Sage advice for hospitals struggling with how to meet the seemingly impossible demands of value-based care—and transform their organization into a truly evidence-based, collaborative, efficiency-minded and patient-centered center of excellence.
Although it has been 25 years since the Centers for Medicare & Medicaid Services (CMS) launched its first-ever bundled payment experiment for coronary artery bypass graft (CABG) surgery, the “lessons learned” remain surprisingly relevant for hospitals mandated to participate in a new set of cardiac bundles next year. I was lucky enough to be recruited as director of cardiovascular services by St. Joseph’s Hospital in Atlanta back in the 1990s when it became one of four demonstration sites for the initial bypass project. The hospital was already very good at heart surgery, had a great group of surgeons and patient outcomes were impressive. Where it needed a hand was in improving communications between cardiovascular surgeons and 100 or so practicing interventional cardiologists in the lead-up to heart surgery.
Sound familiar? It should. Hospitals worldwide continue to struggle with how to build multidisciplinary teamwork, one of the hallmarks of patient-centered care.
The first order of business back then was to build a database—registries were not yet commonplace—so we knew who we were treating and which patients were going to be referred to surgery. But we soon realized that many other people needed to be playing off the same sheet of music, including nephrologists (because of the risk of kidney injury) and neurologists (because of the risk of stroke). And we began to meet regularly to view outcomes, put protocols in place and ensure appropriate staffing levels. Coordination was certainly a necessity at St. Joseph’s, with only 325 beds to accommodate the 2,000 heart surgeries and 3,500 angioplasties it was doing every year.
The lessons learned in subsequent CMS bundled payment programs, including the 2009-2012 Acute Care Episode (ACE) demonstration and the ongoing Bundled Payments for Care Improvement (BPCI) initiative and Comprehensive Care for Joint Replacement (CJR) model, are remarkably similar to those from that original experiment. I have one client that is generating revenue on a BPCI bundle for chronic obstructive lung disease—a miserable, hard-to-treat condition that can involve multiple hospitalizations—by reproducing some of its care redesign tactics for heart failure. It partnered with a long-term care facility and hospice to create a communication channel across the care continuum, ensuring readmissions only happened when warranted, and hired nurse navigators to regularly check in with patients and teach them how to cope with their shortness of breath rather than repeatedly running to the ER.
In a consulting capacity, I offer hospitals preparing for cardiac bundles coming in 2017—covering CABG and acute myocardial infraction (AMI) treated with or without angioplasty—much of the same advice I’ve been doling out for decades:
- Commit to making substantive changes. You can’t dabble in payment bundles and, even if they haven’t yet hit your neighborhood, you need to be prepare for them. An average performer with a good medical staff structure and established communication channels might be bundle-ready in a matter of a few months. But a hospital that hasn’t convened its first real quality meetings or started reducing variability in the way care gets delivered may find itself a year or more behind its competitors.
- Get all the players in one room. For an AMI bundle, that would include emergency room (ER) physicians as well as surgeons and cardiologists. Multidisciplinary decision-making aids in the selection of the most optimal treatment strategy for individual patients because a team of medical minds can better analyze and interpret available diagnostic evidence, as well as consider individual preferences and local expertise.
- Present physicians and nurses with good data. This is the most foolproof way to ensure they make the right decisions. Openly share outcomes data—viewed from their perspective and that of patients—and if they don’t immediately declare “my patients are sicker” they’re probably not listening. Don’t give them a hall pass. Acknowledge that there will never be a perfect data set and engage them in addressing the clearest signals that things are amiss.
- Focus on the patient. Your cath lab should be open for patients having an acute coronary syndrome—even if it is Friday at 4 p.m., their enzymes aren’t sky high and it doesn’t feel like an elephant is sitting on their chest. If you wait until Monday, that’s two days they’ll be laying in a hospital bed wondering if they’re about to have a heart attack. Also be sure to have point-of-care testing and protocols available in the ER so you can quickly rule out some suspected cases of acute coronary syndrome and safely send those patients back home.
- Always do what is best for the patient. An AMI patient you just treated may have three-vessel coronary artery disease and need surgery at some point, and the ideal time may be before the end of the 90-day episode. We know that outcomes are better if surgery is postponed at least 24 hours after the initial AMI, and it may be reasonable to wait longer to give the heart more time to recover. But keep in mind that CMS intends to look at what happens after episode periods end to see if providers are just waiting out the 90 days, turning one episode into two.
- Be good stewards of healthcare dollars. If we were in any business other than healthcare, this would already be the norm. If you need lab results you can’t find, search another 30 seconds before you order it from the stat lab. Better yet, maintain point-of-care testing so clinicians can make better decisions at the bedside. You’ll need to be fastidiously adhere to Clinical Laboratory Improvement Amendments requirements (focused mostly on operator competency), but the practice can help you better manage patients and help ensure optimized clinical outcomes.
- Find ways to shorten lengths of stay (LOS). Patients neither heal nor feel well when they’re in the hospital because the environment deprives them of sleep. They will recuperate better in their own bed. Two decades ago, St. Joseph’s successfully pushed its postoperative LOS for CBAG patients down to five days—two days shorter than the average postop LOS today—all while maintaining good outcomes.
- Educate post-acute providers. Although they care for many heart failure patients, post-acute facilities are staffed largely by LPNs and certified nursing assistants with limited clinical expertise. Plus they have many other patient populations they must tend to simultaneously. Educate them about the patients you’re sending them, familiarize them with new drugs, and inform them of your communication and reporting expectations. Otherwise, physicians could end up fielding more phone calls than they have time for and patients might be inappropriately sent to the ER.
Clinical leaders can become so involved in the complex, day-to-day business of running a service line that they can’t see the forest for the trees; they may need an informed and objective third party to redirect their focus. As an R.N. who has had her boots on the ground for many years, I know only too well that it’s hard to think strategically when you’re worried about whether a patient is ready to send home or if you have enough nursing coverage for the day.