Healthcare Transformation 021115

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Healthcare Transformation: From Service Lines to Programs Michael N. Brant-Zawadzki, MD, FACR Executive Medical Director, Physician Engagement Executive Medical Director, Neurosciences Institute Hoag Memorial Hospital Presbyterian 1 Hoag Drive, PO Box 6100 Newport Beach, CA 92658 [email protected] (949) 764-5942 office (949) 764-6789 fax Jack L. Cox, MD, MMM Senior VP &Chief Quality Officer Hoag Memorial Hospital Presbyterian [email protected] Allyson Brooks, MD Executive Medical Director, Women’s Health Institute Hoag Memorial Hospital Presbyterian [email protected] Junko Hara, PhD Program Development and Scientific Advisor Orange County Vital Brain Aging Program [email protected]

Transcript of Healthcare Transformation 021115

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Healthcare Transformation: From Service Lines to Programs

Michael N. Brant-Zawadzki, MD, FACRExecutive Medical Director, Physician EngagementExecutive Medical Director, Neurosciences Institute

Hoag Memorial Hospital Presbyterian1 Hoag Drive, PO Box 6100Newport Beach, CA 92658

[email protected](949) 764-5942 office

(949) 764-6789 fax

Jack L. Cox, MD, MMMSenior VP &Chief Quality Officer

Hoag Memorial Hospital [email protected]

Allyson Brooks, MDExecutive Medical Director, Women’s Health Institute

Hoag Memorial Hospital [email protected]

Junko Hara, PhDProgram Development and Scientific Advisor

Orange County Vital Brain Aging [email protected]

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ABSTRACT

The Affordable Care Act (ACA) helped focus our country’s need for more effective and more cost-efficient care that

also improves the patient experiences - the so-called Triple Aim. One of that aim’s greatest challenges is the

ongoing fragmentation of providers. This is particularly true among specialists, but lack of integration also

exists at the primary care and specialized services interface. Traditional hospital and medical staff

organizations contribute to the un-coordination of patient care. Transformation of care delivery methods to

overcome this challenge is needed. We here describe our organization’s recent experience with a model for

achieving the Triple Aim in a variety of areas – some inpatient, some ambulatory – even community-based,

by creating programmatically driven infrastructure under an Institute umbrella. This may be a useful tactic

towards such transformation.

Introduction

Though often labeled as “healthcare reform”, the Affordable Care Act’s (ACA) major initial

impact has been on healthcare payment reform through re-structuring of the insurance model

(including a shift of some payer burden to patients). The ACA did provide direction towards

patient oriented, performance and cost accountable healthcare, but the tactics of transforming

healthcare delivery at the point of service remains a significant challenge for providers. The

ACA’s model of at risk primary care medical homes as the major management tactic of

healthcare delivery has been challenged by sub-optimal attention to the appropriate value of

specialized services [Ref 1, 2], with substantial “leakage” to non-aligned specialty services.

Clearly, closer teamwork amongst all providers, as well as the patient (now customer)

community, is needed.

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As Peter Drucker said, the most efficient organizations require well integrated specialists [Ref 3].

However, to date, specialized health care services have been largely fragmented, inefficient, and

in part for those reasons, excessively expensive. Their incentive has been volume rather than

value as many have stated, lacking true metrics of the latter. Incentives aside, most of the

expense of healthcare care resides in specialized services, as complex healthcare problems

require relatively expensive technology, dedicated facilities, and rely on more costly professional

expertise, because that requires years of training and financial sacrifice on the parts of the

providers. Yet specialized care is indispensable.

Methods: The Program Model

The program model is one solution to the challenge posed by the above realities. This model

integrates multidisciplinary specialists, focuses them on patient outcomes, and connects them to

the health care access and triage functions of primary providers. Organizations like the

Cleveland Clinic have pioneered this approach, and we have adapted it to a community hospital

setting. In our growing health system affiliation, the program concept has been piloted in our

hospital for the past 7 years. Our programs create and continually improve care pathways, each

care pathway focusing on a specific patient condition or disorder.

Historically, hospitals have been structured around internal operations, and for financial

accounting, as geographically functional units and cost centers (hospital “departments” - in the

non-academic sense). For instance, the emergency room, the angiography suite, operating room

suite, floor and intensive care nursing units, are “cost centers”. Aggregating operational units

(“cost centers”), such as the catheterization laboratory, the arrhythmia ablation suite, the cardiac

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operating room, the cardiac ICU and floor unit with the work of variably aligned cardiologists

and cardiac surgeons, has been termed a “service line”. Such units and service lines are

internally focused, and measured by process efficiency, contribution margin, and perhaps

transactional service satisfaction surveys of patients [Ref 4].

