• Coordinating Care Across Sites

    Mar 01, 2012

    Progressive hospitals and health systems are systematically coordinating patients' care outside their own walls by testing new approaches, partnerships, and technologies.  

    Key Takeaways
    Healthcare organizations are using a number of key strategies to improve care coordination:

    • Forming tightly integrated and virtual networks of providers who are incentivized to improve quality and cost metrics
    • Reaching out to payers, nursing homes, and others to establish needed partnerships
    • Using navigators to help coordinate care for high-risk patients
    • Setting up follow-up physician appointments for patients before discharge, and providing patients and their families with clear post-discharge instructions
    • Deploying EHRs, clinical decision support, patient portals, and other technologies that can help providers, patients, and other key players exchange information

    pg16_feature-coordinationWhen patients are admitted to Bassett Medical Center in Cooperstown, N.Y., their primary care physicians are notified by email. When a patient is discharged, another email is sent-and the patient goes home with a toll-free number that rings into Bassett's case management department.

    Having a phone number to call helps patients feel like the hospital cares about them-and may prevent an unnecessary trip to the emergency department or the misuse of a medicine that causes a new medical problem, says Ronette Wiley, Bassett's vice president of performance improvement and care coordination. "They can call this number and have their questions answered."

    A few decades ago, hospital leaders rarely worried about coordinating care with other providers. Today, however, everyone understands that good patient outcomes require teamwork among many kinds of caregivers-and hospitals are often expected to serve as the quarterback. The launch of bundled payment, accountable care organizations (ACOs), and other payment and delivery system changes have also created a business imperative for care coordination.

    The following four case studies illustrate various ways that providers are approaching this new paradigm.

    Case Study: Partnering with Payers to Improve Outcomes

    Norton Healthcare, a five-hospital system serving Kentucky and southern Indiana, is operating one of the nation's first ACOs. It was chosen as one of five pilot sites for the ACO Learning Network, which is headed by the Engelberg Center for Health Care Reform at Brookings Institute and the Dartmouth Institute for Health Policy and Clinical Practice.

    ACOs are groups of hospitals, physicians, and other providers that share responsibility for providing coordinated care to a particular population of patients. The Norton pilot, which started in June 2010, includes roughly 10,000 patients, all of whom are employees of either Norton Healthcare or Humana- two of the three largest employers in the Louisville area. Patients were attributed to the ACO if they had used a Norton facility or visited one of its physicians in the year before the ACO started.

    "It made a good testing ground for us because we have such a large population base of employees," says Norton CFO Michael Gough.

    Improving quality and efficiency. Norton is well-positioned for the ACO model because it has employed primary care physicians for the past 15 years, says Gough. More recently, Norton began hiring specialists, and it currently employs nearly 550 physicians. All are paid based on productivity with financial incentives for hitting quality and efficiency goals.

    "This model has worked well for us," he says. "The physicians are largely happy, and we have high patient satisfaction. The key to this whole thing is having the physicians on a production model. Basically, if they don't work much, they don't get paid much. If they want to work really hard, they get paid a lot."

    That alignment between the health system and its physicians is important to Norton's ability to target quality and cost improvement goals. For example, Norton has asked its physicians to prescribe generic drugs when appropriate and to avoid unnecessary radiology images for patients complaining of lower back pain. Both these metrics improved within one year of the ACO's launch (see the exhibit below). Improvements were made in other quality measures as well. For example, the percentage of patients with diabetes who had recommended blood sugar testing increased from 87.7 percent to 93.4 percent.


    Equally noteworthy, the ACO appears to be curtailing costs. As a self-insured employer, Norton has slowed the growth of its healthcare expenditures, says Gough. "In fact, it's almost flat. Our FTE count is up about 6 percent, and our health insurance expense year over year is up about the same," he says. "That's pretty successful."

    Piloting care coordination approaches. Another way Norton is reducing costs is through care coordination. Norton is piloting the use of nurse navigators in five of its largest primary care practices, says Ken Wilson, MD, the system's vice president of clinical effectiveness and quality. The nurses are working with patients who were recently discharged from a Norton hospital and have one or more chronic condition (i.e., congestive heart failure, diabetes, chronic lung disease, and pneumonia).

