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