As the hospital industry enters its second year since the passage of the Patient Protection and Affordable Care Act, more organizations have accepted or are beginning to implement the law's principles and philosophies. Terms like "team-based care" are no longer considered unorthodox. Certain signs of poor performance, such as unnecessary readmissions, have more stringent financial implications. Transparency and highly-informed consumers mean more patients want a larger role in their health, treatment and hospital experience.
All of this means hospitals that are open to innovation in care delivery may be those same hospitals that are more relevant and trusted among patients.
Jason Hwang, MD, MBA, an internal medicine physician and executive director of healthcare at non-profit think tank Innosight Institute, describes in a report "Disruptive Innovation in Integrated Care Delivery Systems" eight care delivery initiatives that hospitals can focus on in 2012.
These goals are interconnected and can help hospitals become more comprehensive anchors of health in their communities with improved access, quality, efficiency and reduced cost.
1. Move care into venues that emphasize convenience, such as retail clinics, patient homes and virtual visits. While this strategy is often discussed for its financial rewards, Dr. Hwang says multi-faceted care delivery is more about patients being able to choose what works best for their lifestyle. "The ultimate goal is not the cost shift," says Dr. Hwang. "It's about giving patients a choice on what venue is most appropriate for them." Dr. Hwang said research showed the venue didn't necessarily have to be cheaper for the patient — it just had to be their most preferred option.
2. Use care teams and allied health personnel like case managers to help prevent the costliest episodes of care, including unnecessary readmissions. The concept of team-based care has been emphasized much more in recent years due to patient-centered medical homes. When hospitals operate under this philosophy, members of the care team do not only serve as assistants but more as "associate decision-makers," says Dr. Hwang. "This requires organizations to accept the fact that allowing every person to practice at top of their licensure is a good thing. Given all these concerns about malpractice, there's a tendency to move in the opposite direction and clamp down on who is practicing what," says Dr. Hwang.
When moving towards team-based care, hospitals should ensure they have the proper tools and technology so nurses and physician assistants can take on more responsibility. Dr. Hwang mentioned some successful models he's seen, where nurses do not merely take phone calls and messages, and then relay them to the physician. "Instead, the nurses are privy to the same data and information the physicians see. They can answer patients' questions to the best of their ability. Then, complex questions still go to the physician, but the nurse can help," says Dr. Hwang.
3. Build connections across the continuum of care that improve chronic disease management and care transitions, such as better coordination among primary care, hospitalization and post-hospital care. Any point where a patient's care transitions between providers is a significant source of problems. "One of the most critical transitions is from the hospital to the home," says Dr. Hwang. To improve this weak spot in the continuum of care, healthcare systems can form transition teams or develop a model that focuses on inpatient and post-hospitalization care simultaneously.
This is especially a concern given the focus on 30-day readmission metrics under the Patient Protection and Affordable Care Act. In Oct. 2012, hospitals with high readmission rates will face penalties of 1 percent of their total Medicare billings. The penalty increases to 2 percent the following year. "This is an example where legislative change has sparked a lot of innovation," says Dr. Hwang.
4. Allow caregivers to focus more effort on sicker patients. This can be accomplished by allotting longer visit times for sicker patients, adjusting physician productivity measures and using e-visits or nurses to help care for patients who are less sick. Related to the third point, providers should make the most of their licensure and take on tasks that are appropriate to their level of training. For instance, certain conditions or diseases classified as "precision medicine" should be treated by non-physician providers, according to Dr. Hwang.
"These are areas where the disease can be precisely identified, and there is a reliable and simple therapy to offer for it — like strep throat," he says. This condition is easily diagnosed with a test and the results are easy to interpret. Non-physician providers would also need to be trained to recognize when a case resembles one condition (like strep) but is actually something else (like epiglottitis).
When non-physicians handle conditions that fall under simple "medical algorithms," physicians are able to spend more time with their sickest patients. Increased physician-patient time may help avoid an unnecessary readmission or patient confusion about post-hospitalization treatment.
5. Cultivate a shared belief in evidence-based medicine. This can be accomplished with organizational support for adopting clinical guidelines, monitoring outcomes and promoting continuous improvement. "There's a knee-jerk reaction that 'best practices' mean the conversion of patient treatment into a factory assembly line," says Dr. Hwang. "What I learned in business school is that standardization doesn't mean you do the same thing every time. It permits and even encourages you to experiment." Hospitals should dispel these doubts and help physicians and medical staff feel empowered through evidence-based medicine, not tied down.
For instance, hospitals can encourage providers to follow protocol, but anytime physicians veer from it, they should record the outcome so the system can learn from it as a whole. "If we start to see patients benefit from that variance, we can learn from it. Otherwise everyone is off doing their own thing and the system can never improve," he says.