    "These nurse navigators are targeting those transition of care problems that research shows impact whether a patient is at risk of being readmitted to the hospital," says Wilson.

    The registered nurses ensure appropriate and timely follow-up care for high-risk patients, complete previsit chart reviews, and use chronic disease and prevention protocols to identify diagnostic and preventive care needs. The nurses assist patients and families in developing and adhering to self-management plans-and frequently interact with the patients to make sure they are complying with the plan.

    Stepping toward bundled payments. The ACO model was created to solve the problem of disjointed and redundant patient care by establishing financial incentives that reward highly coordinated care-specifically, the opportunity to "share savings" achieved for the payer.

    Under the terms of its shared savings contract, Norton is expected to reduce the costs of caring for patients in the ACO by at least 2 percent in the first year. Norton and Humana share any savings beyond that amount. Norton-as the provider-receives 40 percent of the shared savings, and Norton and Humana-as the payers-receive the remaining 60 percent.

    Norton expects its shared savings contract with Humana to be a financial winner for the health system, but the care delivered to ACO patients will not be any different than that for patients in the traditional payment system.

    In fact, physicians do not know which patients are in the ACO. Wilson says physicians would consider it unethical to apply one standard of care to ACO patients and another to patients outside the ACO. "We apply all the new interventions to everybody," he says.

    Gough believes the shared savings model-which incentivizes providers to focus on care coordination, quality, and efficiency- will help Norton transition to a future in which providers are paid for bundles of care. "We don't view the ACO as an end. We look at it as a means to the end," he says.

    Both shared savings and bundled payment models reward providers for improving quality while holding down costs, explains Gough. But an ACO succeeds only if it can reduce the rate of healthcare cost growth year over year-and after a while, the opportunity to generate increasing savings will hit a plateau.

    By contrast, in the bundled payment model, providers differentiate themselves in the marketplace by offering bundles of services for specific conditions-such as joint replacements or cardiac procedures-with price and quality guarantees, says Gough. Thus, the bundled payment model offers unlimited potential for a health system to compete for greater market share.

    Following Norton's lead. Gough advises health system executives not to jump on the ACO bandwagon too quickly because it can create an unnecessary level of risk. For just this reason, Norton decided not to contract as an ACO through the federal government's Medicare Shared Savings Program.

    "It helps to start slow and not big," says Gough, who thinks that health systems should experiment with the ACO model using their own employees. "It helps to work out all the kinks before we go out into the marketplace."

    Gough's second bit of advice: Recognize that changing the way care is delivered is more important than changing the way it is paid for. Norton's physician leaders worked with Humana's medical directors to design their ACO contract, with financial executives contributing on an as-needed basis. "If you ask me, the key to success is having physician leadership in place, because they have to change the care models," he says. "Administrators can't do that, and finance folks can't do that."

    Case Study: Improving Population Health Through Solo Practices

    To date, many of the new healthcare models, such as ACOs and patient-centered medical homes, are being tested by health systems and physician groups that are bound together by common ownership or another close affiliation-making them mutually incentivized to improve patient care. Participating physicians are typically members of large groups that use standardized protocols and pay-for-performance plans to influence physician behavior.

    But going forward, that arrangement may not always be the case. Michael Richter, MD, a pediatrician and internist in Queens, is one of 2,500 independent physicians participating in an electronic health record (EHR) initiative that is creating a "virtual" healthcare system in medically underserved areas of New York City. Collectively, participants in the Primary Care Information Project (PCIP) serve nearly 2 million patients, or one quarter of the city's population.

    As a solo practitioner, Richter enjoys a level of independence that is rare in medical practice today. He makes house calls to homebound patients. His black Labrador, Bartlet, accompanies him to the office. And his vacation photographs and favorite poems are posted on his practice's website. pg20_dr-richter 

    The suggestion that solo practice is a dying business model both surprises him and moves him to indignation. "Who is saying there will be no self-employed physicians?" says Richter. "I disagree with that 100 percent."

    For one thing, patients "are currently knocking my door down here," he says, and when more patients get insurance or Medicaid coverage in 2014, demand for primary care services will only grow. For another, Richter expects that his practice will become even more financially successful in the years ahead-in many ways because of his robust use of PCIP's EHR system.