The program approach transcends the relatively short term orientation of this organization-

centric infrastructure, to one focused on the longer term interests of the patient and their payer

(increasingly the same entity). Programs measure the true value (outcomes/cost) of the health

care delivery process [Ref 5]. Programs expand administratively led and administratively

accountable service line entities to physician led, multidisciplinary teams accountable for process

efficiencies, financial, but most importantly clinical outcomes. It has been shown that physician

leadership is the key to improving quality [Ref 6-7]. As stated, each program focuses on a

specific patient condition, disease, or disorder. Our programs include a spectrum of very

common and basic conditions such as mother and baby (maternity), memory and cognitive

disorders in our aging population, to much more intensive diseases such as stroke, cardiac

valvular disease, cardiac arrhythmia, joint replacement, and a variety of organ specific cancer

programs (brain tumor, melanoma, etc.), as examples.

Programs themselves are aggregated based on commonality and overlap of organ structures

affected, and similarities of needed human as well as facility resources, under an “Institute”

umbrella. Thus, the stroke, brain tumor, memory and cognitive disorders programs are some of

the Neurosciences Institute’s programs. The Institute serves the executive function of strategy

development, resource procurement and allocation, and value monitoring. The Institute

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coordinates the common resources used by the programs (imaging technology, nursing floors,

information systems, etc.), and marshals support from finance, IT, marketing, philanthropy, and

other non-clinical but mission critical components of the organization (Figure1). Representatives

from each support department participate in the regularly scheduled institute and program

leadership committee meetings ad hoc.

Coordination and cross-integration is essential. For example, a patient in the brain tumor

program may develop seizures requiring close coordination of their care with the epilepsy

program. A new mother in the Women’s Health Institute’s maternity program may develop

post-partum depression requiring the services of the Neuroscience Institute’s neurobehavioral

program. Critical to such integration is the presence of nurse navigators, each patient having

access to a navigator who coordinates care amongst the various services provided throughout the

entire organization, linking the in-patient and out-patient continuum. The navigators also lead

the programs’ clinical metrics management, including aggregation of outcome data.

Programs deliver community education, as well as continuing education of providers, and

manage relevant clinical research projects. They are the engine of care innovation and also a

magnet for philanthropy.

Results: Case studies.

Stroke Program: In 2003, our “stroke service line” was marginal, and lagged in providing

evidence-based or even organized care for stroke patients. The numerous private community

general neurologists were hamstrung by their off-site location and demands of office patient

practice. They couldn’t respond rapidly enough given the evolving guidelines in management of

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acute ischemic stroke. Lack of specialized stroke experience lowered their comfort level with

anticoagulants and the emerging use of intravenous thrombolytic therapy on-call after hours.

Likewise, neurosurgical availability for acute hemorrhagic stroke with limited. Though there

was a foundation of advanced neuroimaging and intra-arterial neurointerventional capability for

treatment of stroke and aneurysms, the general neurologists did not utilize those resources well.

The various operational units (emergency department, intensive care unit, nursing floor) were not

organized around, or focused specifically on stroke patients. As a result, there was a low

utilization of then evidence-based intravenous thrombolytic therapy with only a handful of

patients receiving the treatment annually. The complication rate for such therapy was above the

study group rate as published in the NIDS trial [Ref 8]. Length of stay and costs for treating

stroke patients, who were housed throughout the hospital with non-specialized nurses were

above national benchmarks. Patient and family dissatisfaction was high. No process metrics or

clinical outcomes were available.

The needed transformation to programmatic change started with the recruitment of a dedicated

stroke neurologist as the program director with support for his administrative time, and creation

of a services agreement that facilitated attracting a team of neurohospitalists, (one of the first in

the region). The team began creating evidence-based order sets for ischemic stroke that targeted

the emergency department and a nursing floor, where initially 8 beds (now 20) were dedicated as

the “stroke unit” with designated nursing staff. Evidence-based clinical pathways for ischemic,

intracerebral, and subarachnoid hemorrhagic strokes were created. Standardized order set

protocols provided guidelines with inclusion and exclusion criteria for intravenous

thrombolytics, aiding community neurologists who still participated in after hour and weekend

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stroke call. Education also targeted ED and intensive care physicians. Advanced CT techniques

including CT angiography and perfusion were standardized, aiding rapid interpretation by

neuroradiologists to speed triage of patients, including protocol directed intra-arterial

revascularization for eligible patients.

