Emerging Strategies for Improving Hospital Medicine
Improving efficiency, patient safety, metrics and satisfaction Improving communication among the patient’s community of caregivers Your Presenters
Francisco Loya, MD CEO, EmCare Hospital Medicine
Mark Hamm, MBA Executive Vice President Corporate Development
2 Where to start?
"The future is already here – it's just unevenly distributed."
Attributed to William Gibson
Renowned cyberpunk science fiction writer. http://quoteinvestigator.com/2012/01/24/future-has-arrived/ 3 Emerging Roles for Hospital Medicine
Hospitalist involvement in pre-op Utilization APPs / preparation management Scribes Telehealth
Post-acute Marketing Mobile care and and Integrated transitional community Health care relations management
4 Trend Cycle
Normalize New Force •The trend becomes • Expectations the new status quo • Regulations • Discoveries • Industry influences • New competitors
Adjust Change • Fine tuning and New requirements adopting new • Consumer, patient, processes payors • Or overturned • Clinician, hospital • Support services React • Development of new mindsets, processes and tools • Backlash 5 State of Hospital Medicine Report
Quinn, R. (2014, October 13). New State of Hospital Medicine Report Offers Insight to Trends in Hospitalist Compensation, Productivity . Retrieved from The Hospitalist: http://www.the-hospitalist.org/article/new-state-of- 6 hospital-medicine-report-offers-insight-to-trends-in-hospitalist-compensation-productivity/5/?singlepage=1 Key Influencers
Value-Based Purchasing and Technology Bundled Payments
7 Expect to See…
Clinical Increased integration and pressure from collaboration will the growing no longer be demands of optional and VBP. hospitalists are pivotal.
Coordination of Technology- post-acute care based tools may will become a be the key to key driver of improving financial results operational for hospitals. efficiency.
8 Expectations for Value-Based Purchasing
Effective health care services and
high-performing health care providers are
rewarded“ with improved reputations through public reporting , enhanced payments“ through differential reimbursements , and increased market share through purchaser, payer, and/or consumer selection. ̶ http://www.nbch.org/Value-based-Purchasing-A-Definition
For an acute care hospital, this means up to a 2%
9 reduction in every Medicare Part A payment! Expectations for Population Health
“the iterative process of strategically and proactively managing clinical and financial opportunities to improve health outcomes and patient engagement, while also reducing costs.” - Influence Health
Improved Health
Lower Costs
Better Care
10 Hospitals will compete by providing value.
11 Hospital Medicine: Addressing the Challenges of Hospital Executives The Role of Hospital Medicine in Addressing Your Challenges
13 Expansive Impact
Hospital Medicine
Clinical Care Service Operations Cost
Care Delivered Satisfaction Throughput Total Fixed & Variable • Care quality • Patients • Care management • Cost per case • Outcomes • PCPs • Reduce delays • Length of stay • Length of stay • Surgeons • Improve turnover • Post-acute care • Readmissions • Staff • More services for • HCAHPS • Preventable • Hospitalists patients and referrers • MSPB complications • Administration • BPCI
14 VBP
15 Hospital Public Reporting: HospitalCompare.hhs.gov
Facility address
Survey of Patient Experience
Timely and Effective Care
Complications
Readmissions and Deaths
Use of Medical Imaging
Payment and Value of Care
• Medicare Spending per Beneficiary (MSPB)
16
Sources: www.hospitalcompare.hhs.gov, https://www.medicare.gov/hospitalcompare/search.html and https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment- Instruments/HospitalQualityInits/HospitalCompare.html Rapidly Changing Environment Value Based Purchasing program measures are represented in soon to be five different categories:
Incentive Payment 2%
1.75% 15% 1.5% 25% 1.25% 25% 20% 1% 25% 30% 40% 25% 30% 30%
30% 25% 25% 70% 45% 20% 10% 10%
FY 2013 FY 2014 FY 2015 FY 2016 FY 2017
17 Clinical Process of Care Patient Experience of Care Outcome Efficiency Safety Coordinated transition to post-acute setting Current Value-Based to decrease 30 day readmits
Open communication with PCP & home Purchasing Measures health providers
Judicious use of LTACH/SNF to control HM participates in entire patient post-acute cost experience
Studer training to enhance patient 25% 25% Accurate Inpatient Documentation improves communication with physician Risk Scoring and hospital CMI Patient Efficiency Scripted communication for Pain Control Experience Domain PNA: PSI Scoring and rapid time to Careful review of discharge antibiotics. Careful screening for information with patient or caregiver vaccination. Counseling.