    He is seeking recognition as a patient-centered medical home and working to become part of an independent physician association and an ACO. He recently received a check from the federal government for achieving EHR meaningful use in the first year of the incentive program.

    He can prove to insurers that he is doing a good job of providing preventive care services to his patients-and how he compares with his peers. And he is helping New York City's public health department quickly identify flu outbreaks and monitor trends in HIV infection and other public health problems.

    "The solo practitioner who is part of a group-with or without walls-is going to be fine," says Richter. "And I'll tell you what else. There are initiatives coming down the line for doctors to actually be the organizers and be the insurers. Doctors are getting more and more involved in the business of medicine."

    Networking virtually. The PCIP, a New York City mayoral initiative, is run by the city's Department of Health and Mental Hygiene. The project, which won a 2011 Davies Award from HIMSS, has created what it calls a "virtually integrated healthcare system" of more than 470 independent small practices, 34 community health centers, and four hospitals (see the exhibit below).


    Through the PCIP, Richter-like his 2,500 colleagues-was able to purchase an off-the-shelf EHR system at a big discount. He also received extensive EHR training and support, which has helped ensure that he and his staff members can take full advantage of the EHR's functionality.

    PCIP physicians each maintain their own EHR system; they cannot access patient records from other PCIP providers. But the virtual network enables physicians to communicate easily and coordinate care- either by automatically faxing medical summaries, laboratory values, and progress notes to one another or by sending structured data directly into another physician's progress notes when a referral is made. Additionally, the patient portal feature of the EHR allows patients to access their medical information from any Internet-connected computer.

    "If a patient is in a specialist's office and the specialist has a question, the patient can go to the patient portal and say, 'Here is my information,'" says Richter. "The doctor can see whatever he or she needs to see."

    The PCIP is designed to improve patient care through the EHR's clinical decision support function that prompts physicians to remember preventive and chronic care recommendations, particularly for hypertension, diabetes, and smoking. Physicians can also see how their performance compares to their peers' on various quality and EHR meaningful use metrics via personalized performance dashboards they receive from PCIP (see the exhibit below).


    Since its inception in 2007, the project has cost more than $85 million and has been funded by local, state, and federal governments and philanthropic grants. A formal ROI analysis has not yet been completed, but data indicate that patients served by PCIP providers are now more likely to receive recommended preventive and chronic care. Compliance with six evidence-based recommendations-such as blood sugar screening for diabetic patients and blood pressure control for patients with hypertension-has increased by at least 5 percentage points among PCIP physicians. PCIP staff members estimate that the improvement in just one measure-blood pressure control-is averting heart attacks and strokes that reduce costs by $17.16 per patient per year.

    The PCIP project is also encouraging electronic prescribing among physicians, which is known to reduce adverse drug events. In addition, because the system prompts physicians to consider generics when appropriate, electronic prescribing is estimated to reduce costs by $39 per patient per year.

    Bringing solo practitioners on board. The PCIP's most impressive accomplishment might be in figuring out the mix of financial and logistical support needed to turn independent physicians into robust users of EHR technology. When he attended the PCIP's first presentation, Richter was not particularly swayed that computerization was essential. But the fact that the city was putting so much effort into the initiative did get his attention.

    "I went to another meeting, and I thought to myself, 'If the city is spending that kind of money to get doctors to adopt electronic records, this is probably something that is important,'" he says. "I found out that I was not only getting a discount of $4,000 for the software, the training, and a two-year license, but also that the insurance companies were going to reimburse me for some of that cost."

    Jonathan Mohrer, MD, another primary care physician in Queens, was among the first PCIP participants to meet the federal government's criteria for meaningful use of EHR technology and to earn the incentive check that brings.

    The logistical support from PCIP staff that he received was essential to his success. "Without them, I don't think I would have been able to do this," he says. "They spent a lot of time with me, sending out people just to make sure that I'm doing the right thing, making sure that I'm sending electronic prescriptions properly, and that I'm connecting and giving reports in certain ways." 

