Thinking outside the box essential with risk contracting ventures
Thinking outside the box essential with risk contracting ventures
Become accountable for entire care continuum via partnerships
Administrative leaders at the Atlantic Health System in Florham Park, NJ, made some bold decisions related to post-acute services when the system was formed two years ago.
For one, they decided to eliminate the old administrative structure of managers and employees, and instead turned employees into self-directed team members.
"We have made some unbelievable philosophical changes, and we've completely changed our delivery-of-care structure," says Susan Brady, RN, MSN, director of post-acute services for Atlantic Health System, which has four hospitals, a rehabilitation facility, two nursing homes, and other services.
"It's helped tremendously from a managed care perspective," Brady says. "Payers love what we're doing; they love the level of care we provide, and they know the quality of care we provide."
The health system entered the reorganization process saying it would have to be budget-neutral or result in cost reductions, Brady says. "And we did have cost reductions because we eliminated some positions."
The only part of the change that will prove expensive - likely costing millions of dollars - is the information systems project, which will be expanded to multiple sites. Brady says she does not know yet how much that will cost.
The length of stay in the acute rehabilitation area has dropped by 2.5 days over the past two years to an average of 14.9 days. But while this decrease has occurred during the time in which the reorganization took place, the health system cannot definitely attribute it to the reorganization efforts, Brady says.
There were some practice changes that also have occurred in the past two years, Brady adds.
Following a trend that's become most popular among large manufacturing companies such as Saturn Corp., the hospital system has eliminated many post-acute management positions and instead turned to team management. Therapists, nurses and other employees have input to hiring, scheduling, and financial decisions. Patient care is directed by the people who provide it. (See story on how Atlantic Health System switched to team approach to improve continuum of care, p. 112.)
Atlantic Health System also decided to provide a more seamless continuum of care to patients by forming partnerships with post-acute providers.
"We looked at whether we needed to own every piece of the continuum, and we decided we didn't," Brady says. "We already had two nursing homes, but these wouldn't meet all of our needs, so we aligned with partners."
Risk contracts encourage care continuum
Increasing numbers of hospital systems will move in this direction as "continuum of care" becomes more than buzzwords, several experts predict.
Providers, especially when involved in managed care contracts, need to be able to analyze long-term outcomes along the entire continuum of care, says Alan H. Rosenstein, MD, MBA, vice president and medical director for VHA West Coast in Pleasanton, CA. Dallas-based VHA, is a not-for-profit hospital association with 1,600 hospital members nationwide.
Physicians and hospital systems might be setting themselves up to be like the 20th century's last horse and buggy owner in Detroit if they ignore the trends sweeping them into a world where providers will have risk contracts for Medicare and Medicaid patients, as well as for commercial populations.
"Nearly all physicians are feeling the impact," Rosenstein says, adding that their incomes are 20% lower now than they were five years ago.
"Their typical reactions, other than becoming defensive and argumentative is: 'I can live with this' or 'I'll retire in a few years and take it for the short term,'" Rosenstein says.
Providers will need to be proactive and change their style of providing episodic care, which may have served them well in the fee-for-service world, but won't work in today's managed care market. Here's why: if hospital systems, outpatient facilities, post-acute care businesses, and physicians work together to provide a continuum of care, they will be able to eliminate duplication and better handle the health care needs of a population of patients.
The reason these efficiencies are important is because many managed care markets are moving toward shifting risk over to providers, Rosenstein says.
"Physicians think they are all great disease managers, and some of them are," Rosenstein says. "But there are a lot of different pieces to the puzzle."
Real disease management means providers must assess the health care needs of an entire population and make sure patients regularly see their primary care physicians for checkups. Then, if a patient becomes sick, it likely will save health care dollars if the patient receives home care or rehabilitation services after hospital discharge.
"If they need treatment, keep them out of the emergency room, and keep them out of the hospital if you can," Rosenstein says. "So this may mean more frequent office visits or more support of ambulatory services, community support, outpatient clinics, or home health."
On the other hand, continuum-of-care programs have not been studied extensively, and so no one can say that they definitely improve outcomes, says Gregory Compton, MD, medical director and geriatric physician with the Senior Care Center in Fredericksburg, VA.