VBP MI: Aggressive ant-platelet/beta- blocker/ACE-I use. Close coordination with ED and Cardiology to decrease time to PCI. Protocol-driven 10% 40% Counseling. Process Outcome Nearly 100% on HM specific of Care HF: Aggressive beta-blockers/ACE-I/anti- measures Measures arryrthmics. Counseling. Mandatory CME if measures falls below benchmark Review of all deaths that fall within measures
Pt Safety Indicators: CME on Skin examination to prevent decubitus 18 ulcers/monitoring of post-op hemorrhage, sepsis, and wound management. Bundled Payments for Care Improvement (BPCI) Initiative
Seeking an antidote to expensive, fragmented care with minimal coordination across settings
Experiment to see if bundled payments can Goal: Higher quality, align providers, reduce better coordinated care, CMS expenditures and lower cost to Medicare preserve or enhance care
Requires cooperative Based on episodes of arrangements for payment, care (Examples: AMI, financial and performance Chest pain, COPD, CHF, Stroke, Sepsis) 19 accountability
Source: http://innovation.cms.gov/initiatives/bundled-payments/ Medicare Spending Per Beneficiary (MSPB) Episode of Care 3 Days PTA Hospital Stay 30 Days Post Discharge
Home Heath Agency Home Heath Agency Home Heath Agency
Hospice Hospice Hospice
Inpatient Inpatient Inpatient
Outpatient Outpatient Outpatient
Skilled Nursing Facility Skilled Nursing Facility Skilled Nursing Facility
Durable Medical Equipment Durable Medical Equipment Durable Medical Equipment
Carrier Carrier Carrier
20 Page 21
21 How do I manage cost?
Discharge Discharge Documentation Readmission location Transport
Non-emergency Risk Adjusted 30 day LTACH SNF Home Private Auto MICU Medical Measures readmission Transport
22 Technology: Making Complex Requirements Easier Communicating Tracking Documenting Coding Auditing Training Billing 23 Integration: Making Coordination Easier
• Shared processes and technology (data and Non- management information systems, physicians' liaisons, Economic physician connections, medical staff development, branding)
• Shared payments (BPCI, shared monetary payments for Economic services, accountability, improvements, referral services)
• Coordination and management of patient care (scheduling and registration, information systems, care Clinical standards, quality programs, service lines, case management)
24 Source: Milbank Q. 2008 Sep; 86(3): 375–434. doi: 10.1111/j.1468-0009.2008.00527.x PMCID: PMC2690342 Hospital-Physician Collaboration: Landscape of Economic Integration and Impact on Clinical Integration. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690342/ Patient Flow
25 Patient Flow: Impact 136.3 million on the E.D. E.D. visits annually in the US (44.5 visits per 100 persons) 1 11.9% of visits result in hospital admission 1
Overcrowding According to in the E.D. ER Wait Watcher 2 National average 24 minutes Only 27% of patients are seen Wyoming = 15 min. in fewer than Washington D.C. = 53 min 15 minutes 1
26 1 CDC: Emergency Department Statistics (2011) http://www.cdc.gov/nchs/fastats/emergency-department.htm 2 ProPublica: https://projects.propublica.org/emergency/ Clinical Departments Still Operate In “Silos”
27 Current Admission Process
Patients can “Board” in the ED for 3.5 to 5 hours (or more) after work-up is complete. Emergency Physician makes disposition Page Hospitalist = 30 to 60 minutes to respond Hospitalist asks for additional tests = 30 to 60 minutes Time for Hospitalist to arrive in ER = 30 to 60 minutes
Hospitalist evaluates patient = 30 to 60 minutes
Orders placed into system = 30 to 60 minutes 28 The Solution: Powering Clinical Integration with Technology
