Coordinating Evidence-Based Care Across the Continuum

As payers, patients, and policymakers increasingly focus on improving value, or quality and efficiency, in health care, providers have a new priority. They must deliver the right care—whether that be preventive, chronic, outpatient, acute, or long-term care—at the right time and in the right way. This often means coordinating care among disparate providers that previously considered themselves autonomous from one another.

Fortunately, healthcare leaders know how to forge relationships to improve patient care, and many innovative leaders are finding ways to develop the type of care delivery system that will become standard in the future.

Creating a Continuum of Care

Over the years, Hampden County Physicians Associates (HCPA) has pulled together a range of services that allow it to efficiently manage a patient’s total healthcare needs. The Massachusetts-based multispecialty medical group owns an urgent care center, an imaging center, and a laboratory. Its long-term care team provides services, including medical director leadership, at 13 skilled nursing facilities in the area. And the medical practice maintains its own daytime hospitalist service and contracts for night-time hospitalist coverage.

CEO Robert Suchecki does not require each business unit to have its own robust ROI; he is interested in how the components work together to provide an efficient continuum of care. The urgent care center, for example, is no big moneymaker, but it allows HCPA to serve its patients on weekends when the medical offices are closed.

“If we are able to save a number of emergency department visits or hospital admissions, that makes the bottom line more palatable,” he says.

HCPA nurse case managers increase communication across the continuum and provide important support to patients, helping them stay out of the hospital. The case managers meet with HCPA hospitalists every morning to develop discharge plans for patients who will be leaving the hospital, and they meet weekly with skilled nursing facility staff to make sure HCPA patients are progressing appropriately.

Additionally, two of the group’s nurses are dedicated to patients who suffer multiple chronic conditions. Before chronic case management was offered, 3 percent of HCPA’s patients were using 50 percent of the specialty group’s budget. That has fallen to 40 percent.

“We have a $60 million budget for those patients, so that is a lot of money saved,” says Suchecki. “Although the overall cost of our chronic disease and nurse case management program is close to $1 million, we have been able to save over $4 million per year as a result of this highly skilled service.”

The savings come from the intensive relationships established between case managers and patients, says Carol A. Toro, RN, BSN, director of nurse case management services. As part of the initial assessment, the case manager does a depression screen, a falls-risk assessment, and a medication reconciliation assessment to ensure the patient is following physician orders. The frequency of contact and length of the relationship depend on the patient’s acuity level.

“We might call them daily for a week to make sure things are OK or just once every couple of months for patients who are doing fine but really want the extra support,” says Toro.

Knowing that a case manager will check on a patient at home—and arrange for home care visits if the need arises—allows physicians to feel more comfortable about discharging patients home earlier than if the patient did not have that support.

Similarly, the patient can call the case manager at any time, which alleviates the anxiety that prompts patients to go to the emergency department when a physician visit would be appropriate. And patients often rely on case managers to get quick access to their physician, which can head off a downward spiral that lands the patient in a hospital bed.

Building Consensus About Care

In the past four years, the number of patients insured by HealthPartners who received optimal diabetes care has increased by 129 percent.

While Minneapolis-based HealthPartners can take much of the credit for that brag-worthy statistic, Andrea Walsh, executive vice president, says a 15-year-old communitywide collaboration is at the core of HealthPartner’s success in improving patient care and outcomes. The Institute for Clinical Systems Improvement (ICSI) defines what evidence-based care is in the Minneapolis area—and how that care should be measured. ICSI is a collaborative of the major health insurers and physician groups serving the Minneapolis market.

ICSI develops outpatient care guidelines, physician order sets, and protocols for hospital care based on current medical evidence. (All guidelines are available at www.icsi.org.) Because ICSI comprises 57 medical groups in the Minneapolis area representing nearly 9,000 physicians, the majority of physicians practicing in the Minneapolis area agree to comply with ICSI guidance.

For example, when the ICSI guideline for chest pain and acute coronary syndrome was updated in 2008, a team made up of cardiologists, physical therapists, hospitalists, and pharmacists reviewed the scientific literature, graded the evidence, and created a 70-page document that describes best practices and step-by-step directions for chest pain screenings and other common coronary-related situations. It also lists five “priority aims” that keep physicians working toward measurable goals, such as increasing the percentage of heart attack patients using cardiac rehabilita-tion after they leave the hospital.

“Everyone is clear about what the rules of the game are, what the yardstick for success looks like, and what care optimally people should get,” says Walsh.
Take optimal diabetes care, which according to the ICSI consensus, means managing a patient to achieve five attributes:

• Blood pressure less than 130/80 mmHg
• Bad cholesterol, or LDL-C, less than 100mg/dl
• Blood sugar, or A1c level, less than 7 percent
• Tobacco free
• Daily aspirin use (for patients ages 41 to 75)

The measures are known as “D5” among Minnesota healthcare providers. And a web site (www.thed5.org) reports which medical clinics have the highest percentage of patients achieving optimal management for their diabetes.