But clearly, many health care providers are moving in that direction because, at the very least, it will eliminate much duplication.
"I personally believe it is a better way to take care of the chronically ill, to have interdisciplinary teams of professionals caring for the whole patient," Compton says. The Senior Care Center is an outpatient geriatric evaluation unit that is part of the Medicorp Health System, a not-for-profit regional medical center in Fredericksburg. The health system includes the 300-bed Mary Washington Hospital.
The Senior Care Center team is able to take a holistic approach to a patient's illness, providing many different avenues of care at one time. The team may include a geriatric physician, nurse practitioner, geriatric nurse with social work background, and nurse educator.
For example, the center might see an elderly woman of 84, who lives alone, Compton says. The woman's daughter may live in the same small town, and the daughter has found that her mother is losing weight and not taking her medicine. Moreover, the mother has more physical complaints and does not remember conversations.
The daughter will bring her mother in to the center for evaluation. "Our job is to figure out what's going on," Compton says.
"Does she have a new medical illness that has not been recognized? Is she taking too little or too much of her medication?" Compton asks. "Or, we find she has dementia, a previously unrecognized dementia and self neglect, and she really is not totally safe at home."
The center's multidisciplinary team would assess the woman both physically and cognitively. Team members would review her social situation and screen her for depression. They'd order focused and appropriate laboratory tests, and then based on their findings, they'd teach the daughter about dementia and give her some specific recommendations.
"All this might happen in one visit of one to two hours," Compton says.
Then, if the patient needed additional services, the team might refer her to an assisted living community or a specialist.
A continuum-of-care approach also may provide solutions to support system and social problems that cause patients to return too frequently to the emergency department, says Kathleen Brody, BS, PHN, project administrator for the Center for Health Research of Kaiser Permanente in Portland, OR.
A patient, for example, may be wheelchair-bound, but otherwise stable. However, if the caregiver is sick and unable to drive the patient to the physician's office, the caregiver might use an ambulance and the hospital's emergency room for what should be an outpatient primary care visit, Brody says.
"If you don't have support programs in place, you'll receive medical calls for things that are social in nature," Brody adds.
Juergen H. Bludau, MD, a clinical geriatrician and medical director of Morse Geriatric Center in West Palm Beach, FL, has helped to establish this type of multidisciplinary team for the treatment of Alzheimer's disease patients.
Bludau says Alzheimer's patients were treated by a team that included a nurse practitioner and social worker in an outpatient setting at Youville Hospital in Cambridge, MA. Bludau formerly was the program director of a specialized geriatric rehabilitation facility at the hospital.
Members of the rehabilitation center's team included Bludau, a neuropsychologist, a geriatric psychiatrist, and a behavioral neurologist.
"So in this kind of team setting, we first of all diagnose the type of dementia a person has, treat accordingly, address any specific behavioral issues, and provide ongoing primary care and help with education for the family," Bludau says.
The team approach is essential in the care of patients with dementia, because an internist cannot deal with these patients' issues within a 15- to 20-minute office visit, Bludau asserts.
Also, the team would follow patients into the acute and subacute settings. For instance, Bludau might have received a phone call about a patient in an acute care setting, and he would suggest the physician or nurse speak with the team social worker about the case.
"Or once they were discharged, I'd see them as an outpatient for primary care follow-up," Bludau says.
The Extended Care Division of Saint Vincent Healthcare System in Worcester, MA, provides a continuum of care that extends into nursing homes for Medicare risk patients, says Christine C. Schuster, RN, MBA, vice president and chief operating officer. The health system has 350 acute care beds, a teaching facility, outpatient services, 560 skilled nursing facility beds, a home health agency, an adult day care center, and a laboratory company.
Saint Vincent Healthcare's nursing homes have geriatricians and geriatric nurse practitioners who help the hospital manage the utilization of these patients, Schuster says.
"We also have physicians who are emergency room facilitators," Schuster says.
When a patient enters the emergency room, the physician facilitator will assess whether the patient needs acute care or home care, or some other level of care.
"We are fully risk-capitated for acute care, subacute care, and home health care," Schuster says. "We make sure patients receive not too little care, not too much care, but just the right amount."
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