Tomorrow's Hospital Will Be 'Dynamic'
When Linda Moody and her husband Clifford moved from Florida to Albuquerque, New Mexico, three years ago, they had to pick both a doctor and a health insurer. Moody’s boss recommended Presbyterian Healthcare Services, an eight-hospital system with its own health plan and 600 doctors and other clinicians on staff.
Moody, 66, director of business and finance at the National Education Association of New Mexico, is very glad she listened to her boss. Within a year, Clifford, 67, was rushed to Presbyterian Hospital with breathing problems resulting from an egg-sized tumor in his throat. Though doctors warned “he might not make it out of surgery,” Moody says, today he is cancer-free.
Besides the operation, she says, it was what happened afterward that brought them through the crisis. “Kristin,” she says, “came into our lives.”
Kristin Berg is half of Presbyterian Hospital’s “intensive transition of care team,” tasked (along with a social worker) with figuring out which patients are apt to land back inside and making sure they don’t. Besides cancer, Clifford Moody would be dealing with a tracheostomy and a new diagnosis of diabetes. So, in addition to chemo and radiation and care by an oncologist, he would need to see his otolaryngologist, pulmonologist, primary care doctor and a dietitian.
Berg, a nurse case manager, lined up medical appointments and home services, accompanied Clifford to see his primary care doctor and was on call for the Moodys 24/7. She worked with Clifford’s doctors to fine-tune his medicines, expedited orders when there were problems with the trach tube, secured a suction machine and trained the nurse caring for him to use it. “I probably saved them four to five ER visits,” she says. “The goal was to avert rather than react to a crisis.”
This, in a nutshell, is where health care is headed. Far from being a fortress with beds full of sick people, the hospital of the future will be a dynamic system whose tentacles reach deep into the community, aimed at keeping people well and making sure they “get the right care at the right time in the right setting,” says James Hinton, Presbyterian Healthcare’s president and CEO, who is also chairman of the board of trustees at the American Hospital Association.
From coast to coast, the medical profession is experimenting with ways to care for people differently. Hospitals are hiring primary care doctors and coaching the people in their communities to stay well. They’re sending doctors on house calls, and putting nurses in the YMCA. A growing number are now screening patients for mental and behavioral health problems, which so often complicate or cause disease and interfere with treatment. And they’re using telemedicine and mobile devices to help patients better care for themselves.
The big motivator behind all this outreach, of course, is money. The end appears to be coming for fee-for-service payment systems that encourage a piling on of tests and treatments even when less would be more. Indeed, payment systems are changing in all sorts of ways that reward hospitals for keeping people well and make it costly to admit them.
Some insurance plans provide predetermined monthly payments per patient, and hospitals have to provide all care for that amount or lose money. Others hand over a lump sum for every element of care related to a heart attack or knee replacement, say, so hospitals have an incentive to keep stays short and provide treatment at home.
Tightly integrated health systems like Presbyterian and Intermountain Healthcare in Salt Lake City have a head start, partly because they are putting patient data to good use. By culling electronic records to look for good candidates for house calls, Presbyterian has been able to send doctors and nurses out to treat some 900 pneumonia, heart failure and other patients in their own bedrooms, for example. Telemonitoring allows instant access to clinicians and the checking of vital signs between daily visits.
Compared to traditional patients, the people participating in this “Hospital at Home” program die at rates 2.6 percent lower, get readmitted 7 percent less often, are more satisfied, and are some 20 percent less costly to care for.
“There’s no question about it, this was better than being in the hospital,” says Ben Guhrke, 87, who recently underwent surgery to repair a broken femur and had some post-surgical edema treated as a Hospital at Home patient. The service, he marvels, was “so responsive.”
Intermountain Healthcare, a system of 22 hospitals and 185 clinics in Utah and Idaho, relies on sophisticated number-crunching and is developing predictive analytics to identify its highest-cost patients – the 1 percent who account for fully a quarter of spending on care – and is changing the way it attends to them. These “hotspotter” patients visited hospitals or doctors an average of 41 times each in five years, versus six times for the typical patient. That doesn’t cut it in a system where a growing proportion of patients are served through an affiliated health plan that provides fixed premium payments to cover all the care they need.
Betting that “a better investment might be in helping patients to help themselves,” Intermountain this year launched two different interventions for hotspotters, says Scott Pingree, chair of high-cost patients and hotspotting.
Members of a new community care management team (a primary care doctor, a nurse, a care manager, a pharmacist, a social worker and a “transitionist”) travel to see them, coaching and cajoling them to better manage their medication, eat well and call on team members for home health visits rather than go to the ER. The team also helps get patients in touch with other assistance that can be key in heading off a health crisis, from Meals on Wheels to fuel or housing help to a contractor to fix a mold problem or to add a ramp or railing.
