIO leaving a few years ago to bring all of IT, including the CMIO, under his CMO umbrella. "It's such a critical part of what we do," he says. "If IT people aren't linked in to quality initiatives, then quality leaders can only opine on what they would like the technology to do. Our team can get it done."
This realignment of resources has been instrumental for systemwide efforts such as reducing and eliminating hospital-acquired infections. For instance, having oversight enabled his team to effectively winnow the organization's scorecard from 200 metrics to 42.
"We only consume resources for things related to the scorecard, so I'm charged with saying no a lot," he says. For example, a group within the organization asked him to look at the issue of advanced directives, and he told them, "You're going to have to connect that problem with something on the scorecard for me to pay attention to it."
His team works to identify common denominators among reporting programs, including CMS, Leapfrog Hospital Survey, and the CDC's National Healthcare Safety Network to develop metrics that have the broadest applicability to patients. For instance, instead of just focusing on CAUTIs in the ICU for CMS reporting, the system tracks CAUTIs across all of Piedmont's facilities.
While many say the CQO title is the best way to demonstrate commitment to quality in a health system, Hamby says his situation proves any combination of a C-level title with quality responsibilities can be effective.
Baylor's Ballard points out that "in smaller organizations, people have to wear multiple hats so they might not have someone at the corporate level who can focus exclusively on safety or perhaps the patient experience." Even so, they should start to formalize the function by developing quality structures and tactics that are as effective and efficient as possible, he says.
To Kramer, CQOs are a necessity in organizations because "there is too much change and complexity in healthcare to leave this to leadership that is also managing complex recruitment, practice relationships, mergers, integration, bundled payments, and EMRs," he says.
The procedures are becoming more viable in an outpatient setting, but only if the right patients and resources are involved.
This article first appeared in the September 2016 issue of HealthLeaders magazine.
Theodore Stringer, MD, a surgeon with Colorado Springs Orthopaedic Group, a board-certified orthopedic physician practice with subspecialty care offerings such as sports medicine, spine, and trauma, is laying the groundwork to begin offering outpatient joint replacement surgery. He expects payers to mount pressure to shorten hospital lengths of stay, but says of outpatient joint replacement, "I didn't want to be the first person [to do outpatient joint replacement surgeries], but I also don't want to be the last."
Stringer has studied the logistics of starting this venture, met with peers across the country who already provide these services, and surveyed interest from his own team, and realized that missing any key ingredient in the setup of offering outpatient joint replacement surgery could result in poor patient outcomes.
For outpatient joint replacement surgeries to be successful, the facility must have anesthesiologists skilled at regional blocking anesthesia, a 24-hour medical team must be in place for patient follow-ups and emergencies, and most important, the practice must be focused on patient selection and preoperative education and preparation.
"Outpatient joint replacement is not an option for a majority of patients, so we are preparing and trying to find the right patients," Stringer says.
The concept of outpatient joint surgery, which primarily includes total hip replacement, total knee replacement, and partial knee replacement, is not yet palatable to many surgeons. In fact, of the four arthroplasty specialists in CSOG's 18-person practice, only Stringer himself is currently on board and only wants to perform total knee replacements to start.
Scott Bergman, MBA, board member of the New Jersey Association of Ambulatory Surgery Centers and administrator at Cherry Hill, New Jersey–based Millennium Surgical Center, an advanced outpatient surgical center focusing on orthopedics, spine, pain management, and podiatry, says outpatient total knee replacements, which his multispecialty surgery center has been doing since 2014, are "profitable procedures, so you'd like to do more."
"In speaking to insurance carriers, they like outpatient joint replacement surgeries as well," he says. But like Stringer, he says candidate selection and preop screening dictate success.
Millennium Surgical Center has only performed 20 outpatient total knee replacements in the past two years due to the limited pool of patients who meet the team's stringent criteria.
"They tend to be younger and healthier patients who don't want to spend three or four days in a hospital, and are motivated to recover," Bergman says.
Doing total knee replacements outpatient at an ambulatory center, he says, lowers the risk of infection compared to doing so in hospitals. "We don't have sick patients here, so you don't have the risk of comingling. Also, we only do outpatient orthopedic procedures, so the patient isn't exposed to the risk that comes with following 'dirty' colonoscopies or other gastrointestinal procedures," he says.
Millennium has spent time and money to improve the knee replacement surgery program. But several technological advances have made the procedure minimally invasive. Surgeons use custom knee implants, created from CT scan images, to ensure a proper fit. "This cuts down on operating time and recovery time," Bergman says.
Patients are transferred to a private rehabilitation facility up to 23 hours after surgery. Surgeons have worked closely with the facility to create best practices for recovery. "There they get physical therapy two to three times a day to get the knee moving," he says.
Keith Reinhardt, MD, orthopedic surgeon at Northwell Health's Southside Hospital, a 341-bed tertiary facility in Bay Shore, New York, that specializes in multidisciplinary orthopedic care, says he is the only surgeon of three in his group doing outpatient joint replacement.
Reinhardt operates two days a week, performing three to six surgeries each day. Of those, one or two are outpatient and can be total knee replacements, partial knee replacements, or anterior total hip replacements. Unlike Millennium, Southside sends outpatient joint replacement patients home if they meet all discharge criteria.
