Integrated Clinical Pathways Improve Management of Chronic Disease Patients

Ryan Shanahan

Ryan Shanahan , MD

Emergency Physician, St. John's Regional Medical Center
Kabir Yousuf

Kabir Yousuf , MD

Cardiologist, Maryland Cardiovascular Specialists
Samit Desai

Samit Desai , MD

Emergency Physician, St. Agnes Healthcare

Published March 15, 2018

Representation of a clinical pathway
The shift toward value-based care has created a need for greater collaboration and care coordination across healthcare settings. Nowhere is this truer than in Maryland, where all hospitals are operating on fixed "global budgets" as part of a five-year healthcare experiment.

In order to succeed under global budgeting, hospitals must find ways to reduce costs while delivering excellent outcomes. In today's post, we'll share how emergency physicians and specialists at one Baltimore hospital are working together to better manage patients with chronic disease.

Reducing Admissions: It's Complicated

Under global budgeting, the ability to manage population health is a critical success factor. With inpatient stays averaging around $2,000 a day, one of the most effective ways to cut costs is to reduce preventable admissions by shifting care to outpatient settings.

Of course, this is easier said than done.

Here's a scenario that illustrates why patients with chronic disease exacerbation are routinely admitted from many EDs. Let's say a patient with chronic heart failure (CHF) presents to the emergency department complaining of nausea and shortness of breath. Her records are so voluminous that they would literally take hours to read. And she doesn't have a primary care physician who can fill in the blanks. From the emergency physician's point of view, an admission is the safest course of action.

There are a few things hospitals can do to change this pattern. First, they need to proactively identify patients who might benefit from more intensive management and care coordination. Second, they must mobilize departments, providers, community organizations, and fellow hospitals to coordinate care and to seamlessly transition patients across settings.

That's where clinical pathways can make a difference.

Asking the Data

When Vituity began managing Saint Agnes' ED, the group was eager to help the hospital meet its quality goals. Incoming ED Medical Director Pascal Crosley, DO, established a task force to identify frequent ED utilizers and write care plans that included a capsule history and recommendations.

The task force was so successful that Saint Agnes expanded it into a hospital-wide initiative. To further enhance care, specialists from across the organization divided into disease-specific task forces aimed at managing the hospital's three most costly conditions:
  • Congestive heart failure (CHF)
  • Chronic obstructive pulmonary disease (COPD)
  • Diabetes-related illness

The newly formed task forces analyzed mountains of patient data, including number of inpatient days, number of ED visits, and spending per patient. They found that like many other hospitals, Saint Agnes was routinely admitting ED patients with multiple chronic and comorbid conditions.

In some cases, these admissions were entirely appropriate. However, each task force identified a subset of patients that could be effectively managed on an outpatient basis. Generally speaking, these were patients who had already received a satisfactory workup and presented to the ED in stable condition.

The task forces also wanted to address the root causes of frequent ED utilization. Almost any chronic condition can be worsened by medication issues, infections, poor diet, and lack of access to follow-up care. However, it's difficult to address these problems during an ED visit or short inpatient stay.

Cutting a Path

To better manage chronic disease patients, each task force created an integrated clinical pathway specifying actions and evidence-based interventions to be carried out by the care team. To illustrate, let's take a closer look at the CHF pathway, which is anchored by the ED and the Heart Failure Center (an outpatient clinic located on the hospital campus).

The pathway starts in the ED, where emergency physicians identify CHF patients who can be safely treated and discharged. They confirm that the patient has had a prior workup for CHF and rule out serious issues like pneumonia and renal failure.

If everything checks out, the ED nurse navigator makes a referral to the Heart Failure Center and arranges to transfer the patient. The emergency physician also calls the center to hand the patient off.

The center is supervised by a cardiologist and staffed with nurse practitioners, RNs, and a nurse navigator. The staff administers IV diuretics and modifies and titrates the patient's medications. In most cases, this allows that patient to be safely discharged home.

One advantage of treating patients in the Heart Failure Center is the wealth of resources offered, including:
  • A robust educational program that addresses diet, medication reconciliation, and other issues related to living with heart failure.
  • Referrals to primary care providers, home health, and specialists, plus assistance in coordinating appointments.
  • Referrals to community programs that can assist with housing, transportation, and nutrition.
  • Palliative and spiritual care for patients with advanced disease.
  • An additional point of contact for questions, concerns, and follow-up.

Making It Happen

Saint Agnes' disease-specific clinical pathways are still quite new, and the task forces are learning new lessons every day. But those interested in creating similar pathways, here are a few tips for getting off the ground.

Nurture champions. At Saint Agnes, the task forces benefited from the guidance of Samit Desai, MD, Chief Medical Informatics Officer, who is an expert in population health initiatives. Vituity emergency physician Ryan Shanahan, MD, and Heart Failure Center Medical Director, Kabir Yousuf, MD, laid much of the groundwork for the CHF pathway described above.

Think logistics. One of our biggest challenges with the CHF pathway was creating capacity in the Heart Failure Center so that ED patients could be treated in a timely manner. That process is now facilitated by the nurse navigators, who track openings and prioritize patients as needed.

Be intentional about communication. A clinical pathway should specify who communicates what, to whom, and when. In the CHF pathway, the ED nurse navigator makes the referral, and the ED physician performs a handoff to the receiving provider. In addition, the Heart Failure Center staff regularly reaches out to the ED in order to "pull" CHF patients who may be waiting.

Obtain buy-in. All providers who participate in the pathway need to feel confident that patients are receiving the best possible care. Allowing everyone to give input on pathway criteria and protocols will foster transparency and help to put minds at ease.

Looking Ahead

One of our overarching goals at Saint Agnes is to improve long-term management of our chronic disease populations by addressing the root causes of exacerbations. For example, many of our patients have difficulty purchasing healthy, fresh foods, because there are so few grocery stores in West Baltimore. By connecting patients with community nutrition programs, we hope to improve their diets and their long-term health outcomes.

We also hope to create pathways for additional disease processes. One of the most promising is atrial fibrillation. The release of new oral anticoagulant medications now allows us to manage more of these patients outside the hospital. We're also looking to implement a low-risk chest pain protocol in which suitable ED patients are referred to a cardiologist for a same-day or next-day consultation.

Finally, we want to increase the number of patients participating in each pathway. The data suggest that many who aren't necessarily "high utilizers" might still benefit.

Overall, we're excited about the possibilities of these pathways. While hospitals all over the country are pioneering approaches to value-based care, sheer necessity has driven Maryland ahead of the curve. As ACOs and risk-sharing arrangements become more prevalent, pressure to manage populations and reduce inpatient utilization will increase.

Hopefully the care delivery innovations we pioneer in Baltimore can benefit patients across the country.

Originally published June 15, 2016. Updated March 7, 2018.

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