6. Leverage information and decision tools that can improve quality or lower costs. Hospitals should focus on the way EHRs and other HIT tools are perceived and used in the organization. For example, some people think EHRs are tools to simplify work flow within the existing system. The full potential of the tool goes unrealized when hospitals do not utilize EHRs to add value.
"EHRs can't be seen only as more efficient billing machines," says Dr. Hwang. "It also can't be seen as the modern equivalent to a file cabinet." Instead, hospitals should promote these tools for population health management and trend analysis. For instance, Dr. Hwang mentioned a hospital system that used its EHR system to track and identify the linkage between an analgesic and increased heart attacks. The same drug was later pulled by the FDA, but months after the hospital had already stopped using it.
7. Shift from fee-for-service to value-based payment models. Hospitalizations and emergency care should not be revenue opportunities, but rather costs to be avoided. "Most hospitals work this way: they view the volume of care provided, or what's known as intensity, as a prime driver of revenue that keeps them in business," says Dr. Hwang. Since integrated systems are paid under a different model, it changes the hospital's perspective as well as how clinicians worked. "If you pay a provider through some form of a capitated model or bundled payment that emphasizes value, you still focus on quality care but [are] also [more conscious of the] bottom line," says Dr. Hwang.
8. Engage and incentivize patients to take healthcare out of the exam room. Hospitals can do tis through wellness programs, rewards for maintaining specific health goals and online tools to support wellness. If hospitals are to become the anchors of health in their communities, they need to follow through in this role and help patients adopt a proactive approach to their own health management. "There are a lot of barriers to good health," says Dr. Hwang. New tools have made it much easier for providers to identify and address these barriers.
For instance, Dr. Hwang mentioned a health system whose EHR alerted them to a patient that had frequently missed oncology appointments. The patient later explained she couldn't drive and she couldn't afford a taxi to her appointments. "That was a barrier that had nothing to do with healthcare, yet was clearly impeding it. So the system had to figure out a way to help her with transportation, and the sustainable solution was to form a network of drivers among their patient population," says Dr. Hwang.
Hospitals can also give patients a more participatory role in their healthcare. "Don't ignore the patients' role," says Dr. Hwang. "That doesn't mean every patient is qualified, but the choice should be available. The care is invariably better when I have an engaged patient who knows a lot about their personal disease." This type of relationship can lead physicians and patients to tailor health plans to the patient's lifestyle. "That's much better than seeing a patient every few months and making recommendations they don't follow," says Dr. Hwang.
From Treating the Sick to Managing Community Health: Hospitals' New Role in Managing Population Health
Believing in Quality Care and Delivering it: How UPMC Has Mastered Both
All of this means hospitals that are open to innovation in care delivery may be those same hospitals that are more relevant and trusted among patients.
Jason Hwang, MD, MBA, an internal medicine physician and executive director of healthcare at non-profit think tank Innosight Institute, describes in a report "Disruptive Innovation in Integrated Care Delivery Systems" eight care delivery initiatives that hospitals can focus on in 2012.
These goals are interconnected and can help hospitals become more comprehensive anchors of health in their communities with improved access, quality, efficiency and reduced cost.
1. Move care into venues that emphasize convenience, such as retail clinics, patient homes and virtual visits. While this strategy is often discussed for its financial rewards, Dr. Hwang says multi-faceted care delivery is more about patients being able to choose what works best for their lifestyle. "The ultimate goal is not the cost shift," says Dr. Hwang. "It's about giving patients a choice on what venue is most appropriate for them." Dr. Hwang said research showed the venue didn't necessarily have to be cheaper for the patient — it just had to be their most preferred option.
2. Use care teams and allied health personnel like case managers to help prevent the costliest episodes of care, including unnecessary readmissions. The concept of team-based care has been emphasized much more in recent years due to patient-centered medical homes. When hospitals operate under this philosophy, members of the care team do not only serve as assistants but more as "associate decision-makers," says Dr. Hwang. "This requires organizations to accept the fact that allowing every person to practice at top of their licensure is a good thing. Given all these concerns about malpractice, there's a tendency to move in the opposite direction and clamp down on who is practicing what," says Dr. Hwang.
When moving towards team-based care, hospitals should ensure they have the proper tools and technology so nurses and physician assistants can take on more responsibility. Dr. Hwang mentioned some successful models he's seen, where nurses do not merely take phone calls and messages, and then relay them to the physician. "Instead, the nurses are privy to the same data and information the physicians see. They can answer patients' questions to the best of their ability. Then, complex questions still go to the physician, but the nurse can help," says Dr. Hwang.
3. Build connections across the continuum of care that improve chronic disease management and care transitions, such as better coordination among primary care, hospitalization and post-hospital care. Any point where a patient's care transitions between providers is a significant source of problems. "One of the most critical transitions is from the hospital to the home," says Dr. Hwang. To improve this weak spot in the continuum of care, healthcare systems can form transition teams or develop a model that focuses on inpatient and post-hospitalization care simultaneously.
