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Denver Health’s program to reduce share of ‘super utilizers’

Denver Health is taking steps to reduce the problem of a small number of patients using a hugely disproportionate share of hospital services. They’re often called “super utilizers.”

Chief Quality Officer Thomas MacKenzie, M.D., told Hospitals & Health Networks that the system has not only improved the care of these people  it has also saved millions of dollars over a two-year period.

H&HN says:

“Much of the impetus for Denver Health’s shift in priorities came from a report out of Camden, N.J., which found that just 1 percent of the city’s population accounted for 30 percent of its health care costs. In a 2011 article in The New Yorker, Atul Gawande, M.D., chronicled how Camden health care leaders developed a comprehensive program to identify and serve those super-utilizers.

“’In that article, he really described well the dilemma we face in terms of [continually confronting] chronic medical conditions,’ recalls MacKenzie, who is an internal medicine doctor and also teaches at the University of Colorado School of Medicine. Inspired by the story, ‘we set out to avoid high-cost utilizations that we felt were preventable,’ McKenzie says.

“Using funding from the Center for Medicare and Medicaid Innovation, Denver Health set out to transform its primary care practice into one that uses population health strategies and predictive modeling to improve health care delivery and reduce costs. ‘We applied it to the entire population,’ MacKenzie says. ‘That was something we hadn’t seen done in other healthcare systems.”’

H&HN reported that Denver Health decided to divide its roughly 150,000-patient primary-care population  into four tiers:

  • “Tier One – Patients without a history of hospitalizations or chronic medical conditions.
  • “Tier Two – Patients accounting for health care expenditures four times greater than Tier One’s. Denver Health designated patient navigators for Tier Two, embedded behavioral health technicians and had social workers focus on this group.
  • “Tier Three – Patients with quadrupled health care costs compared with Tier Two. Members of Tier Three have multiple chronic medical conditions, may have mental illness and substance abuse issues.
  • “Tier Four – These are Denver Health’s ‘hot spotters,’ Tier Four often deals with homelessness, substance abuse and serious mental illness. Denver Health created a special outpatient clinic for this patient group, designated psychologists, nursing care coordinators and substance abuse counselors”

To read more, please hit this link.

 


Berwick: Focus on competition instead of cooperation hurts healthcare

Don Berwick, M.D., says the current emphasis in the healthcare industry on competition instead of cooperation prevents  the sector from accomplishing the goals of the Triple Aim — higher quality care for individuals, improved population health and lower costs.

Dr. Berwick is president-emeritus and senior fellow at the Institute for Healthcare Improvement (IHI) and former acting administrator of  the Centers for Medicare and Medicaid Services.

“Competition is not the answer,” he said. “It is the problem.”

FierceHealthcare reported that “Dr. Berwick contends that healthcare leaders and their teams must learn to act and think in a fundamentally different way. And it requires cooperation, which may be difficult for some healthcare professionals to do in such a competitive industry.”

To read the Fierce piece, please hit this link.


Video: ‘Infrastructure’ before ‘culture’

In a NEJM Catalyst video, Brent James, M.D., vice president and chief quality officer for Intermountain Healthcare in Utah, says that ” infrastructure” lays the foundation for institutional “culture,” and that it can act as a tool for reducing stress and increasing resilience in the care-delivery workforce.

By “infrastructure” he means  such things as workflow and clinical processes, transparency into interactions with patients and information technology. “In your role as a {physician} leader, the infrastructure that you create is your hand that reaches beyond the organizational grid. It will last long after you are gone, far longer than anything else you do. You can create an environment that changes the future.”

“Clinicians are the only ones who have fundamental knowledge about the workflows that define their care. But they don’t control the systems that set the context within which they work. The key question for a leader is, how do we make it easy for them to do it right?”

To see the video, please hit this link


Make patients custodians of their medical records

Kumar Yogesh, M.D., an independent primary-care physician in Dresden, Tenn., writes in Medical Economics:

“During the good old days…. the role of primary-care physician (PCP) was a respected position. I’m guessing that during that time, we, the physicians, assumed the role of custodians of patients’ medical records.