When Minnesota clinics started reporting on the D5, fewer than 4 percent of patients were under perfect control for their diabetes; today, the statewide average is 19 percent—and the average for HealthPartners Medical Group is 25 percent, with one of its clinics providing optimal care to 42 percent of its diabetic patients.

For HealthPartners’ patients, the improved diabetes care means that about 115 heart attacks, 925 cases of diabetes-related eye disease, and 155 amputations were avoided over four years, says Patrick Courneya, MD, medical director for delivery systems at HealthPartners Health Plan.

Meanwhile, the health plan is saving $15 million a year on costs attributed to diabetes care. The annual medical tab for the healthiest diabetes patient is $5,000—compared to $60,000 for patients who are frequently hospitalized because their disease is not under control.

A sponsor of ICSI since its inception, HealthPartners uses ICSI evidence-based guidelines to develop quality improvement programs and create financial incentive programs that help encourage physicians to adopt the guidelines (see page 22).

“We still have quite a ways to go,” says Walsh. “But we are starting to see some really nice improvements year to year because we are gaining momentum. Our aspiration is to take some big leaps here in the next couple of years.”

Driving Quality Across a System

At Intermountain Healthcare, evidence-based medicine is pushed out through systemwide clinical programs designed to improve specific aspects of care. Based in Salt Lake City, Intermountain is an integrated system that includes hospitals, a health plan, a medical group with more than 800 employed physicians, and a wide range of ancillary services.

Intermountain is one of health care’s foremost leaders in the use of IT. A pioneer in the use of an electronic health record (EHR) system that reminds physicians of care guidelines for specific medical situations, Intermountain also uses its EHR to review treatments and outcomes, thereby identifying what works and what does not.

According to Dartmouth Atlas researchers, the nation could reduce healthcare spending on acute and chronic illnesses by up to 40 percent if all healthcare providers followed Inter-mountain’s care protocols.

Each of Intermountain’s eight clinical programs—cardiovascular, oncology, women and newborns, primary care, intensive medicine, surgical services, pediatric specialties, and behavioral health—use improvement projects to achieve quality goals established by the board of trustees.

For example, when the physicians in charge of Intermountain’s women and newborns clinical program determined that elective inductions before 39 weeks of gestation increased the risk of complications, Intermountain’s board of trustees set a goal of reducing early elective inductions, says CFO Bert Zimmerli.

The system’s physicians were initially skeptical about whether there were really adverse outcomes associated with early labor inductions, and whether their patients were experiencing any complications. Because the actual number of complications that might be seen annually by an individual physician was small, it was difficult for the physicians to see many adverse outcomes. The clinical program team used Intermountain’s own outcomes data to prove that the early-induction complications, first recognized at the national level, were also evident at home.

“When the physicians were presented with information about their own patients, we got buy-in,” says Zimmerli.

The result? The percentage of Intermountain’s elective inductions performed at earlier than 39 weeks of gestation fell from nearly 30 percent in 1999 to less than 4 percent in 2005.

Another result is that Intermountain treats fewer babies in its neonatal intensive care unit, which of course reduces Intermountain’s revenues. “This is a situation in which the incentives are not aligned as well as they should be, but from management’s standpoint and the board standpoint, there was never any issue as to whether we would do this,” says Zimmerli. “As a community, there is no question that this is the right thing to do—it’s safer and less expensive.”

The clinical programs also provide a way for Intermountain to deliver the same quality of care at its small community access hospitals as it does at its tertiary care facility.

“We have the opportunity to have the clinical program leaders visit our facilities and to meet with our local medical staff to present new clinical care models and evidence-based medicine,” says Jim Beckstrand, administrator for Intermountain’s Delta Community Medical Center and Fillmore Community Medical Center in south central Utah.

Both hospitals have 20 beds; Delta Community is served by three independent family practice physicians, while Fillmore Community is staffed by three physicians employed by the Intermountain Healthcare Group. Regardless of their employment status, the physicians are expected to adhere to protocols approved by the system’s clinical programs. That means that a patient who presents with pneumonia symptoms should receive the same care at Delta
Community as at the flagship Intermountain Medical Center.

“There is a checklist, both manual and computerized, for a physician to be able to recognize, diagnose, and follow the treatment program for a pneumonia patient,” says Beckstrand. “It takes the guesswork out and makes sure the care plan will really help the patient recover the fastest and with the least costly measures.”