Helping patients help themselves is not a traditional hospital competency, but mobile technology is laying a pathway for it to become one. Davie Rivera of New York City, 41, says the text messages he began getting last fall from Montefiore Medical Center, which were programmed in by his care manager, have “helped a lot” in his effort to lose weight.
On disability for scoliosis and weighing more than 300 pounds a year ago, Rivera felt paralyzed by a lack of confidence. Getting regular texts reminding him of appointments with his nutritionist and for his spine condition and offering personal affirmations and tips for healthy eating helped him drop almost 100 pounds. They made him feel that the hospital “is in your corner,” he says.
Montefiore started its own health plan and began tightly managing patients two decades ago, as part of a struggle – in one of the country’s poorer counties, the Bronx – to stay solvent. Today, it’s one of the nation’s most successful Pioneer Accountable Care Organizations, a new government-supported model emphasizing prevention and high-quality care that avoids redundant or unnecessary tests and procedures and readmissions. ACOs share in any money they save Medicare, or they share the losses.
Montefiore was able to collect $14 million in shared savings for 2013, says Andrew Racine, senior vice president and chief medical officer, by moving a big proportion of care outside the hospital walls and substantially reducing readmissions.
As at Presbyterian, a “Medical House Calls” program brings doctor to patient. People who have suffered heart failure are equipped with smart scales that record and transmit daily weights to their providers, who can actively manage their condition using real-time data. The unacceptably high local diabetes rate has prompted a concerted effort by doctors and social workers to make sure patients understand their treatment plans and follow them. And Montefiore has set up more than 20 primary care locations throughout the area.
Most of these are “patient-centered medical homes” that provide primary and preventive care for every stage of life, with a focus on wellness and improved health. Medical homes combine the advantages of the old-fashioned family doctor, who makes the time to sit and talk with you, with a modern team approach to care that supports patients with psychologists, pharmacists, care managers and social workers. Evening and weekend hours help to accommodate busy schedules. By visiting MyMontefiore.net, patients can email their doctor, request a medication refill, create their own personal health record and access a library to help them find answers to their health concerns.
Presbyterian, too, has organized its 130 primary care providers, all of whom are on the payroll, into 10 patient-centered medical homes. In addition to routine care, doctors and nurse practitioners tell overweight patients to use the walking trails along the Rio Grande river, and prescribe fresh fruit and vegetables at the local farmers’ markets. Doctors can refer patients to mental health professionals down the hall.
Clinic care managers run weekly reports showing which of 14,000 patients with diabetes are overdue to get their hemoglobin A1C, LDL and blood pressure levels checked. Those patients are contacted to schedule appointments. “We’ve honed in on prevention that works,” says Dion Gallant, director of primary care services.
In some places, the hospital front lines are moving into other institutions. Carolinas HealthCare System, a 7,800-bed network based in Charlotte, North Carolina, embeds registered nurses, dietitians and athletic trainers in a dozen YMCA locations around the city. People dealing with diabetes or heart disease, say, or who are trying to lose weight, can get health coaching and exercise regimens to reach goals set by their doctors. The Y-based clinicians can view medical records and update them. So far, more than half of the people in the program who started off with above-normal blood pressure have lowered it significantly, and those with high LDL cholesterol levels have seen reductions averaging 15 points.
In Wyoming, Delaware, Susan Hoffmann, a school nurse at W.B. Simpson Elementary School, recently assembled a care plan for a first-grade boy who had just been diagnosed with diabetes. Hoffmann was able to access the boy’s medical information through an electronic health records system that Nemours/Alfred I. DuPont Hospital for Children created with schools in the state earlier this year so the Wilmington children’s health system could enlist other pediatric clinicians in an effort to improve kids’ health. Hoffmann’s plan included steps his teachers and school bus driver should follow if the boy became hypoglycemic. “It made a huge difference in the child’s seamless transition back to school,” she says.
A big part of keeping people physically healthy, it turns out, is making sure that their mental health needs are met. Not only do issues like substance abuse and depression cause physical harm and exacerbate ailments, but also they interfere with patients’ ability to comply with doctors’ orders. Montefiore this year established behavioral health services for children and adults in each of its primary care sites so it can quickly get them needed treatment; Intermountain has also been moving the two types of care into single clinics.
“Untreated childhood mental health problems cause more than half of the chronic medical problems in the country,” says Michael Hogan, former commissioner of the New York State Office of Mental Health. A report this past spring by Seattle-based consulting firm Milliman concluded that integrating the two can save the nation as much as $48 billion annually.
At Carolinas, the goal is to build access to mental health screening and consults into all locations, from the hospital bedside to the ER to the doctor’s office, so emotional well-being becomes “another vital sign,” says John Santopietro, chief clinical officer of behavioral health.
Since 1997, Carolinas has been providing telepsychiatry to people in the ER; some 300 consults a month now occur in the Charlotte area, a number expected to triple over the next year. Next, Carolinas is poised to beam the support of mental health professionals farther outward, to vulnerable people in hospital beds and primary care offices across its network.