Examples of tactics in the program include the critical development of the “Code 20” flow

process (Figure 2), aimed at obtaining a comprehensive CT angiographic and perfusion analysis

within 20 minutes of documented symptom onset (both for patients brought into the ED and in-

house stroke onset patients). This required the creation of a “Stoke Swarm” of designated

individuals in the ED, and also on the floors for in-patient stroke onset. Daily interdisciplinary

“huddle” rounds were initiated in the stroke unit. Focused care pathway education for nurses,

with specific components such as NIH stroke scale evaluation, dysphagia screening, sleep apnea

screening, etc., was instituted. Physical therapy was initiated on day one. Patient and caregiver

education booklets specific to the patients risk factors and diagnosis were developed. The local

county emergency medical services teams were educated raising awareness of rapid transport, a

major factor in stroke rescue. Local interaction with emerging teams in nearby hospitals with

stroke care capabilities created leadership advocacy that lobbied the Orange County supervisors

for the creation of a county-wide comprehensive stroke receiving center network, our hospital

being a founding member.

Our program now sees over 800 stroke patients annually, a volume facilitating the program’s

high level care as well as clinical research activities (which are served by 2 dedicated

neurosciences clinical research coordinators), including involvement in several NIH trials. The

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continuing quality improvement of the stroke program is guided by the Stroke Process

Improvement Team (SPIT) which is interdisciplinary, manages process performance, conducts

peer review, and oversees protocol evolution. The SPIT group includes physicians from the

various operational units including ED, intensive care, and neuroradiology, and also social work,

case management and physical therapy representatives. The team meets monthly, with a stroke

steering committee subcomponent meeting weekly. The “Get with the Guidelines” metrics of

the American Heart Association are now strictly observed. The stroke program also includes

public education of stroke awareness, including a recent “Strike Out Stroke” event at Angel’s

Stadium (Anaheim, CA). Routine follow up in the stroke clinic is arranged. More recently, with

the expansion of our hospital to a second facility in Irvine, CA, telemedicine has been adopted

with a stroke robot interfacing the acute stroke neurologist either from the flagship hospital or

home (after hours), allowing extension of the stroke program’s capabilities to that facility, which

now too has a small stroke unit.

The current quality “scorecard” of the stroke program is demonstrated in figure 3. Our average

door to CT scan time for acute stroke patients is now 16 minutes. Over the last measurement

year, 100% of patients eligible (by guidelines) to receive intravenous thrombolytic therapy got it

(this is much higher than in previously reported community trials). Patients are routinely placed

on guideline directed medications, including antiplatelet and statin therapy. Most importantly,

our program measures the clinical outcomes of patients at 30, 60 and 90 days. 63% of our

patients return to self-sufficiency at 90 days (modified Rankin score – a standardized metric – of

0-2). The mortality rate for ischemic stroke is 0.55 versus a CMS expected mortality of 5.46%.

The average length of stay is superior to expected, at 3.4 days. The average cost per discharge

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has been driven below to $7,700. Patient satisfaction exceeds 95%. Perhaps reflecting the

community’s acceptance of its partnership role in improving the quality of their health care, and

the documentation of our results, philanthropy for the program has flourished into eight figures.

The program’s efforts and quality achievements have been recognized with numerous awards,

most recently the Gold Plus Award from the American Heart Association, Stroke Care

Excellence Award from Healthgrades (ranking our program #1 in Orange County, and in the

country’s top 5%), and it has achieved mention in national publications, including U.S. News

and World Report. Our next challenge is the creation of a post-acute physical rehab unit on our

campus, as that critical component of stroke recovery is currently out-sourced. This missing

piece prolongs in-patient length of stay, and detracts from patient and family satisfaction with

our services.

Mother and Baby: Maternity is a health condition, not a disease or disorder in most cases,

which makes it somewhat different than other programs. It resides in the Women’s Health

Institute, along with other programs like Breast Care, Gynecological Oncology, etc. A major

interface to our community, the maternity experience has a major impact on our reputation and

referral patterns for other health care needs. Thus the programmatic strategy became critical.