Technology
Integration
29 Referrals
30 Referral Management in the U.S.
Exchanging patient Often citing information reasons: •ease of Non communication 66% PCP to Specialist 34% 66% refer to a colleague •share my medical record system Specialist to PCP Non 50% 50% 50% refer to a colleague
31 Source: J Gen Intern Med. 2012 May;27(5):506-12. doi: 10.1007/s11606-011-1861-z. Epub 2011 Sep 16. Reasons for choice of referral physician among primary care and specialist physicians. Retrieved May 11, 2015 at http://www.ncbi.nlm.nih.gov/pubmed/21922159 The Problem with Referrals…
3 of every 10 tests are Only 16% of 3 referrals are reordered completed Redundant tests electronically 1 cost $8 billion per year (2.7% of inpatient costs) 4
20% of patients Direct referred to a communication specialist don’t between hospitalist and show up where PCP only in they’re 2 3% - 20% of referred discharges 5
Sources: 1. Gaps in Referral Process between US Medical Providers http://www.practicefusion.com/pages/pr/survey-gaps-in-referral-process-between-us-medical- providers.html?_sm_byp=iVVfD1PnJkMktqqV 2. Specialty Referral Completion among Primary Care Patients http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1934973/ 3. A Healthy System,” Technology CEO Council http://www.techceocouncil.org/reports/tcc_reports/ 4. Health Affairs. Improving Safety And Eliminating Redundant Tests: Cutting Costs In U.S. Hospitals. http://content.healthaffairs.org/content/28/5/1475.full and J Am Med 32 Inform Assoc. 2010 May-Jun;17(3):341-4. doi: 10.1136/jamia.2009.001750.A preliminary look at duplicate testing associated with lack of electronic health record interoperability for transferred patients. http://www.ncbi.nlm.nih.gov/pubmed/20442154 5. Deficits in communication and information transfer between hospital-based and primary care physicians http://www.ncbi.nlm.nih.gov/pubmed/17327525 Physician Referrals as a Measure of Engagement: Gallup Study
“Engaged physicians gave the hospital an average of 3% more outpatient referrals and 51% more inpatient referrals than physicians who were not engaged or who were actively disengaged.”
Gallup Article: Want to Increase Hospital Revenues? Engage Your Physicians. By Jeff Burger and Andrew Giger. http://www.gallup.com/businessjournal/170786/increase-hospital-revenues-engage-physicians.aspx 33 Managing Costs, Reimbursement, Average Length of Stay and Transitional Care
34 Poor continuity of care The Cost of Poor Communication Delayed care
Medical errors
“The Joint Commission Sentinel Event database suggests poor communication Redundant testing contributes to nearly 70% of sentinel events, surpassing other commonly identified issues Wasted such as patient assessment and procedure resources compliance.”
Lower patient satisfaction
Lower rate of referrals/ admissions 35 Source: http://www.ncbi.nlm.nih.gov/books/NBK43683/ Poor Follow-up Leads to Readmissions and Medication Errors
50.2% of those readmitted never had a follow-up visit with a PCP
Patients lacking PCP follow up were 10 times more likely to be readmitted (adjusted 21% readmission) versus 3% with timely PCP follow-up
About 23% of follow-up patient appointments were missing test results and medical records
About 60% of medication errors occur during transitions of care (annual cost of $3.5 billion)
Source: http://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/2011/Apr/1473_SilowCarroll_readmissions_synthesis_web_version.pdf 36 HiMSS paper Reducing Readmissions Top Ways Information Technology Can Help The Hospital Readmission (sources New England Journal of Medicine, Journal of Hospital Medicine and The Commonwealth Fund) http://www.himss.org/files/himssorg/content/files/controlreadmissionstechnology.pdf Reducing Readmissions Through Integration and Technology
“Integrating hospital and outpatient care is key to reducing readmissions.”