"I've always been a big proponent of recovering at home. Recovery is better and [patients] have lower complication rates because they are forced to do more. They are up and around more, which means there is less risk for deep vein thrombosis," Reinhardt says. "Home is the right discharge place."
To ensure a smooth experience for the patient, Reinhardt held interdisciplinary meetings to explain to all staff interacting with patients the importance of a positive outlook regarding the outpatient surgery. "From the moment [patients] walk in the door to the minute they go home, they have to know they are going to do great."
He is also heavily involved in the patient selection process, working closely with a nurse practitioner and social worker to ensure the patient is fully prepped for surgery, postop, and discharge through a full home environment and social screen.
The nurse practitioner conducts a preop visit with the patient to learn of comorbities, medications, and other red flags. "If there is anything significant, we have them seen by a medical doctor after surgery and given medical clearance for discharge," he says. A social worker also contacts the patient to set up home physical therapy and a home visiting nurse as well as a walker and other equipment. "By the time the [surgery] day comes, the patient is aware and ready," Reinhardt says.
The power of anesthesia
Elie Joseph Chidiac, MD, chief of regional anesthesia section and residency program director at Detroit Medical Center/Wayne State University in Detroit, says outpatient joint replacement surgery is succeeding because modified surgery techniques cause less tissue damage, inflammation, and pain, and anesthesiologists, using a multimodal approach, are able to better control side effects such as nausea and pain. Detroit Medical Center does both outpatient and inpatient knee replacements, but only patients with partial knee replacements are allowed to go home on the day of surgery.
In addition to preoperative medications to control nausea, allergies, and pain for patients, the team uses an adductor canal catheter with a diluted local anesthetic to block the nerve. The patient is able to go home with the catheter and remove it after three days, Chidiac says. The anesthesiologist who placed the catheter is required to not only follow up with the patient but to supply a phone number to the patient for emergencies.
Southside's Reinhardt says that while he considers a catheter an effective mode for anesthesia, he worries whether the patient would be able to keep it clean. Therefore, his team uses a periarticular injection administered during surgery that lasts for one to two days.
Outpatient surgeries cause more work for anesthesiologists because they require advanced nerve blocking skills, Chidiac says. As a result, anesthesiologists tend to be more involved with patient screening, asking deeper questions about a patient's general health. "We also have to have a backup plan in case the patient reports severe pain in postop," he says.
The benefit, though, is in most cases you have an alert and pain-free patient postop, Chidiac says. "You have higher patient satisfaction for less cost," he says.
A big operation
Although surgeons report satisfaction among the limited outpatient surgeries they are performing, some worry that there could be a false sense of security.
"This is still major surgery—I don't care how you slice it," says William J. Dowling, MD, chair of orthopedics services at Morristown Medical Center in New Jersey. "While we've become much more sophisticated and facile with surgical technique, this is still significantly invasive," he says.
Of the 2,200 joint replacement surgeries orthopedics services performs each year, Dowling says 2% percent (or 44 surgeries) are outpatient—primarily partial knee replacements.
Like Reinhardt, he says home for recovery is the right place for carefully screened patients and has found the risk of being readmitted to the hospital from home lower than from a rehabilitation or skilled nursing facility. "When you go home, you tend to fend for yourself and get back to your life as opposed to being a patient," Dowling says.
But, he warns, that doesn't mean patients can't have the same complications as their inpatient counterparts such as heart attack, stroke, blood loss, infections, and blood clots. "The reason you stay in the hospital is not only to control pain discomfort, but also to monitor excessive anemia and lightheadedness that can come with blood loss," he says. Also physicians must ensure that patients can walk and be able to function safely without fear of falling or injury. There must be room for judgment calls in postop, including hospital admittance, Reinhardt says.
Exiting the outpatient waters
William Long, MD, medical director of the Orthopaedic Computer Surgery Institute at Good Samaritan Hospital in Los Angeles, has a cautionary tale about the potential downsides of outpatient joint replacement surgery.
Long's early experience with outpatient hip replacement taught him that it is not an appropriate option for many patients. He learned that outpatient hip replacement requires special education for the patient and the family, and a special support team of providers to take phone calls around the clock.
"You must be better at figuring out who the patient is before you operate on them than for inpatient," Long says. "It's also your responsibility to know the family and know whether this is the right decision for them."
He says this requires longer office visits with the surgeon before surgery, because it can take up to an hour to explain the procedure and answer all the patient's questions. "Following surgery, an inpatient can push a button to summon a nurse for assistance," he adds. "Outpatients also require access to a knowledgeable provider to ask questions, such as, 'What do I do about uncontrolled pain? When is blood on the dressing an emergency? What do I do with persistent nausea?' "
Patients must feel comfortable enough with the outpatient procedure and what to expect after the surgery that they don't rush to the ER or ask to be readmitted to the hospital.
Surgeons are required to have a 24-hour number manned by skilled nurses or the surgeon. After the RN assigned to his 24-hour line left the practice, Long began taking the calls and was soon exhausted. "I had to take personal responsibility for everyone that went home that night," he says.
