Research by Marty Stempniak

ABOUT THIS SERIES

H&HN has created this exclusive yearlong series called Fiscal Fitness with the support of the VHA. Finding ways to rein in expenses without sacrificing quality and safety is imperative for hospitals as they struggle to maintain financial viability in a shifting payment system even as their operational costs continue to climb. Over the next several months, we'll look at everything from the supply chain to pharmacy, IT and more. Follow the Fiscal Fitness series in our magazine and in our e-newletter H&HN Daily.

The Mrs. Johnson visiting Rahul Koranne, M.D., at the hospital was a fake, — dolled- up and straight from the beauty parlor. It wasn't until he paid a visit to her home that the doctor saw the real Mrs. Johnson, and the factors that were keeping her from managing her health — urine-soaked furniture, wires creating trip hazards all over, no contact information for her son, and no advanced care plan anywhere to be found.

CEOs who treat post-acute providers like a "black hole," who never visit those outside sites, and hope for a smooth landing once a patient leaves their hospital "do not get it," says Koranne, vice president of four-hospital HealthEast Care System, and executive medical director for Bethesda Hospital, a long-term acute care provider in St.aint Paul, Minn.

"That's the Mrs. Johnson that creates the costs in the U.S. health care system. How are we going to deal with her?" says Koranne. "We cannot deal with her from our executive offices and sitting inside a hospital or a clinic. The only way to truly care for Mrs. Johnson is to be with her where she is."

Making that leap of faith with skilled-nursing facilities or with home-health agencies is getting tougher and tougher, with everything from penalties for unnecessary readmissions, to patient surveys that gauge provider communication and discharge planning. Change, though, has to be lead by the health care industry and not the government for it to truly take hold, says Max Reiboldt, president and CEO of the Coker Group consulting firm.

Payers and providers alike are eyeing such innovations as bundled payment and accountable care organizations as strategies that could foster greater integration. By lumping together one sum for an entire episode of care, bundled payment ideally will force clinicians to better communicate better with each other, share data and more accurately calculate the total cost of care. All of the providers involved in a patient's care can then share in the savings. To do so, hospitals must come up with an alignment strategy with physicians and other facilities, followed by the and then forming a clinically integrated networks or accountable care organization, according to Reiboldt.

One of the biggest impediments to integration can be old hard feelings, between hospitals and physicians, and a lack of trust, he says.

"Predictably, it's history, things that have happened in the past where doctors don't trust hospitals and vice- versa. I'd say that's the No. 1 inhibitor to putting these arrangements together. Simply, there's a lack of trust that really goes both ways," he says.

Hospitals need to start working now to strengthen communication channels between their post-acute care facilities, rather than waiting until the industry has settled into a value-based payment model, says Laura Jacquin, R.N., managing director in the clinical operations practice of Huron Healthcare. If those outside providers aren't owned by a hospital or health system, strong contracts are essential to ensure that the right staff isare in place, quality metrics are being followed, and that a plan is in place for a smooth transition. On the front end, hospitals need to associate themselves with efficient primary care and specialty clinics that employ continuum-based providers who streamline patient access to help avoid the acute-care setting. Physicians, nurse practitioners or patient navigators, using a collaborative, patient-centered approach possibly can help patients to possibly avoid reaching that acute stage.

If they're not getting the results expected, contracts negotiations give hospital leaders a forum wherein which they can sit down and talk to partner providers about what needs to change. Often, cutting ties isn't an option, especially in rural marketplaces where there aren't many partners from which to choose from. Experts say that hospital leaders need to start figuring this out now, so they are not scrambling to form relationships that don't benefit either side once the reimbursement switch flips.

"Historically, we've discharged the patient, kind of wiped our hands and hoped everything works out well. We don't have that luxury anymore," Jacquin says. "So for [leaders of] an organization, they now need to hink beyond the four walls of the hospital, and they need to understand that reimbursement methodologies are changing."


Case Study

HealthSouth - Toms River, N.J.

For HealthSouth Rehabilitation Hospital, communication is key to integrating care with its referring hospitals. Through every step of each patient's care path, HealthSouth obsesses over every detail. A rehab physician reviews each preadmission screening form beforehand; doctors poke and prod to see if any extra tests are needed, and this information is then relayed to the acute-care hospital. If a patient is referred from an emergency department, HealthSouth staffers make sure to contact the ED physician to discuss the next step, and the same occurs when the rehab hospital has to send a patient over to the ED for urgent testing. An interdisciplinary team huddles to review records from the past week's transfers, overseen by the medical director, and the findings are disseminated among hospital staff.

Liaisons at several partner facilities keep an eye on referrals and put a face to the physicians who are filtering patients over to HealthSouth."I think it's helpful to meet the referring physicians and attach a face to the name," says Carol Sonatore, D.O., medical director for HealthSouth.

All told, the initiatives have helped HealthSouth drop its acute-care readmissions rate by 44 percent as of spring 2010.

Case Study

Advocate Health Care - Hazel Crest, Ill.

Collaboration and communication also have been key at Advocate South Suburban Hospital, part of the large, integrated Advocate Health Care, based in Oak Brook, Ill.

Advocate South Suburban, in Hazel Crest, has carefully developed the criteria for whether patients should be admitted to its in-house, skilled-nursing facility, says Jennifer Dominow, R.N., administrator of clinical integration services. The medical director is active and involved with the SNF, and so is the physician advisor. They conduct a daily huddle five days a week to discuss whether certain patients might be better suited for skilled nursing.

Those efforts have translated to lower readmission rates, shorter lengths of stay, and fewer falls and pressure ulcers, Dominow says. Locating the SNF within the hospital has been helpful with integration, although she doesn't believe it's essential. "When you have that skilled-nursing facility in an acute care setting, you really use a standardized approach with all that you do," she says. "We don't say, 'Oh, well, that's on the SNF's unit, so we're not going to help them.' "


Barriers to integration

According to Max Reiboldt, president and CEO of the Coker Group, there are several barriers to care integration with both physicians and post-acute care providers that hospitals might face:

1. Contentious history: Doctors may have a hard time trusting hospitals and vice versa.

2. Economic stresses: on dDoctors and hospitals, with are both struggling to make ends meet in some markets.

3. Competition: The traditional competition among between hospitals, physicians and other facilities might be hard to overcome.

4. The unknown: Some doctors and hospital leaders are still uncertain about the future of the industry and the possible negative ramifications if they enter a poorly devised partnership with another provider.

5. Interfacing electronic health record systems: Sometimes it can be hard to coordinate with your partner providers without integrating the EHR.

6. Physician supply: There are so few doctors out there, especially in primary care, and it can make it more challenging to align with physicians.

Content by Health Forum, Sponsored by: VHA.