“In today’s world of electronic medical record systems, we all have realized that tremendous unnecessary data is being generated to satisfy regulatory agencies and billing systems. Patients have taken it on themselves to see multiple physicians while marginalizing the concept of  the PCP. In such an environment, being custodian of these records is becoming increasingly cumbersome, useless and very expensive.

“I would like to propose a novel idea to our fellow physicians. …Tremendous amounts of time, energy and money can be saved and redundancies eliminated, resulting in much less stress for our staff and much less destruction with performance and duties of physicians. Let all physicians unite and demand to relinquish control of medical records and transfer this responsibility to the patient.”

“No consulting office, emergency room or hospital will have to call us anymore, since they can obtain all this information from the patient. When we order our tests such as CT scan, MRI, or if we prescribe any medications, the controlling authorities can look into the patient record for their approval process. No need to bother us anymore for any prior authorization and let us be doctors focused with patient care. I can imagine my office being a lean, mean machine with 100% dedication toward patient care. Would this not be a dream?”

To read all of Dr. Yogesh’s essay, please hit this link.

 


Data digging into social determinants of health

John Glaser and Tanuj Gupta, M.D., write in Hospitals & Health Networks about  providers’ using data to more holistically  understand their patients. Among their remarks:

  • “Look for links between geographical ‘hot spots’  that have high medical costs and relevant SDOH {social determinants of health} in those areas.
  • “Identify patients with risk factors related to SDOH .
  • “Classify patients into groups based on health outcomes, utilization, cost or other relevant factors and divide them into low risk, rising risk and high-risk subgroups.
  • “Link rising risk and high-risk patients to the appropriate community resources or care provider to help them mitigate their risks.

“Providers can apply analytics to entire communities to do a comprehensive community health needs assessment. They can assess gaps in social and clinical needs, select priority community health issues and plan improvement strategies. For example, a study of the data might reveal a large prevalence of homelessness in a geographic area that is also a ‘hot spot’ for high medical costs. Public libraries often become a safe place for homeless people to take shelter.

“The health system and the public library may be able to work together on programs to address health issues and homeless issues. If a geographic region has lower-than-average availability for affordable housing due to restrictive zoning, the health system might partner with a law firm to help address zoning issues in the area.’’

To read their whole report, please hit this link.


Study: Almost half of U.S. healthcare provided by EDs

 

A study published in the International Journal of Health Services determined that hospital emergency departments provide nearly half of all medical care in America. No wonder U.S. healthcare is so astronomically expensive! But are these data too old ?

University of Maryland School of Medicine (UMSOM) researchers studied available data between 1996 and 2010 from several national healthcare databases and determined that emergency departments contributed an average of 47.7 percent of the medical care in the U.S., and that  the percentage increased steadily over the 14-year study period.

“I was stunned by the results. This really helps us better understand healthcare in this country. This research underscores the fact that emergency departments are critical to our nation’s healthcare delivery system,” David Marcozzi, M.D., an associate professor in the UMSOM Department of Emergency Medicine, and co-director of the UMSOM Program in Health Disparities and Population Health, said in a study announcement. “Patients seek care in emergency departments for many reasons. The data might suggest that emergency care provides the type of care that individuals actually want or need, 24 hours a day.”

The researchers found that African-Americans, Medicare and Medicaid beneficiaries, residents of the South and West, and women accounted for increasing percentages of ED use over the 14 years.

Dr. Marcozzi said that while hospitals have been trying to discourage patients from using emergency departments for non-emergencies,  policymakers might want to reconsider that approach given the fragmented structure of the country’s healthcare system. Instead, he suggested, perhaps  emergency departments should be considered  as part of a  wider approach to  healthcare reform, including boosting population-health efforts.

To read the study, please hit this link.

To read FierceHealthcare’s comment on the report, please this link.


Addressing hospitalists’ burnout

Hospitals & Health Networks’ Lola Butcher looks at the very serious problem of burnout among hospitalists.

She notes that over 52 percent of hospitalists and nearly 55 percent of outpatient internists are affected by burnout, according to the 2014 Journal of Hospital Medicine study.

“But hospitalists differed from internists in some ways. For instance, hospitalists were more likely to have low scores on one key symptom of burnout: personal accomplishment. But hospitalists and outpatient internists had similar scores on emotional exhaustion and depersonalization, which are other common symptoms.”