Long realized he did not have the resources to staff his practice adequately to handle the demands of outpatient joint replacement patients. Most surgeons who perform joint replacement do not have the resources to pay for an on-call team, and hospitals are not required to provide those resources, he says. "Outpatient surgeons save hospitals money because the hospitals don't have to provide care for the patient after the operation; there is no requirement that the hospital provide care for the patient at home. That responsibility could fall squarely on the surgeon and his personal resources. Surgeons can't be expected to operate all day and take calls all night."
He worries that if payers start pressuring surgeons toward outpatient, they won't consider these requirements. "Yes, outpatient surgery can be a great thing if the patient has adequate personal resources, but it could also be an evil thing if it is just forced upon the public as the new standard of care," he says.
Dowling agrees. He says he understands the lure of outpatient procedures for surgeons and payers. "Almost every year, there's a shift of 10% to an outpatient setting, and I expect this to continue, including shoulder replacements," he says. "Compensation reimbursement in ambulatory settings is decent, and that's attractive to surgeons if they want to assume risk," he says. "But you have to set yourself up so other contingencies are available."
He adds that if doctors were comfortable with outpatient joint replacement procedures, you'd see a greater increase in those doing them. "We're not seeing that. Instead it's slow and incremental," he says.
Community health workers are being dispatched to the front lines of care delivery to better understand patients' socioeconomic circumstances and steer them away from costly ER visits in favor of cost-efficient and proactive care.
This article first appeared in the July/August 2016 issue of HealthLeaders magazine.
Healthcare systems are trying to improve patient outcomes and reduce costs by ensuring high-risk patients receive preventive care and comply with medical orders. But oftentimes patients have obstacles in their lives clinicians are unaware of that keep them from engaging with the health system.
Enter the community health worker, or CHW—an emerging resource that is becoming a critical part of the integrated care team.
CHWs are being dispatched to the front lines of care delivery by primary care practices, health systems, and insurers to better understand patients' socioeconomic circumstances and steer them away from costly ER visits in favor of cost-efficient and proactive care.
The American Public Health Association, publisher of the American Journal of Public Health, defines a CHW as "a frontline public health worker who is a trusted member of and/or has an unusually close understanding of the community served." APHA adds: "This trusting relationship enables the worker to serve as a liaison/link/intermediary between health/social services and the community to facilitate access to services and improve the quality and cultural competence of service delivery."
While some healthcare organizations require CHWs to have college degrees or certification in a health-related field, others place more emphasis on a CHW's knowledge of community services, language skills, and shared life experiences with the target patient population.
Priority Health's Medicaid insurance plan, which has more than 100,000 members in Western Michigan, uses CHWs "to meet the patient where they live," says Sheila Wilson, director of care management for the Medicaid product at the nonprofit health plan in Michigan. CHWs work one-on-one to advocate for members, mentor them, and help them navigate the complex medical and social systems. They resolve barriers to care such as transportation, safe living conditions, jobs, nutrition, culture, and language. She puts the CHW need bluntly: "If people don't know where they're sleeping or getting their next meal, they can't get to the next step of care."
Something as seemingly simple as coordinating office visits for a mom and baby can be the difference between life and death, according to Wilson, who illustrates the CHW impact for stakeholders with this recent example: A mother in poor health was overwhelmed by the number of doctors' visits she and her baby faced following the newborn's 133-day stay in the NICU. She missed the baby's appointments, leading to the baby's readmission to the hospital 58 days later.
Priority Health dispatched a social worker and a CHW to help the mother in-hospital and through the transition home. The CHW, among other things, created a more manageable schedule of coordinated doctors' visits so the mom didn't have to leave the house as many times a week with the medically fragile baby. The CHW then followed up with the mom daily. "You have to wonder what would have happened to that child and mother had we not been there," Wilson says.
Although Priority has had CHWs, previously called field service representatives, for more than 20 years, it formally hired four CHWs in 2014 to assist its high-risk Medicaid population, and it hopes to soon grow that number to eight.
"We know CHWs are valuable members of the patient care team, and we continue to determine how we best can demonstrate the impact and value of CHWs."
Priority's CHWs gain their case-loads in two ways: risk stratification and provider referral. Priority analyzes claims to see which members are using the ER as a primary care service or are in the ER because they didn't properly manage their chronic conditions. Also, Priority's partner providers are able to call in a CHW to assist patients.
Working closely with services already established in the patient's community, CHWs are able to assess and address member needs quickly, such as getting a domestic abuse victim into a shelter, connecting families with nutritional needs to food banks, and using translators to help families understand care instructions.
Wilson says the return on investment of CHWs is proven in the shift from ER visits to preventive care and monitoring granular improvements, such as better A1C rates of diabetic patients paired with CHWs. "We can engage people through other communications, but we have far more success when we engage them face-to-face," she says.
Integration is essential
Hennepin County Medical Center, an integrated hospital and clinic system serving downtown Minneapolis and surrounding neighborhoods, integrated CHWs into its primary care clinics as part of its patient-centered medical home certification, which, in Minnesota, is referred to as Health Care Homes certification. According to Hennepin's publication A Year in Review, its clinics had nearly 600,000 visits in 2015.
While social workers handle patients with mental health–related issues and nurses deal with patients' medical management, CHWs are charged with identifying other issues that patients encounter, such as transportation challenges, understanding how to access primary care, basic education about chronic conditions, and how to afford medications.
