Emerging Strategies for Improving Hospital Medicine

Transcription

1 Emerging Strategies for Improving Hospital Medicine Improving efficiency, patient safety, metrics and satisfaction Improving communication among the patient s community of caregivers

2 Your Presenters Francisco Loya, MD CEO, EmCare Hospital Medicine Mark Hamm, MBA Executive Vice President Corporate Development 2

3 Where to start? "The future is already here it's just unevenly distributed." Attributed to William Gibson Renowned cyberpunk science fiction writer. 3

4 Emerging Roles for Hospital Medicine Hospitalist involvement in pre-op preparation Utilization management APPs / Scribes Telehealth Post-acute care and transitional care management Marketing and community relations Mobile Integrated Health 4

5 Trend Cycle Normalize The trend becomes the new status quo New Force Expectations Regulations Discoveries Industry influences New competitors Adjust Fine tuning and adopting new processes Or overturned Change New requirements Consumer, patient, payors Clinician, hospital Support services React Development of new mindsets, processes and tools Backlash 5

6 State of Hospital Medicine Report 6 Quinn, R. (2014, October 13). New State of Hospital Medicine Report Offers Insight to Trends in Hospitalist Compensation, Productivity. Retrieved from The Hospitalist:

7 Key Influencers Value-Based Purchasing and Bundled Payments Technology 7

8 Expect to See Increased pressure from the growing demands of VBP. Clinical integration and collaboration will no longer be optional and hospitalists are pivotal. Coordination of post-acute care will become a key driver of financial results for hospitals. Technologybased tools may be the key to improving operational efficiency. 8

9 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. 9 For an acute care hospital, this means up to a 2% reduction in every Medicare Part A payment!

10 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

11 11 Hospitals will compete by providing value.

12 Hospital Medicine: Addressing the Challenges of Hospital Executives

13 13 The Role of Hospital Medicine in Addressing Your Challenges

14 Expansive Impact Hospital Medicine Clinical Care Service Operations Cost Care Delivered Care quality Outcomes Length of stay Readmissions Preventable complications Satisfaction Patients PCPs Surgeons Staff Hospitalists Administration Throughput Care management Reduce delays Improve turnover More services for patients and referrers Total Fixed & Variable Cost per case Length of stay Post-acute care HCAHPS MSPB BPCI 14

15 15 VBP

16 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: and Instruments/HospitalQualityInits/HospitalCompare.html

17 Rapidly Changing Environment Value Based Purchasing program measures are represented in soon to be five different categories: Incentive Payment 2% 1.75% 1.5% 15% 1% 30% 1.25% 25% 30% 20% 30% 25% 40% 25% 25% 70% 45% 30% 20% 25% 10% 25% 10% FY 2013 FY 2014 FY 2015 FY 2016 FY Clinical Process of Care Patient Experience of Care Outcome Efficiency Safety

18 Current Value-Based Purchasing Measures Coordinated transition to post-acute setting to decrease 30 day readmits Open communication with PCP & home health providers HM participates in entire patient experience Studer training to enhance patient communication with physician Scripted communication for Pain Control 25% Patient Experience 25% Efficiency Domain Judicious use of LTACH/SNF to control post-acute cost Accurate Inpatient Documentation improves Risk Scoring and hospital CMI Careful review of discharge information with patient or caregiver PNA: PSI Scoring and rapid time to antibiotics. Careful screening for vaccination. Counseling. Protocol-driven Nearly 100% on HM specific measures 10% Process of Care VBP 40% Outcome Measures MI: Aggressive ant-platelet/betablocker/ace-i use. Close coordination with ED and Cardiology to decrease time to PCI. Counseling. HF: Aggressive beta-blockers/ace-i/antiarryrthmics. Counseling. Mandatory CME if measures falls below benchmark Review of all deaths that fall within measures 18 Pt Safety Indicators: CME on Skin examination to prevent decubitus ulcers/monitoring of post-op hemorrhage, sepsis, and wound management.

19 Bundled Payments for Care Improvement (BPCI) Initiative Seeking an antidote to expensive, fragmented care with minimal coordination across settings Goal: Higher quality, better coordinated care, lower cost to Medicare Experiment to see if bundled payments can align providers, reduce CMS expenditures and preserve or enhance care 19 Requires cooperative arrangements for payment, financial and performance accountability Based on episodes of care (Examples: AMI, Chest pain, COPD, CHF, Stroke, Sepsis) Source:

20 Medicare Spending Per Beneficiary (MSPB) Episode of Care 3 Days PTA Hospital Stay 30 Days Post Discharge Home Heath Agency Hospice Inpatient Outpatient Skilled Nursing Facility Durable Medical Equipment Carrier Home Heath Agency Hospice Inpatient Outpatient Skilled Nursing Facility Durable Medical Equipment Carrier Home Heath Agency Hospice Inpatient Outpatient Skilled Nursing Facility Durable Medical Equipment Carrier 20

21 21 Page 21

22 How do I manage cost? Documentation Discharge location Discharge Transport Readmission Risk Adjusted Measures LTACH SNF Home Private Auto MICU Non-emergency Medical Transport 30 day readmission 22

23 Technology: Making Complex Requirements Easier 23 Communicating Tracking Documenting Coding Auditing Training Billing

24 Integration: Making Coordination Easier Non- Economic Shared processes and technology (data and management information systems, physicians' liaisons, physician connections, medical staff development, branding) Economic Shared payments (BPCI, shared monetary payments for services, accountability, improvements, referral services) Clinical Coordination and management of patient care (scheduling and registration, information systems, care standards, quality programs, service lines, case management) 24 Source: Milbank Q Sep; 86(3): doi: /j x PMCID: PMC Hospital-Physician Collaboration: Landscape of Economic Integration and Impact on Clinical Integration.

