Efficiency Ensures Access
To successfully bend the cost curve, health care reform must redeploy resources now spent for acute care toward preventive and primary care practiced in community-based settings. For health care networks looking to manage the care of their patients, that means using each component of the delivery network seamlessly. Non-acute settings such as primary care practices, nursing homes and home care services are now essential assets in care management. In 2010, each affiliate within URMC focused on improving efficiency – an effort that enables the system to meet rising demand without sacrificing fiscal stability.
Hospitals Begin “Epic” Journey
Recognizing that truly integrated care requires the ability to securely access all of a patient’s medical information and history at a variety of settings, those who framed health care reform provided funding for health care networks to implement electronic health records (EHR). URMC seized this opportunity to rapidly move forward with building a single patient-centric EHR that spans URMC's entire acute care system – inpatient and outpatient.
The Epic system, known at URMC as “eRecord,” will put nurses, attending physicians, even community doctors on the same page (or, technically, the same screen), as they leverage the same integrated tools to promote patient safety, enhance care quality and efficiency, and extract the data needed to drive clinical research. The centerpiece technology of the Medical Center’s strategic plan, $80 million investment in eRecord is also a critical tool in URMC’s effort to become more patient and family centered.
In preparation for going live with the inpatient electronic health record at Strong Memorial in the first quarter of 2011, URMC is completing the final testing on its new eRecord system to ensure that all interfaces with laboratory, pharmacy and other ancillary departments function smoothly and is training 8,000 users. Afterward, Highland users will begin training, prepping for that hospital’s go-live in fall 2011.
Nursing Home Tests Value Purchasing
The Highlands at Brighton is participating in a federal, three-year, pay-for-performance effort, the Nursing Home Value-Based Purchasing Demonstration. This Centers for Medicare and Medicaid Services-sponsored (CMS) project will assess the performance of participating nursing homes based on selected quality measures. CMS will then offer financial incentives to nursing homes that meet certain conditions for providing high quality care in an effort to improve the quality and efficiency of care provided to Medicare beneficiaries. The demonstration project is currently in New York, Wisconsin, and Arizona.
Lean Performance Improvement
URMC added to its arsenal of efficiency improvement tools in 2010 by establishing a more robust program in Lean Performance Improvement techniques, and naming Marvell Adams as its director. Tapping Kodak Operating System experts, Strong and Highland hospitals each launched a series of Lean Improvement projects, including an effort to ensure that both hospitals’ operating rooms function on a timely schedule. Participants conducted a “Kaizen” event – using a Japanese problem-solving exercise that helps teams spot waste and inefficiency by breaking activities into their most basic steps. Consistently starting surgeries on time enables the hospitals to increase cases within their existing facilities and minimizes stress on patients and families.
Among the inefficiencies of the U.S. health care system that caught the attention of those shaping health care reform was the nearly one in five Medicare patients who are readmitted within 30 days of discharge from a hospital. Experts estimate the cost to society for these readmissions at more than $17 billion per year. In addition to placing undue physical, emotional, and financial stress on patients, these avoidable readmissions strain access to Rochester’s already crowded Emergency Departments and inpatient units. In 2010, Strong Memorial Hospital vowed to reduce avoidable readmissions from 5 percent down to four percent through a concerted effort led by division chief of General Medicine Marc Berliant, M.D., along with director of Social Work and Patient and Family Services Kelly Luther and associate director of Nursing Anna Lambert. Pilots on the 5-1400 and 7-1200 units helped drive a “Safe Transitions” formula for success: flagging the charts of those patients at high-risk for readmission then targeting them for more intensive follow-up. But there are certain standard measures that all patients will now experience, including more timely communication between the hospital and their primary care doctors at the time of their discharge, a follow-up phone call within 24 hours of discharge, and making sure that patients have follow-up visits with their primary care physicians within three to five business days after discharge. Plus, a member of the care team will phone the physicians of high-risk patients to see what else can be done to ensure recovery. In January of 2011, the Safe Transitions effort will become standard on all inpatient units at Strong. It represents an unprecedented partnership between nurses, pharmacists, specialists, hospitalists, and community physicians. Following staff and provider education, Highland Hospital began implementing this approach in December of 2010 with a pilot on inpatient units W6 and W7, with the intent to expand the effort to all inpatient units in 2011.
Efforts to prevent needless readmissions have not only forged a partnership between hospitals and primary care physicians, they have enabled URMC to leverage the services of its home health agency, Visiting Nurse Service (VNS). Working through the Finger Lakes Health Systems Agency, VNS is one of two home care agencies to introduce “Transition Coaching,” a four-week program that matches patients with complex care needs with a transition coach who teaches them self-management skills as they move from hospital to home. Tools include an electronic Personal Health Record, discharge preparation checklist, medication list and a follow-up visit with the patient’s primary care physician. This low-cost, low-intensity intervention includes having a home health nurse visit the patient while still hospitalized, again after discharge, and maintain contact through a series of phone calls for 30 days after discharge. An assessment of the Transition Coaching effort in 2010 showed that participants were 38 percent less likely to be readmitted for up to six months. Patients also reported that their symptoms were better managed and their recovery was improved.
Insurers Tap Telehealth
VNS’s success using telehealth technology to remotely monitor patient symptoms and vital signs caught the attention of insurers looking for ways to reduce hospitalization rates among the chronically ill. In 2010, Monroe Plan and MVP contracted with VNS to provide telehealth services to their patients based on reports documenting the agency’s program reduced hospitalization dramatically. Patients with heart failure who enrolled in VNS’s telehealth program were 52.91 percent less likely to be hospitalized, and 46.49 percent less likely to require an emergency room visit. These results eclipse those of all home care agencies in the region, state, and nation. Equally as compelling, patient satisfaction with VNS’s telehealth program ranges between 80 to 90 percent with all aspects of the program.
Late in 2010, Highland Hospital opened a nine-bed short-stay unit that will streamline care in the Wolk Emergency Department (ED). Highland’s Observation Unit will focus on patients who require stays of 24 hours or less as doctors determine whether they require admission. Creating dedicated space for these types of patients takes them out of the flow of the mainstream ED without using limited inpatient beds. Highland’s ED leadership estimates that as many as 10 percent of the hospital’s ED patients could take advantage of the new unit. The Observation Unit is one way in which Highland is looking to improve efficiency and ensure a more patient-friendly experience for patients and families as it cares for an increasing number of patients.
Highland Hospital also completed construction of an expanded and all-new hospital lobby in 2010. The project added seating capacity to accommodate the rising number of inpatients and surgical cases at Highland, along with several amenities such as an outpatient pharmacy, patient education kiosk with computer access, a coffee shop, fireplace and piano.
Major Facilities Projects Completed in 2010
Strong Memorial Hospital:
- Electrophysiology Laboratory Expansion
- Gastroenterology Endoscopy Laboratory and Clinic at Sawgrass
- Addition of Ambulatory Operating Rooms at Sawgrass
- 10 beds added to Medicine/Behavioral Inpatient Unit
- Five incremental beds added to 4-3400 unit
- Nine short-stay beds added to Wolk Emergency Department
- Lobby renovation with addition of outpatient pharmacy, education kiosk, and coffee shop