Kristen Godfrey Walters, MPH, community care coordination manager at Hennepin, says the health system's 30 CHWs, a majority of whom are based in primary care clinics, bridge gaps in care, freeing other clinicians such as nurses to work at the top of their licensure.
Hennepin uses a risk-stratification model within the EMR to identify clients for CHWs, including inpatients; patients with chronic conditions such as diabetes, asthma, and vascular care; patients who are no-shows for visits; and other red flags. "The CHW's main goal is to get people back into the primary care system," Walters says.
Caseloads for the CHWs are larger than Walters would like, with each CHW handling as many as 200 patients annually. Ideally, she would like to see that drop to 80–120 patients and is fine-tuning Hennepin's recently developed risk-stratification model, based on CMS-HCC Medicare Risk Adjustment Model, which identifies patient risk of future healthcare utilization based on clinical complexity. She says Hennepin already has modified the model to be more specific to pediatric conditions and is working to better incorporate social determinants of health. For example, an unstable housing indicator is being developed to incorporate the risk of individuals who are homeless. Determinants like that affect the amount of care coordination and support services that impact CHW caseloads but may not be reflected in the current risk stratification, she says.
Referrals play a hefty role in broadening the CHWs' workload as well. If a CHW is working with one child in a family, he or she might take over the needs of all the children. Providers also have recognized the CHWs' value through patient satisfaction surveys and program evaluation, and, as a result, have boosted referrals. Walters says the care coordination model evaluation focuses on decreasing unnecessary utilization (ED and inpatient visits), increasing primary care visits, reducing readmissions, and reducing length of stay, for example. "We know CHWs are valuable members of the patient care team, and we continue to determine how we best can demonstrate the impact and value of CHWs," she says.
Beyond the clinic walls
At the Penn Center for Community Health Workers, a community/academic partnership funded by the University of Pennsylvania Health System, 24 CHWs supervised by managers with extensive social service experience assist 1,500 high-risk patients annually. The CHWs support patients of two hospitals and five primary care facilities that are part of UPHS, as well as a Veterans Affairs Medical Center and a federally qualified health center. All facilities are located throughout West and Southwest Philadelphia.
A primary requirement for the CHWs, according to Penn Center for CHWs Director Jill Feldstein, is to share similar life experiences with the patients. "Do they have the skill set to get the patient to open up about what's going on in life?" she says. "Our patients have tremendous stress, such as poverty, community violence, and housing instability. The CHW has to be able to build a trusting relationship."
"Nurses and doctors can only handle who walks through the door. They need an army of people who are creative and skilled to manage other parts of the care system. We're moving from being a reactionary system to a proactive system."
CHWs were integrated into UPHS because patients voiced a disconnect from healthcare providers. They felt the doctors didn't understand what it was like in the real world for patients. Feldstein says in 2011 Penn Center for CHWs hired a community-based interviewer to ask high-risk patients about their experience with healthcare. "We recorded, transcribed, and analyzed the interviews. Over and over again, we heard patients talk about the disconnect they felt from traditional medical personnel. An illustrative quote was: 'They can give you advice, like here's the kind of medicine you need. But they don't really know how it works in the real world,' " she says.
CHWs are assigned to hospital and outpatient care teams and meet with patients, asking them what they need to be able to focus on their health. Together, they develop an action plan and the CHW helps the patient to carry it out. CHWs embedded in hospital teams work with patients for two weeks to three months, providing social support, advocacy, and navigation in the transition from hospital to home. In the outpatient setting, CHWs work with patients for six months, providing support, health coaching, and navigation to help patients manage their chronic conditions.
The Penn Center for CHWs determines patient eligibility for the CHW intervention by using information extracted from the medical record: geography (residence in an eight ZIP-code area with the highest rates of household poverty and readmission to system hospitals), insurance status, chronic disease status, and current hospitalization.
"CHWs help solve everyday challenges facing high-risk patients such as childcare, transportation, and emotional support," Feldstein says. A CHW might accompany a patient to the YMCA to work out or host a three-way call to understand prescription coverage.
CHWs join the communication flow of the clinical practice itself, participating in daily huddles, sending and receiving EMR messages, and attending case conferences. "Every time we integrate CHWs into a new care team, such as the Veterans Administration, we introduce the program, meet with all the patient teams, and illustrate the impact with a case study," Feldstein says.
CHWs also regularly meet with one another to share best practices, troubleshoot, provide constructive criticism, and participate in professional development.
Transforming care with CHWs
At Montefiore Medical Group, which provides primary and specialty care services in more than 20 locations in the Bronx and Westchester County, the quest to achieve PCMH certification, which the system received, illuminated the need for CHWs.
CHWs are embedded at sites with populations that are more challenged and less affluent, and have a high prevalence of chronic conditions. "They bring patients back into the system who have been lost," says Namita Azad, transformation manager at Montefiore.
The primary focus of the four CHWs—that number is expected to grow to eight or nine in the near term—is care coordination and care management. CHWs are used as patient liaisons, health educators, and patient navigators for group visitors. And although the PCMH model targets Medicaid, Montefiore provides CHW services to all patients.