    Case Study: Moving Patients Smoothly From Hospital to Home

    Effective Oct. 1, 2013, hospitals with higher-than-expected readmission rates for patients with certain conditions will face financial penalties. When that day comes, Bassett Medical Center, a 180-bed teaching hospital in Cooperstown, N.Y., will be ready. Beginning in late 2009, a multidisciplinary team at Bassett began devising and implementing strategies to help high-risk patients make a smooth transition when they leave the hospital.

    Ronette Wiley, vice president of performance improvement and care coordination, says the group's focus was more on improving patient care than on reducing readmissions. But it seems the two go hand-in-hand: Bassett's 30-day readmission rate for high-risk patients fell from 13.4 percent in 2009 to 3.1 percent in 2010.

    And that success comes with a bonus: On the HCAHPS survey question about discharge planning, Bassett consistently scores within the 98th percentile compared to hospitals nationally.

    Targeting specific patients. Bassett started improving care transitions by targeting a specific population of patients. At the time of admission, nurses administer a screening tool-developed by the Society of Hospital Medicine-to identify patients who are at high risk of being readmitted within 30 days. The screening tool evaluates eight specific points:

    • Problem medications (for example, anticoagulants, insulin)
    • Psychological issues (for example, a positive depression screen)
    • Principal diagnosis (for example, cancer, stroke)
    • Polypharmacy, or the need for five or more medications
    • Poor health literacy
    • Patient support, or the absence of a caregiver to assist with discharge/home care
    • Prior hospitalization (that is, a nonelective admission in last six months)
    • Palliative care, or the need for end-of-life care

    All high-risk patients receive two interventions that have been proven effective in reducing readmissions: a follow-up phone call within 72 hours of discharge and a follow-up appointment with a physician within seven days of leaving the hospital. Bassett nurses have also been trained in teach-back methods, which is a patient education approach that encourages patients to repeat back healthcare instructions in their own words. This approach helps nurses verify that patients understand their care plans and what they need to do after discharge.

    Bassett also created a new position-patient services coordinator-to make the phone calls, using a script designed to elicit information about whether patients have filled their prescriptions, are using their medicines correctly, and have a primary care visit scheduled. If the coordinator identifies potential problems, he intervenes.

    Komron Ostovar, MD, the hospitalist in charge of Bassett's Care Transitions program, says the coordinator previously worked in an administrative position at the hospital. He was chosen because his work experience at Bassett has allowed him to develop a network of relationships that can benefit patients. "The coordinator uses that network to help make appointments and navigate for these patients," says Ostovar. "Most important, the patient services coordinator was able to establish a relationship with some of the schedulers in primary care clinics to help get patients seen sooner than they otherwise would have been."

    Two other discharge supports:

    • A toll-free number to the hospital's case management department for patients or their caregivers who have questions about symptoms or care plans-and are unable to get through to a physician
    • Patient-friendly discharge instructions, written to be free of medical jargon, that include "event scenarios" that patients might experience-such as bleeding from a surgical site-and guidance on what to do if these scenarios occur.

    Getting started. Despite Bassett's impressive results, reducing readmission rates is difficult work and hospitals should expect slow but steady progress, says Wiley. She encourages hospitals to establish process goals-for example, the percentage of patients who already have a physician's appointment scheduled at discharge and the percentage of patients who receive a follow-up call within 72 hours-to stay focused on continual improvement.

    Another key to success, she says, is finding the right physician leader. In Bassett's case, Komron Ostovar, MD, has been a tireless champion for the program to his hospitalist colleagues and everyone else in the organization. "It certainly helped us get a lot of credibility for this project upfront with our board of trustees and our senior leaders," she says. "It helps keep the enthusiasm for the work alive."

    Case Study: Transitioning Patients from Nursing Facilities to Home

    When hospital patients go to a skilled nursing facility before they return home, coordinating their care becomes more complex because another set of caregivers gets involved. Recognizing that nursing facilities can be a differentiating factor in a patient's successful recovery, Aetna and Genesis HealthCare, a post-acute care provider, are using a shared savings quality incentive program designed to prevent avoidable readmissions to the hospital.