25 25 Patient Flow

26 Patient Flow: Impact on the E.D. 11.9% of visits result in hospital admission million E.D. visits annually in the US (44.5 visits per 100 persons) 1 Overcrowding in the E.D. Only 27% of patients are seen in fewer than 15 minutes 1 According to ER Wait Watcher 2 National average 24 minutes Wyoming = 15 min. Washington D.C. = 53 min 26 1 CDC: Emergency Department Statistics (2011) 2 ProPublica:

27 27 Clinical Departments Still Operate In Silos

28 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 28 Orders placed into system = 30 to 60 minutes

29 The Solution: Powering Clinical Integration with Technology Technology Integration 29

30 30 Referrals

31 Referral Management in the U.S. 66% 50% Non 34% Non 50% Exchanging patient information PCP to Specialist 66% refer to a colleague Specialist to PCP 50% refer to a colleague Often citing reasons: ease of communication share my medical record system 31 Source: J Gen Intern Med May;27(5): doi: /s z. Epub 2011 Sep 16. Reasons for choice of referral physician among primary care and specialist physicians. Retrieved May 11, 2015 at

32 The Problem with Referrals Only 16% of referrals are completed electronically 1 3 of every 10 tests are reordered 3 Redundant tests cost $8 billion per year (2.7% of inpatient costs) 4 20% of patients referred to a specialist don t show up where they re referred 2 Direct communication between hospitalist and PCP only in 3% - 20% of discharges 5 32 Sources: 1. Gaps in Referral Process between US Medical Providers 2. Specialty Referral Completion among Primary Care Patients 3. A Healthy System, Technology CEO Council 4. Health Affairs. Improving Safety And Eliminating Redundant Tests: Cutting Costs In U.S. Hospitals. and J Am Med Inform Assoc May-Jun;17(3): doi: /jamia A preliminary look at duplicate testing associated with lack of electronic health record interoperability for transferred patients Deficits in communication and information transfer between hospital-based and primary care physicians

33 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. 33 Gallup Article: Want to Increase Hospital Revenues? Engage Your Physicians. By Jeff Burger and Andrew Giger.

34 34 Managing Costs, Reimbursement, Average Length of Stay and Transitional Care

35 The Cost of Poor Communication Delayed care Poor continuity of care Medical errors The Joint Commission Sentinel Event database suggests poor communication contributes to nearly 70% of sentinel events, surpassing other commonly identified issues such as patient assessment and procedure compliance. Redundant testing Wasted resources Lower patient satisfaction 35 Source: Lower rate of referrals/ admissions

36 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) 36 Source: 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)

37 Reducing Readmissions Through Integration and Technology Integrating hospital and outpatient care is key to reducing readmissions. The Commonwealth Fund 37 Source: 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)

38 DASH

39 Direct Admit System for Hospitals (DASH) DASH integrated clinical technology and process flow changes referral patterns improves market share 39

40 DASH By the Numbers August 2012 December 2014 >700 Referring Medical Facilities 44% Requested Ambulance 4% Isolation Requested Self-pay 3% Federal 36% State 13% Payor Mix Commercial 48% 19 Hospitals 3 additional under contract 11% Re-Routed DX Entry 47% ICD 9 1% ICD 10 52% Free Form OP/OBS 24H w Tele 17% Med/Sur g w/o Tele 26% OP/OBS 24H w/o Tele 7% Pediatrics Bed 2% Bed Type 5% change ICU 8% IMU 8% Med/Sur g w Tele 32% Critical 3% Fair 1% Guarded 14% 40 >10K Admissions <1% No-Show Top 2 Conditions Respiratory Gastrointestinal Stable 82% Status

41 Easy as 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

42 Direct Admit Form 3 minutes Avg time to complete form 7 Only Mandatory Fields HIPAA Compliant Patient Information Protection 42

43 Direct Admit Recipients Admitting Physician House Supervisor DOC-to-DOC Sample Health System Click Link to securely login Click DOC to DOC to call referring Clinician 43 Admission Routed to referring facility s preferred on call admitting physician

44 Hospital Boarding Pass Sample Health System Sample Health 44

45 DASHBoard Analytics & Metrics Analytics & Metrics Overall Direct Admissions Click to Bed Time Bed Unavailability Rate Physician Acceptance Patient Throughput Referral Analytics Referring Physicians Referring Facilities... and many more Executive Dashboard 45 Live Streaming Analytic Data On Demand Analytic Reports

46 DASH Hospital Benefits Increased Hospital Occupancy Improved Hospital Throughput / Efficiencies Reduce Splitters Increase Referral Base Decreased Medical Utilization Decreased ER Crowding 46 Improve Focused Marketing Strategy Improve Patient Satisfaction

47 Building the Connection with Hospital Medicine Enhance communication between physicians Create stickiness in your referral network Expand your referral footprint Close the loop at time of discharge 47

48 Summary: Emerging Strategies for Improving Hospital Medicine VBP / BPCI / MSPB Patient Flow / Boarding VBP Integration Technology Transition Timing Treatment ALOS / Cost Per Case / CMI & Readmits Referrals 48

49 Hospital Medicine as Part of the Healthcare Evolution Changing expectations and demands in population health require new paths to success Moving toward a greater healthcare ecosystem requires shaping and adapting to survive in the new environment All must constantly create value within the ecosystem Accountability for performance is a necessity The right framework enables hospitalists to enhance hospital competitiveness 49

50 Q & A Francisco Loya, MD, MBA CEO, EmCare Hospital Medicine Francisco.Loya@emcare.com Mark Hamm CEO, EmCare Development Mark.Hamm@emcare.com Call (877) or visit