Even with the anticipated growth in the CHW workforce, Azad says it won't be enough. "We're never going to be at ideal levels in terms of staffing, because we're always going to want to make more use of CHWs," she says.
For instance, she would like to see the CHWs go out into the community and do patient engagement, but that requires coordination and level setting not possible right now. "That's the next frontier," she says.
However, that doesn't mean the CHW voice isn't strong internally. The CHW is an equal member of a multidisciplinary transformation team that includes nursing staff, front desk operations, health educators, psychiatrists, and physicians. "CHWs have been designed into the workflow and help drive quality improvement," Azad says. "If we're putting together a workflow on outreach to diabetic patients, it will not be firmed up until we receive input from the CHW and the health educator."
"Nurses and doctors can only handle who walks through the door. They need an army of people who are creative and skilled to manage other parts of the care system," Azad says. "We're moving from being a reactionary system to a proactive system."
Sending out an SOS
In 2008, Dodie Grovet, LISW, program manager at Long Beach, California–based Molina Healthcare, which operates health plans for families and individuals who qualify for government-sponsored programs and medical clinics across the country, received a report about high ER usage among members of the New Mexico plan.
"Instead of receiving care from their primary care physicians, they were utilizing the emergency room. Members were hospitalized because they weren't managing their chronic conditions on an outpatient basis," Grovet says.
Grovet deployed CHWs, now called community connectors, to interface with members in their home settings. They addressed diabetes, asthma, heart disease, and other medical conditions as well as addressing social determinants of health that impact members' ability to access care. Within two to three years, Grovet was able to demonstrate cost savings—a 4:1 ROI—and improved health outcomes for members.
"The New Mexico health plan served as the pilot for the program, and once leaders saw the positive results, they implemented the program enterprisewide," she says.
Today, risk stratification also looks at escalation in medication usage for chronic conditions, visits to pain doctors, claims and scheduling, and even homecare oxygen orders. The CHW can offer to connect the patient to necessary services such as diabetes clinics and eye doctors.
Caseloads are fluid at Molina. "Even after members have received the full continuum of services from a community connector, should they require further intervention, the door is left open. Members always have access to a community connector," she says.
Cancer screenings
Gloria Coronado, PhD, senior investigator and Mitch Greenlick Endowed Scientist for Health Disparities at Kaiser Permanente Center for Health Research, used CHWs to study a serious challenge in the Latina community. Despite breast cancer being the most common cancer among women in the United States, Latina women are more likely than non-Latina whites to be diagnosed with breast cancer in advanced stages, according to Coronado.
"We know from data that Latinas don't get mammography screenings. They are unaware of the need for screening unless they have symptoms, or they may fear the possibility of having cancer," Coronado says.
With the help of Sea Mar Community Health Centers, which provide medical, dental, and behavioral services in clinics throughout Washington state, Kaiser Permanente Center for Health Research looked at whether having a promotora—a community health worker—visit Latinas in their home and use motivational interviewing skills increased their likelihood to get screened for breast cancer. Free mammography screenings were offered in conjunction with the study.
"In addition to the home visit, the promotoras called the women to check in two weeks after their visit to discuss their next step toward getting screened, including talking to a friend or scheduling a screening," she says.
"The result was a modest but significant increase in screenings, but even a modest increase, when it comes to cancer, could save lives," Coronado says.
She acknowledges that promotoras might be an expensive proposition for health systems, but said costs could be decreased with automated phone calls and other low-cost reminders that would winnow the CHW targets. "Only the people that didn't respond to the less-intensive reminder would need follow-up," she says.
She stresses: "I do think the community health worker has a unique perspective and connection with patients that other people in the health system do not."
The emerging role of chief pharmacy officer is aiding care coordination, with positive side effects that improve drug cost efficiencies, prevent readmissions, and in some cases, lighten the load from nurses' discharge work.
This article first appeared in the June 2016 issue of HealthLeaders magazine.
RWJBarnabas Health, a New Jersey–based integrated healthcare delivery network that serves more than 2 million patients annually, sent a clear message in July 2015 when it named its first chief pharmacy officer, Robert T. Adamson, PharmD, FASHP: Pharmacy professionals will be at the forefront of caring for patients.
"Pharmacy has been considered a supportive care division and involved along the line, but having pharmacy at the table from the beginning is fruitful," Adamson says. "Without a CPO, it's very difficult to marry the strategic plan of the health system with the direction of pharmacy."
Adamson, who had been RWJBarnabas Health's vice president of clinical pharmacy services, now oversees all pharmacy services across the health system, including RWJBarnabas Health's six retail pharmacies and in-hospital services for its 11 acute care hospitals and three acute care children's hospitals.
The goals of the CPO, he says, are to standardize the pharmaceutical segment of clinical pathways, such as order sets; find cost efficiencies in drug purchasing and usage; and use pharmaceutical insight to reduce length of stay and prevent readmissions.
Prescribing value
RWJBarnabas Health is not alone in promoting the visibility of pharmacy. The American Society of Health-System Pharmacists wrote in 2015 that "complex hospitals and health systems benefit from having a pharmacy executive responsible for the strategic planning, design, operation, and improvement of their organization's medication management system."