Originally, the maternity “service line” consisted of 52 independent private practice obstetricians

(OBs) competed for patients, caring for common obstetrical conditions and complications such

as preeclampsia, preterm labor, premature rupture of membranes, etc. All OB patients stayed on

a single unit regardless complexity, their evaluation and care coordination predominantly

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provided by OB designated nursing staff, aided by primary OB phone consults and outpatient

based perinatologists when needed - as available by office schedule. Pay for night call was

provided to any willing individual OBs. Evidence-based pathways were lacking. Care was

physician centric. “Convenience” inductions of labor and elective primary cesarean sections

were commonly scheduled. Wide variation in length of stay for routine deliveries, induction

rates, cesarean section (CS), vaginal births after CS (VBAC) rates, and cost-per-discharge were

unexplained by patient acuity.

Programmatic transformation started with recruitment of an integrated hospital-based OB

intensivist group, allowing immediate consultations for acute OB conditions, both maternal and

fetal. As the group leadership and its relationship with the community OBs matured, co-

management of perinatal patients in the ICU evolved, and nursing education blossomed

including emergency simulation drills, and multidisciplinary labor and delivery rounds were

instituted with nursing and care planning with pharmacist, nutritionist, respiratory/physical

therapist. Educational seminars with ED, ICU and Hospitalist care teams, also started. The in-

house group then expanded to provide emergency and after hour laborist services as well.

Additional innovations included: Creation of separate 14-bed antepartum unit: Implementation of

a licensed 4 bed OB emergency department: Development of condition-specific order sets and

clinical pathways for emergencies like fetal heart rhythm deceleration, and maternal hemorrhage:

Participation in a risk-sharing ACO with a maternity goal to reduce cesarean section rate, LOS

and cost-per-discharge: Offering of advanced remote patient care monitoring and expanded use

of tele-health technology. Program coordination with our outpatient Diabetes Center for optimal

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management of gestational and type I diabetics and creation of a Maternal Fetal Board to

develop antepartum care pathways for complicated obstetrical cases occurred. Routine maternal

education (e.g. Waiting for Baby video) and support, post-discharge phone calls, and satisfaction

surveys were developed.

The program now represents a large proportion of in-patient activities, is growing despite a

regional declining birth rate in OC, with over 6000 deliveries and 450 NICU babies per year; it

partners with Children’s Hospital of Orange County for higher levels of care. The leadership

team continues to monitor the flow process, to refine evidence based care pathways for simple as

well as complicated deliveries, and to select best-practice benchmarks for measuring processes

and outcomes while searching for innovative solutions to drive down the cost of care, as

financial metrics are in its scope of management. A portion of the “scorecard” for the program,

which embraces the triple aim is shown in figure 4.

The reduction of CS and episiotomy rates, and the rising rates of vaginal deliveries after CS

represent desirable outcomes engineered by the team. Numerous other process and outcome

metrics are routinely followed by program and Institute leadership. The program spans the

continuum of care service lines from wellness and prevention, through acute care and

procedural/surgical services to post-acute care and primary care hand-offs. The multidisciplinary

approach includes primary care physicians, obstetricians, laborists, neonatal care r67iririand

primary care pediatricians, as well as affiliated caregiver staff. Accolades include the Women's

Choice Award for Obstetrics and Patient Experience 2011-2014, and inclusion in Becker's Top

100 for Women's Services.

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Memory and Cognitive Care Program: The decision to develop a memory and cognitive

program within the Neurosciences Institute was driven by the looming epidemic of age-related

cognitive disorders in our country. Every day, 10,000 Americans turn 65, and the prevalence of

cognitive impairment including Alzheimer’s dementia (AD) in those individuals is

approximately 1 in 8 [Ref 9, 10]. Indeed, the prevalence of all memory disorders in this age

group (including reversible ones due to depression, medication side effects, etc.) is

approximately 1 in 4 [Ref 11,12]. The cost of care for a Medicare recipient is 3 to 4 fold higher

when dementia is present [Ref 12, 13]. Such financial, as well as societal and individual quality

of life issues compelled us to create a programmatic strategy based in the out-patient community

setting.