The Commonwealth Fund
Source: http://www.commonwealthfund.org/~/media/Files/Publications/Case%20Study/2011/Apr/1473_SilowCarroll_readmissions_synthesis_web_version.pdf 37 HiMSS paper Reducing Readmissions Top Ways Information Technology Can Help The Hospital Readmission (sources New England Journal of Medicine, Journal of Hospital Medicine and The Commonwealth Fund) http://www.himss.org/files/himssorg/content/files/controlreadmissionstechnology.pdf DASH Direct Admit System for Hospitals (DASH)
DASH integrated clinical technology and process flow • changes referral patterns • improves market share
39 Self-pay DASH – By the Numbers 3% August 2012 – December 2014 State 13% Commercial 48% Payor >700 Mix Referring 44% 4% Federal Requested Isolation 36% Medical Ambulance Facilities Requested
Pediatrics Bed 2% OP/OBS 24H w/o ICU Tele 8% OP/OBS 7% IMU 24H w 8% Tele 17% Bed DX Entry Type 19 5% change Hospitals 11% • 47% ICD 9 Med/Sur Med/Sur • 1% ICD 10 g w/o g w Tele • 3 additional Re-Routed Tele 32% under • 52% Free contract Form 26%
Fair Critical 3% 1%
Guarded 14% Top 2 >10K <1% Conditions Status Admissions No-Show • Respiratory • Gastrointestinal Stable 40 82% Easy as 1-2-3
Direct Admit Form Sample
1. Click 2. Complete 3. Confirm ON THE DASH EASY TO USE BED ASSIGNMENT WITH BUTTON/APP DIRECT ADMIT FORM HOSPITAL BOARDING PASS
41 Direct Admit Form 3 minutes Avg time to complete form
Only HIPAA 7 Compliant Patient Mandatory Information Fields Protection
42 Direct Admit Recipients
DOC-to-DOC Admitting House Physician Supervisor
Sample Health System
Click DOC to DOC Click Link to call referring to securely login Clinician
Admission Routed to referring facility ’s preferred on call admitting physician 43 Hospital Boarding Pass
Sample Health System
Sample Health
44 DASHBoard Analytics & Metrics
Analytics & Metrics • Overall Direct Admissions On • Click to Bed Time Demand • Bed Unavailability Rate Analytic • Physician Acceptance Reports • Patient Throughput • Referral Analytics • Referring Physicians • Referring Facilities ... and many more
Executive Dashboard
45 Live Streaming Analytic Data DASH Hospital Benefits
Increased Improved Hospital Hospital Throughput / Occupancy Efficiencies
Increase Decreased Decreased ER Reduce Referral Medical Crowding Splitters Base Utilization
Improve Focused Improve Patient Marketing Strategy Satisfaction 46 Building the Connection with Hospital Medicine
Enhance Create Expand your Close the loop communication “stickiness” in referral at time of between your referral footprint discharge physicians network
47 Summary: Emerging Strategies for Improving Hospital Medicine
VBP / BPCI / Patient Flow / MSPB Boarding
VBP Treatment Integration Timing Technology Transition
ALOS / Cost Per Referrals Case / CMI & Readmits
48 Hospital Medicine as Part of the Healthcare Evolution
Moving toward a Changing greater The right expectations healthcare All must framework and demands in ecosystem constantly Accountability enables population requires shaping create value for performance hospitalists to health require and adapting to within the is a necessity enhance new paths to survive in the ecosystem hospital success new competitiveness environment
49 Q & A
Francisco Loya, MD, MBA CEO, EmCare Hospital Medicine [email protected]
Mark Hamm CEO, EmCare Development [email protected]
Call (877) 416-8079 or visit www.emcare.com.