In his nearly one year in the new role, Adamson already has brought about significant change, including centralizing formerly siloed groups such as ambulatory, home infusion, mail order, and specialty pharmacy services. "Before, pharmacy was fragmented and underutilized, and now we are one voice connecting to the patient," he says.
Although ASHP recommends that CPOs report directly to the organization's principal executive like a CEO or chief operating officer, Adamson reports to the chief medical officer.
RWJBarnabas Health CMO John Bonamo, MD, MS, FACOG, FACPE, considers the CPO role a critical part of value-based purchasing. "Pharmacy is not just about lowering drug costs; it's about patients having a good experience and getting the best care," he says. Having a CPO fills the triple aim of healthcare, according to Bonamo, who points out that while, to his knowledge, fewer than 50 organizations have a CPO today, a few years from now, that number will be in the hundreds.
Bonamo considers the CPO a value-added service for physicians and key to health system goals such as antibiotic stewardship. "Our physicians rely on the CPO's advice because pharmacy is so complex. They realize they don't know what the pharmacist knows," he says.
For example, Bonamo says, if a hospital floor experiences an outbreak in urinary tract infections, Adamson would be alerted to a sudden rise in medication ordered via the health system's pharmacy application. After studying the patients' laboratory cultures, he would request tests of certain antibiotics to see which are most effective at stopping the infection. He would then rate the antibiotics by how safe they are and their cost.
"There might be a $12 antibiotic that's less toxic to the kidneys and liver," Bonamo says. Adamson would then insert the recommended treatments into the electronic medical record system so physicians would immediately see them upon diagnosis. "It's a very exacting process, as opposed to a shot in the dark," Bonamo says, acknowledging that getting to such targeted therapy has required a new lab system that is interoperable with the EMR and pharmacy applications.
The cost of value
Bonamo says Adamson also has been entrusted with the health system's more than $100 million spend on drugs. "That's a lot of money, so we have to negotiate well with pharmaceutical companies and be smart about our contracting with managed care companies who cover specialty drugs," Bonamo says.
Adamson oversees a group focused on pharmacy financials as well. "They read every contract we have with suppliers as well as insurers and then go through patient bills to find things we could have billed for that we didn't and things we should have billed differently," Adamson says, adding that through that process, they uncovered $9.5 million in revenue.
The pharmacy team also found that the unused part of single-dose vials of high-priced drugs such as those used in chemotherapy could be billed as waste, capturing another $60,000 to $70,000 in revenue per month, Adamson says.
In addition to drug costs, Adamson has focused his team on impacting length of stay and readmission rates. For the former, they identified diagnoses where an oral drug could be used instead of an IV drug to enable patients to be discharged faster, such as those with COPD. "While the pharmacy didn't save any money, the length of stay was reduced by almost a day," he says.
His team also dug into mitigating the side effects of drugs provided at discharge because "a majority of a patient's aftercare involves medication," he says. For instance, patients who are ordered a narcotic receive an accompanying stool softener because constipation is a common side effect. "These issues are much more difficult to mitigate once they happen," he says, adding that complications from medications are a common source of readmission.
The side effects of value
Roy Guharoy—vice president of clinical integration and chief pharmacy officer at Ascension, a health system in 24 states and the District of Columbia that has 137 hospitals and more than 30 senior living facilities—says he has been focused on lowering readmission rates through pharmacy since he assumed the CPO role three years ago. His primary goals have been to reduce the variances in pharmacy, improve processes, and improve patient outcomes.
Guharoy, who reports to Ascension's chief clinical officer, has worked with IT to create a medication management system within the EMR system for the pharmacy teams, and it is currently being rolled out to Ascension facilities across the country. Because Ascension has numerous EMRs, Guharoy says it will take six to eight months for the alert system to be at all facilities.
Alerts are based on algorithms that analyze patients' lab results, radiology tests, and other important data, detecting changes such as decreased kidney function. "You have to address that right away. If you wait another day or two, the patient's kidney could be gone and the length of stay goes up," he says. When the pharmacy team receives an alert, it instructs the patient's medical team in the ICU, emergency department, surgical units, or elsewhere what to do.
Pharmacists also are notified when a physician recommends a drug that varies from the organizational standard. "If our recommendation is different, we have a discussion with the physician," he says. Although pharmacy has received some pushback, "a majority of physicians have embraced" its heightened involvement, Guharoy says.
His team also studies medication-related deaths and gaps-in-care incidents within the system and across the country to ensure appropriate changes are made when necessary. For example, if a national journal publishes a report about how an IV drug compounded a certain way caused contamination and resulted in infections and hospitalization, Guharoy will direct internal pharmacists to change course.
Also, if a patient is getting multiple drugs for the same disease, the pharmacy team can help whittle it down to just one. "Some combinations of drugs can cause the heart rate to slow, which would lead to a readmission," he says.
"If not well managed, pharmacy drugs can cause a lot of harm," says Guharoy. "And despite how good a CMO is, there can be gaps," he says, pointing out that in a value-based care delivery model, gaps are unacceptable. "Pharmacists can easily fill those gaps and assist with patient care."