Initially, a neurologist was recruited, one with research expertise and a passion for age-related

cognitive disorders, who shared our vision for a populational, community based approach to the

problem. Almost immediately, the clinical practice of the program mushroomed, and the need

for involvement of community primary care physicians and general neurologists to handle

demand became obvious. An advisory panel of interested community neurologists and primary

care physician leaders was convened to help guide strategy. The vision of a multidisciplinary

team with skills in neuropsychology, social work, informatics, grant administration, and clinical

research was supported initially by philanthropy of grateful patients. A grant proposal was

generated focusing on community primary care physician education, creation of care pathways,

and triage tools for management of patients with mild to moderately advanced cognitive

disorders, and creation of a patient portal. The UniHealth Foundation awarded the program 6

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years of funding for a project based on an aspirational road map of the Leon Thal Symposium

[Ref 14-17] to prevent dementia (a paradigm for the Obama administration’s subsequent

National Alzheimer’s Project Act of 2011- Public Law 111-375). Thus the “Orange County

Vital Brain Aging Project” was born, and a resource rich web portal established for the

community and physicians (www.ocbrain.org).

Through the program, primary care and other physicians are taught best practice in standardized

memory testing yearly (Medicare now mandates testing of cognition with the annual physical).

The team selected an easily administered, validated, highly sensitive test differentiating

abnormal memory impairment from the normal memory alteration of aging [Ref 18-19].

Physician and office staff are offered support to test properly, and for appropriate triage of

abnormals. A major component of the educational effort was the aggregation of literature-based

behavioral and lifestyle prevention guidelines aimed at the 3 in 4 individuals who test normal. A

formal set of evidence-based directives for appropriate blood tests and other diagnostics in the

minority who test abnormal was incorporated into a booklet created by the program director and

the advisory panel, as were the appropriate guidelines for combination drug therapy once the

diagnosis of AD is established [Ref 20-21]. Collaboration with advocacy and support groups,

e.g. Council on Aging, Alzheimer’s Association, is active.

The program combats the nihilism around AD, including the notion “nothing can be done, so

why bother screening?”, alleviates anxiety in 3 of four who test normal, aims to reverse memory

impairment from treatable causes (e.g. depression, medication side effects), and plans to verify

that early behavioral interventions combined with appropriate use of medication can delay the

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onset or progression of early AD – a potentially successful approach studies are beginning to

support [Ref 22-23]. To document cost savings through such interventions, the program is

collaborating with our at-risk primary care group to gather data. Also, the program facilitates

meaningful clinical research in potentially efficacious emerging diagnostics and therapies.

Over the past 5 years, the program produced 43 Continuing Medical Education (CME) lectures,

for over 1,000 Orange County primary care physicians. A new grant is funding a web-based

CME module for physicians. Seventy five community lectures have been provided as of this

writing, with over 12, 000 individuals educated about healthy brain aging. Over 3,500 self-

referred individuals have been screened through testing provided by the program’s employees in

senior centers, community centers, throughout our region. An additional 13,000 memory

assessments have been performed in the offices of affiliated physicians. A “brain fitness class”

is available to those with early mild cognitive impairment. Ten active clinical research trials o

evaluating new pharmaceuticals and imaging techniques are running. Cross institute

partnerships have developed, for instance a project on cancer and cognition targeting “chemo

brain”, and another to better manage and reduce post-operative delirium in older patients

undergoing orthopedic surgery by identifying cognitively at-risk patients.

The up-front financial benefits of this program are relatively minor for our organization. It is

difficult to account for the elimination of unnecessary brain imaging in those individuals worried

about memory loss who were previously administered costly examinations such as MRI

inappropriately. The down-stream savings could be significant [Ref 12]. Given that 3 of 4

concerned individuals screened test normal, considerable diagnostic expense may be eliminated.

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Lowering hospitalizations when impaired patients remember (or are reminded) to take

appropriate medications for mild infections, their diabetes or hypertension as directed is a goal.

Optimizing the ability to remain at home instead of institutionalization by adhering to behavioral

tactics such as exercise, social habits, and healthy diets, are also a part of the program’s targeted

cost benefit research.

Discussion

The above three case studies were selected from our spectrum of highly procedural to out-patient

continuum of care programs, illustrating their design, strategy and deliverables to date. Over

65% of our hospital organization’s revenues now flow through the institute/program

infrastructure, a number that has grown over time and will increase further as new institutes

stand up (a Digestive Disorders Institute is being added to the existing Neurosciences, Women’s

Health, Cancer, Heart and Vascular, and Orthopedic ones). The financials are but the by-product

of the “why” – the sustainable delivery of integrated specialized services coupled to the

continuum of care from prevention and wellness, through episodic acute care, to chronic disease

management. That coordinated continuum of care is facilitated through the programmatic team

approach we champion - one that intertwines focused specialized services with the primary care

providers, while delivering demonstrably superior value from the patient’s perspective.

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