    Focusing on care transitions. The contract builds on Genesis' transition-to-home program, in which case workers follow patients for 30 days after they are discharged from the nursing facility at many locations. "For acute care health systems to be successful, they are going to need post-acute providers that can partner with them in meeting their clinical objectives-and of course, rehospitalization reduction is No. 1 on the list," says Paul Bach, Genesis HealthCare's Central Area president. "By positioning our services to focus more attention on rehospitalization reduction and care transitions, we give the hospital and health systems a reason to partner with Genesis in caring for its patients."

    That sounds good to Aetna. The contract, which went into effect last spring, covers 141 Genesis skilled nursing facilities in seven eastern states. Aetna and Genesis intend to decrease the number of patient readmissions from these facilities by 10 percent to 20 percent over the next several years. That would translate into up to $2 million in medical costs saved each year.

    Genesis' performance will be based on Aetna's claims data, says Bach. A preliminary review of Genesis' own data suggests that the initiative is working. "We're optimistic, from what we can see internally, that we are beginning to reduce the rate of rehospitalizations."

    Keeping patients out of the hospital. As part of this relationship, Genesis made infrastructure improvements that include establishing a cardiac care management services program for patients with heart disease and congestive heart failure and expanding its rehabilitation services to either six or seven days a week. Both efforts are designed to speed patients' recovery, which decreases the likelihood of a return to an acute-care facility.

    Additionally, Genesis is selectively employing physicians and nurse practitioners rather than contracting out for those services, which is typical for skilled nursing facilities, says Bach. Its goal is to better control the level of care that those professionals provide to Genesis patients.

    By employing physicians and nurse practitioners, Genesis increases its ability to diagnose and treat patients onsite, says Bill Stout, Aetna's head of national contracting. "Say we have a post-acute joint replacement patient with pneumonia comorbidity. Rather than sending that person to the hospital for treatment, we expect that patient to get treated right there at the Genesis facility, rather than having to do a transfer," he says.

    Genesis also recently started accepting admissions around-the-clock. "If one of our members hits the emergency department but does not meet acute care criteria for admission, we want the Genesis facility to be available on a subacute basis, so that the member gets to the right place for the right level of care," says Stout.

    Meanwhile, Aetna and Genesis worked together to develop an expanded discharge planning and education program. The goal is to ensure that patients and their families know what to expect after discharge-and have arranged for the support needed for a successful transition to home.

    Genesis ensures that, before a patient is discharged from a nursing facility, community-based services have been arranged and an appointment with the patient's primary care physician has been scheduled. After discharge, patients receive calls from a Genesis nurse to ensure that there are no gaps in services or additional needs.

    "We want to see how they're doing in transitioning to home and make sure the arrangement for home care and medical equipment was satisfactory," says Bach.

    Devoting Resources

    Highly coordinated care has long been linked to better patient outcomes, and now the business rationale for investing in care coordination is strengthening as healthcare organizations identify ways to reduce costs per patient encounter. "Over time, if we are doing the right thing for patients, that is how we will be known and that will become a key driver in terms of business," says Norton Healthcare's Ken Wilson, MD. "In my opinion, we providers will become increasingly accountable, not only for the quality and safety of care, but for at least some portion of the cost of that care. All of those things fit together."  

    Interviewed for this article (in order of appearance):

    Michael Gough is CFO, Norton Healthcare, Louisville, Ky. (michael.gough@nortonhealthcare.org).

    Ken Wilson, MD, is vice president of effectiveness and quality, Norton Healthcare (Ken.Wilson@nortonhealthcare.org).

    Michael Richter, MD, is a pediatrician and internist, Queens, N.Y. (mrichtermd@hotmail.com).

    Jonathan Mohrer, MD, is a primary care physician, Queens, N.Y. (jmohrer@gmail.com).

    Ronette Wiley is vice president of performance improvement and care coordination, Bassett Medical Center, Cooperstown, N.Y. (ronette.kinzelmann@bassett.org).

    Komron Ostovar, MD, is a hospitalist, Bassett Medical Center (komron.ostovar@bassett.org).

    Paul Bach is central area president, Genesis HealthCare, Kennett Square, Penn. (Paul.bach@genesishcc.com).

    Bill Stout is head of national contracting, Aetna, Hartford, Conn.