Achieving Integration Inside and Out

John Fredericks

John Fredericks , MD

Regional Director

Published September 17, 2015

Achieving meaningful integration has been a significant topic of discussion on Perspectives lately. We’ve highlighted how one hospital improved throughput with ED provider and hospitalist collaboration and how another organization co-designed shared processes between emergency medicine and hospital medicine to improve patient satisfaction. In this post, we build on the discussion by showcasing one organization’s efforts to integrate and improve coordination of care between the emergency department, hospital medicine, as well as intensivists, both inside and outside the hospital’s walls.

Joining Forces

Vituity has been staffing emergency departments (EDs) for Palomar Health for decades. Building on their success in the ED, they began providing hospital medicine services just over two years ago. Since then, the health system has seen improvements in hospital length of stay, case mix index and patient satisfaction scores.

Just this summer, we expanded our partnership with Palomar Health and began providing intensivist services to two of its hospitals - Palomar Medical Center and Pomerado Hospital. After seeing improvements from adding our hospitalist program, administrators hoped that staffing all three services with a single multispecialty group would help further improve care coordination and efficiency.

Our team is now committed to achieving similar improvements in the key intensivist quality, service and throughput metrics through focused efforts at improved communication, coordination and collaboration across all three practice lines.

Integrating Intensivists

We identified two intensivists with a long history at Palomar Health to serve as the Site Management Team. We’ve included them in the current emergency department-hospital medicine initiatives to improve care coordination and efficiency. Just a couple of months into its newly integrated structure, the team has worked side-by-side to implement several initiatives and activities to help Palomar Health reach its goals, including:

Co-designing integrated care solutions. Each month, emergency department, hospitalist and intensivist Site Management Team members come together to design integrated care solutions to make processes more coordinated, efficient and patient centered.

Opening the lines of communication. To identify opportunities to improve the patient experience, we established a secure Care Concern Line, where physicians can report issues or concerns affecting patient quality, safety, throughput or service. Identified issues are reviewed with hospital administration at the monthly JOC meeting to develop action steps for resolution.

Monthly performance metrics review. Palomar Health C-suite executives and practice line medical directors hold a monthly JOC meeting to review quality, service and throughput performance metrics.

Achieving hospital-physician alignment. To achieve Palomar Health’s strategic priorities, we’ve aligned hospital medicine and intensivist contract performance metrics to the organization’s goals.

Hospital-wide collaboration. Our physicians are leaders across the hospital, participating in a wide range of key committees and medical staff leadership activities. Aligning three service lines creates new opportunities for physicians to collaborate across the hospital.

Engaging system leadership. We’ve established quarterly meetings with Palomar Health’s CEO, the Vituity regional director and the emergency medicine, hospitalist and intensivist medical directors. These meetings provide a forum to discuss strategy and share updates on how the practice line integration efforts support the health system’s goals.

Clinical pathways development. We are developing clinical pathways to standardize care, improve outcomes and reduce costs. Palliative Care and Chest Pain (HEART Score) clinical pathways are now in place with others under development.

Improving transitions of care. We’ve implemented a number of measures to help patients transition smoothly from the ED to the hospital, including bedside handoffs, use of transition orders, and hospital medicine and intensivist photo care cards. Our intensivists prepare care summary notes when patients are transferred out of the ICU to the hospitalist service. In addition, for select patients presenting to the ED, we’ve adopted a team case review approach to consider alternatives to admission, such as palliative care, skilled nursing facility, home health and ED observation.

Beyond Hospital Walls

As the Centers for Medicare and Medicaid Services (CMS) shifts away from fee-for-service reimbursement and toward payment for value, coordinating care outside of the hospital setting is becoming much more important. Having a continuum of care in place can prevent hospital readmissions and offer alternative care settings for patients better served outside of the hospital.

With our newly integrated practice lines in place, Viuity and Palomar Health are engaged in several initiatives to improve ED-hospitalist-intensivist care coordination outside the hospitals’ walls. Those efforts include:

Dedicated psychiatric emergency services. Vituity and Palomar Health are in discussions with San Diego County Mental Health to establish and staff a freestanding psychiatric Crisis Stabilization Unit. The unit would help ease ED overcrowding, reduce costs associated with boarding psychiatric patients, and provide prompt intervention and stabilization for behavioral health patients.

Integrating Federally Qualified Health Centers. In an effort to decrease uncompensated and undercompensated ED care and to reduce avoidable ED visits, negotiations are underway to provide staffing for urgent care services at two Federally Qualified Health Centers. The model we’re proposing would utilize Vituity physician assistants to provide urgent care services, reducing ED use for non-emergent care.

Following patients to skilled nursing. Our hospitalists recently began providing care to three area skilled nursing facilities (SNFs) with additional SNF locations in development. This allows a single physician group to coordinate care across multiple care settings with the goal of discharging the patient back home. Benefits of this approach include continuity of care, appropriate use of resources in the event a patient experiences complications, reduced ED visits and reduced readmissions.

Coordinating care for long-term acute care patients. We are in discussions for our intensivist partners to provide services at a nearby long-term acute care (LTAC) facility for patients with serious medical conditions that require ongoing care. Having an intensivist presence at the LTAC will help manage the transition from the hospital to post-acute care setting, maintain continuity of care, and reduce the likelihood of a hospital readmission.

Improving access through telemedicine
Discussions have begun with Palomar Health and other local healthcare partners regarding the use of telemedicine to deliver healthcare services outside clinic or hospital walls to improve access to care and reduce healthcare costs.

Palomar Health’s ED-hospitalist intervention has resulted in significant improvements in length of stay, case mix index and patient satisfaction over the past two years. While we’re only a couple of months into the journey, we anticipate our new ED-hospitalist-intensivist alignment structure will result in better, more efficient care both within Palomar Health and beyond.

Partnering to improve patient lives

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