A binding agent
At Froedtert & the Medical College of Wisconsin, Todd Karpinski, PharmD, MS, FASHP, FACHE, became CPO of the regional health network in 2012. The system has three hospitals with 784-staffed beds, nearly 40,000 annual admissions, and more than 930,000 annual outpatient visits. Immediately, he restructured to have pharmacy teams at each facility report into him. "I think the biggest benefit of the CPO role and pharmacy realignment has been implementing best practices across the system. Instead of having to re-create best practices at each entity, we can share them," he says.
Like his peers, Karpinski has been able to standardize drug products and thereby reduce drug inventory. "We've been able to discover what drugs we are using and how we are using them."
Although he reports to a vice president, Karpinski has the support of senior executives to participate in executive-level strategy meetings that include the CEO, CMO, CNO,COO, and CFO. Having a seat at the executive table, which he says is more important than reporting structure, has enabled him to enact "innovative pharmacy practices at the bedside."
When a patient is admitted to the hospital, a pharmacist takes a detailed report of the patient's past and present medications, replacing the cursory review by nurses and physicians. "We know what drugs they are taking, what the dosage is, and how long they've been taking them," he says. "We continually reconcile that list with what they are put on at the hospital." Each hospital now has attending pharmacists who check in on patients throughout the week.
Karpinski says he is most excited about changes made at discharge. "Data shows that 31% of patients, when they leave the hospital, never take their medications, and this is a huge concern for us," he says. "We put them on medication so they don't have to come back to the hospital."
Pharmacists are dispatched to patients' bedsides at discharge to deliver medication, take payment, and review all drug instructions. They make sure that there are no duplications or unnecessary drugs. "We educate patients on their new drugs and let them know what can be stopped," he says. If patients can't afford medications, they are connected with a manufacturer assistance program or Froedtert's assistance program.
"Before this bedside program, only 9% of patients had their medications filled. Now that number is at 44%. We are aiming to get into the 60s," he says. He notes that not all patients can fill their prescriptions with Froedtert because of their insurance.
To ensure a large-enough pharmacy team to handle this new program, 12 full-time pharmacists were added. Karpinski has paid for these positions by demonstrating the value of medication management and the additional pharmacy revenue from prescriptions being filled on-site.
He says the program also has benefitted nurses and doctors who no longer have to be involved with that aspect of discharge. There was some concern, he says, that nurses would find the program an invasion of their territory, but instead they say the program helps them focus on their own expertise at discharge. "We've cut out the go-between" by allowing patients to have direct conversations with the pharmacist, he says.
Karpinski says large health systems need a CPO and that the CPO must be at the executive table. "Pharmaceuticals are becoming a huge part of the financial obligation of healthcare organizations, and these organizations are realizing the value that pharmacy brings," he says.
Using 3-D printing techniques, complex structures such as heart openings can be designed with such accuracy that implants work better and recovery from surgery is improved.
This article first appeared in the April 2016 issue of HealthLeaders magazine.
Three-dimensional printing in healthcare has received a lot of attention as a gee-whiz, futuristic technology, with photos of prosthetics for injured soldiers and children. But 3-D printing is about to get a whole lot more personal. Sophisticated imaging and modeling means that complex structures such as heart openings can be designed with such accuracy that implants work better and recovery from surgery is improved.
"3-D printing already is becoming more patient-specific, and that will continue. Instead of having different sizes that you have to fit the patient into, implants will be modeled from the patient's own anatomy," says Joseph Lipman, MS, director of device development at Hospital for Special Surgery in New York City. Physicians at HSS perform more than 29,000 surgical procedures annually.
The 3-D printing market is expected to reach more than $4 billion by 2018, according to a 2014 report by Visiongain, a London-based intelligence provider. Not only are the printers being used to customize medical implants but also the associated models, guides, and tools.
HSS uses stacked 2-D scans to create detailed 3-D images that can then be printed using ABS plastic. Use cases are increasingly sophisticated. For instance, a recent surgery involved a hip replacement complicated by bone that had grown around a previously implanted plate. The surgeon used a 3-D printed model to practice removing the plate to make the surgery more effective and efficient.
"Surgeons are tactile, and before we could only show them 2-D pictures and they'd have to create the 3-D image in their head," says Lipman, who collaborates with HSS' orthopedic surgeons on 3-D modeling and printing. "Now they have a 3-D physical object to give them a sense of scale and help visualize how to cut the bone and better align it."
As 3-D printers evolve in granularity and the materials they use, HSS has started experimenting with replacement joints for fingers, thumbs, and elbows—something that had been out of reach thus far because of the size and complexity of the joints. "We now can make the metal porous where we need it to be porous, enabling implants to affix better to the bone, change shape, and be smaller," he says.
Lipman says 3-D-printed models also will help surgeons to communicate better with patients. They can use the model to spark a conversation about expectations and to explain "tricky anatomy." The visual aid, he says, will help patients become more educated about their rehabilitation and lead to improved outcomes.
Heart openings
At Henry Ford Hospital's Center for Structural Heart Disease, 3-D printing is being squarely focused on the problem of repairing hearts of all shapes and sizes.
Center director William O'Neill, MD, FACC, says the center is printing customized models of each patient's heart to properly size new bioprosthetic valves, as well as devices used to seal off left atrial appendage occlusions. Typically, the devices come in a circular shape. But O'Neill says 3-D imaging reveals many of the heart openings they're designed to fit in are actually oval or other odd shapes. Incorrectly sizing the devices can lead to leaks, which, once detected, have to be sealed in another surgery.