Ms. Butcher writes: “The causes of burnout among hospitalists — and the actions needed to prevent or mitigate burnout — vary from one hospital unit or department to the next. But there are a few burnout contributors specific to hospital medicine that health system executives should investigate,” says Danielle Scheurer, M.D., chief quality officer at Medical University of South Carolina in Charleston.

“A root cause of burnout among hospitalists, in her view, is an ever-expanding list of responsibilities.”

”’They can be in situations where they end up being the jack of all trades — the pharmacist and the case manager and the social worker,’ says Dr. Scheurer. ‘They don’t necessarily have the skills and competencies to be great at those things, and it takes away from their core background skills and competencies.”’

Dr. Scheurer suggests simple ways to help  stem burnout, such as:  “Let’s create a whiteboard or a chat room in the medical record so the hospitalist can address nonurgent things as opposed to getting paged every 10 to 15 minutes.”


Conn. Children’s Medical Center focuses on analytics to make improvements

Hospitals & Health Networks reports that “analytics are the heart of data-driven continuous improvement and performance excellence initiatives at Connecticut Children’s Medical Center in Hartford.”  To read H&HN’s whole report, please hit this link.

Richelle deMayo, M.D., the hospital’s chief medical information officer, said: “Reporting, dashboards and registries permit us to examine relationships between process and outcome. We can also identify and address opportunities to achieve operational efficiency. Patient throughput, readmissions, timely discharge, clinical documentation improvement and charge capture have all benefited from our ability to benchmark and track key performance indicators.”

Hospitals & Health Networks reports that  the hospital focuses on:

  • “Developing reporting tools and dashboards for performance improvement.
  • “Using clinical and business intelligence tools to track patient and provider-level metrics and outcomes.
  • “Reviewing scorecards regularly by all clinical managers, directors and vice presidents.
  • “Using scorecards for early detection of potential problems and care redesign.
  • “Redesigning EHRs to remove features with questionable value that distract and detract from clinician-patient interaction.”

 

 

 

 

 


The foggy future of ACA implementation

Ken Bottles, M.D., a lecturer at the Thomas Jefferson University School of Population Health, in Philadelphia,  and chief medical officer of PYA Analytics, made these predictions to FierceHealthcare:

  • “Congress will not revisit the repeal and replacement of the Affordable Care Act before the end of the year. It is simply dealing with far too many other issues—passing a budget, raising the debt ceiling, approving disaster aid for Harvey and Irma, not to mention its desire for tax reform—that lawmakers must address.
  • “While the Senate HELP committee is attempting a bipartisan effort to shore up the ACA, the issues listed above will make it almost impossible for such a law to be passed during this session.
  • “The leadership of the Department of Health and Human Services ideologically opposes the very concept of the ACA and is also responsible for implementing the law. The tension between those two facts will lead to confusion and uncertainty for those of us in healthcare.
  • “The passage of the ACA changed the terms of debate around healthcare reform. Granting health insurance to more than 20 million Americans has now shifted public opinion so that a solid majority believes the federal government should ensure that its citizens have insurance.
  • “The ACA is not failing, but going forward it can be undermined without congressional action.”

To read more,  please hit this link.

 


Probe suggests Joint Commission accreditation a joke

The Joint Commission, the accrediting organization for about 80 percent of U.S. hospitals,  rarely revokes its approval of facilities out of compliance with Medicare rules, reports The Wall Street Journal.

The WSJ, after digging into  Joint Commission inspection reports from 2014 through 2016, found that in 2014, about 350 hospitals with Joint Commission accreditation had violated Medicare requirements that year, and about a third had additional violations in 2014, 2015 and 2016.

The paper reported that the commission  revoked accreditation for just 1 percent of hospitals out of compliance with Medicare. More than 30 hospitals retained their accreditations even though the Centers for Medicare & Medicaid Services found their violations important enough to cause, or likely cause, serious patient injury or death.

“It’s clearly a failed system and time for a change,” said Ashish Jha, M.D., a health policy researcher at Harvard’s T.H. Chan School of Public Health and a practicing internist, told the paper.  The probe “shows accreditation is basically meaningless—it doesn’t mean a hospital is safe.”

To read more, please hit this link.


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