This is especially a concern given the focus on 30-day readmission metrics under the Patient Protection and Affordable Care Act. In Oct. 2012, hospitals with high readmission rates will face penalties of 1 percent of their total Medicare billings. The penalty increases to 2 percent the following year. "This is an example where legislative change has sparked a lot of innovation," says Dr. Hwang.
4. Allow caregivers to focus more effort on sicker patients. This can be accomplished by allotting longer visit times for sicker patients, adjusting physician productivity measures and using e-visits or nurses to help care for patients who are less sick. Related to the third point, providers should make the most of their licensure and take on tasks that are appropriate to their level of training. For instance, certain conditions or diseases classified as "precision medicine" should be treated by non-physician providers, according to Dr. Hwang.
"These are areas where the disease can be precisely identified, and there is a reliable and simple therapy to offer for it — like strep throat," he says. This condition is easily diagnosed with a test and the results are easy to interpret. Non-physician providers would also need to be trained to recognize when a case resembles one condition (like strep) but is actually something else (like epiglottitis).
When non-physicians handle conditions that fall under simple "medical algorithms," physicians are able to spend more time with their sickest patients. Increased physician-patient time may help avoid an unnecessary readmission or patient confusion about post-hospitalization treatment.
5. Cultivate a shared belief in evidence-based medicine. This can be accomplished with organizational support for adopting clinical guidelines, monitoring outcomes and promoting continuous improvement. "There's a knee-jerk reaction that 'best practices' mean the conversion of patient treatment into a factory assembly line," says Dr. Hwang. "What I learned in business school is that standardization doesn't mean you do the same thing every time. It permits and even encourages you to experiment." Hospitals should dispel these doubts and help physicians and medical staff feel empowered through evidence-based medicine, not tied down.
For instance, hospitals can encourage providers to follow protocol, but anytime physicians veer from it, they should record the outcome so the system can learn from it as a whole. "If we start to see patients benefit from that variance, we can learn from it. Otherwise everyone is off doing their own thing and the system can never improve," he says.
6. Leverage information and decision tools that can improve quality or lower costs. Hospitals should focus on the way EHRs and other HIT tools are perceived and used in the organization. For example, some people think EHRs are tools to simplify work flow within the existing system. The full potential of the tool goes unrealized when hospitals do not utilize EHRs to add value.
"EHRs can't be seen only as more efficient billing machines," says Dr. Hwang. "It also can't be seen as the modern equivalent to a file cabinet." Instead, hospitals should promote these tools for population health management and trend analysis. For instance, Dr. Hwang mentioned a hospital system that used its EHR system to track and identify the linkage between an analgesic and increased heart attacks. The same drug was later pulled by the FDA, but months after the hospital had already stopped using it.
7. Shift from fee-for-service to value-based payment models. Hospitalizations and emergency care should not be revenue opportunities, but rather costs to be avoided. "Most hospitals work this way: they view the volume of care provided, or what's known as intensity, as a prime driver of revenue that keeps them in business," says Dr. Hwang. Since integrated systems are paid under a different model, it changes the hospital's perspective as well as how clinicians worked. "If you pay a provider through some form of a capitated model or bundled payment that emphasizes value, you still focus on quality care but [are] also [more conscious of the] bottom line," says Dr. Hwang.
8. Engage and incentivize patients to take healthcare out of the exam room. Hospitals can do tis through wellness programs, rewards for maintaining specific health goals and online tools to support wellness. If hospitals are to become the anchors of health in their communities, they need to follow through in this role and help patients adopt a proactive approach to their own health management. "There are a lot of barriers to good health," says Dr. Hwang. New tools have made it much easier for providers to identify and address these barriers.
For instance, Dr. Hwang mentioned a health system whose EHR alerted them to a patient that had frequently missed oncology appointments. The patient later explained she couldn't drive and she couldn't afford a taxi to her appointments. "That was a barrier that had nothing to do with healthcare, yet was clearly impeding it. So the system had to figure out a way to help her with transportation, and the sustainable solution was to form a network of drivers among their patient population," says Dr. Hwang.
Hospitals can also give patients a more participatory role in their healthcare. "Don't ignore the patients' role," says Dr. Hwang. "That doesn't mean every patient is qualified, but the choice should be available. The care is invariably better when I have an engaged patient who knows a lot about their personal disease." This type of relationship can lead physicians and patients to tailor health plans to the patient's lifestyle. "That's much better than seeing a patient every few months and making recommendations they don't follow," says Dr. Hwang.
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Believing in Quality Care and Delivering it: How UPMC Has Mastered Both