By printing a model of the heart that matches the patient's anatomy and allows doctors to plan procedures in advance, follow-up surgeries can be avoided.
The project is currently in the pilot incubator stage, but O'Neill says he is confident it will become an important application for cardiac departments. "Sizing valves and deciding how to place them with 3-D images and models could be a mainstay," he says.
Bone reconstruction
David Dean, PhD, associate professor in the department of plastic surgery at The Ohio State University in Columbus, has been making use of 3-D printing for clinical cases since the late 1990s, studying how to print replacements for skull bone as well as the tools and guides needed to properly set them. Implants for the skull must be carefully designed because they could inadvertently pinch off arteries to the scalp or press on the brain and cause damage.
Today, through a grant from the Department of Defense Armed Forces Institute of Regenerative Medicine, Dean is focused on facial reconstruction, specifically for soldiers, including those injured by improvised explosive devices, or IEDs. "Craniomaxillo-facial injuries make up more than one-quarter of today's battlefield injuries," he says.
Dean 3-D prints porous, resorbable implants, which are then seeded with bone progenitor cells. Those cells are cultured in a way that results in a bonelike coating of the implant prior to its implantation. Once implanted, the body replaces the implant with bone. During the replacement process, the 3-D printed resorbable polymer fully resorbs in time for the bone to remodel itself, a necessary process if the bone is to become strong.
Dean's current research is focused on the lower jaw because the blood supply in the upper jaw is more challenging. This research is expected to go to clinical trial at the end of 2018.
Printing costs
While 3-D printing is decidedly the wave of the future, who will absorb the costs is not yet wholly decided. At Mercy Medical Center in Baltimore, Chief of Orthopedics Marc Hungerford, MD, MBA, has worked with the hospital's 3-D printing vendor to even out costs.
Mercy uses a qualified Boston-based factory to manufacture perfect matches of patients' knees using 3-D printing, along with kits of customized instruments to set them.
"We know the better an implant fits, the better it works," Hungerford says. "It's the difference between a tailored suit and an off-the-rack suit."
Though he says there is not enough data to support his theory yet, outcomes with 3-D-printed services should improve patient outcomes through a better fit after the implant.
Because the vendor charges the same amount for a custom-made implant as a traditional one, the hospital has approved the 3-D procedures. "If the implant was twice as expensive, the hospital would say no," he says. Knee replacements are a bundled service so implant costs are more or less expensive, but hospital reimbursement is fixed.
He says if custom-made 3-D implants ever prove to be of better quality and price than traditional implants, they could be mandated.
Some industry observers believe the prospect of better outcomes will resonate with employers who pay for bundled services. If recovery time drops by a week or two using customized implants, employers will consider them.
Becoming the better alternative
John P. Geibel, DSc, MD, AGAF, is Yale School of Medicine professor of surgery (gastrointestinal) and of cellular and molecular physiology. He says 3-D printing will become attractive to payers when they outpace the alternative, such as complicated transplants, expensive treatments, and recurring hospitalizations.
Geibel is researching how 3-D printing can be used to cure gastrointestinal conditions such as short gut syndrome, in which children are born with an intestinal malformation that prevents them from properly absorbing nutrients and secreting waste.
Currently these patients must receive complex and costly inpatient care to ensure proper nutrition and bowel movements. Although there are intestinal transplants that can be performed, they are rare—only about 100 are done every year, with 10,000 adults and children waiting for the procedure—and there are considerable complications, including rejection, he says.
Geibel aims to use the patient's own cells to print sections of their intestine as well as the infrastructure, or rods, to secure the implant in place once in the patient's body. If successful, short gut syndrome patients will be able to receive iterative intestinal implants that align with the child's natural growth cycle.
In 2014, Yale announced a collaboration with 3-D bioprinting technology maker Organovo to develop bioprinted tissues for surgical implantation research. Geibel's research strategy has been intentionally slow and methodical, with no end date marked out as of yet. Instead, he is creating incremental benchmarks, including printing smaller cylindrical items, such as blood vessels and arteries, to be studied in rats.
He says his cautious approach will be instrumental in showing payers the viability of 3-D printing. "We'll be able to prove that using the individual's own cells reduces risk of rejection and might eliminate the need for antirejection drugs, which have their own side effects." Also the cost comparisons will be persuasive, he says.
For instance, total parenteral nutrition, a common treatment for intestinal failure, can cost $100,000 to $200,000 a year. "As reagents get more expensive and patients require recurrent hospitalizations, that number jumps up," he says. "These patients cost an incredible amount of money to maintain." As 3-D printing costs decrease, implants, he says, will likely be less expensive than the alternative.
So although he expects insurance companies to initially consider 3-D implants "risky" and to be conservative in approval, ultimately, he says he expects them to understand the advantage to the patient and overall care costs.
Payers already recognize the value of 3-D printing, and that will only increase if the science is supportive, according to Geibel. "If you're getting into 3-D printing, move cautiously," he says.
Henry Ford Hospital's O'Neill says, "If you don't have a clinical use for 3-D printing, it will die out." However, he says he is confident that helping resolve cardiac issues will be just one of many applications that will keep the technology around.
