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August/September 2011 In this Issue
1
“Hospital at Home”
Programs Improve
Outcomes, Lower Costs
But Face Resistance from
Providers and Payers
5
Hospital at Home Program
in New Mexico Improves
Care Quality and Patient
Satisfaction While Reducing
Costs
9
News Briefs
10 Publications of Note
13 Editorial Advisory Board
Published August 31, 2011
Quality Matters is a newsletter from
The Commonwealth Fund. Published
bimonthly, the newsletter explores
issues of quality and efficiency in
health care.
Past issues of Quality Matters are
available on The Commonwealth
Fund Web site at
www.commonwealthfund.org/
Publications/Newsletters/QualityMatters.aspx
Quality
Matters
A Bimonthly Report
on I nnovations in
Health Care Quality Improvement
Welcome to Quality Matters, a bimonthly roundup of news and opinion on quality
and efficiency, information technology, performance improvement initiatives, and
policy innovations.
“Hospital at Home” Programs Improve Outcomes,
Lower Costs but Face Resistance from Providers
and Payers
By Sarah Klein
Summary: Hospital at home programs that enable patients to receive acute care at home have
proven effective in reducing complications while cutting the cost of care by 30 percent or more, leading to entrepreneurial efforts to promote their use. But widespread adoption of the model in the U.S.
has been hampered by physicians’ concerns about patient safety, as well as legal risk, and by the
reluctance of payers, include Medicare, to reimburse providers for delivering services in home settings.
Hospital at home programs that enable patients to receive hospital-level care in the
comfort of their homes have flourished in countries with single-payer health systems,
but their use in the U.S. has been limited—despite compelling evidence that wellmonitored, at-home treatment can be safer, cheaper, and more effective than traditional hospital care, especially for patients who are vulnerable to hospital-acquired
infections and other complications of inpatient care.1
Such programs are well established in England, Canada, Israel, and other countries
where payment policies encourage—or at least do not discourage—the provision of
health care services in less costly venues. In Victoria, Australia, for example, every metropolitan and regional hospital has a hospital at home program, and roughly 6 percent
of all hospital bed-days are provided that way. For specific conditions, the use of athome care is significantly greater: nearly 60 percent of all patients with deep venous
thrombosis (DVT) were treated at home in 2008, as were 25 percent of all hospital
patients admitted for acute cellulitis.2
Instituting this type of substitution in the U.S. could produce dramatic savings for the
Medicare program and private payers, chiefly by eliminating the fixed costs associated
August/September 2011
Quallity Matters
with operating a brick-and-mortar hospital. Indeed, pilots of the model have already achieved savings of 30 percent and more per admission, while delivering equivalent
outcomes and fewer complications than traditional hospital care.3 In addition to such savings, at-home care may
also help avoid shortages of beds in U.S. hospitals.
New policies that encourage efficiency may spur interest in this model in the U.S. In recent years, a number
of payers and providers have sought advice from clinicians at Johns Hopkins Medicine (Johns Hopkins), the
Baltimore, Maryland–based system that has operated a
hospital at home program since 1994 (see Hospital at
Home Programs: Step by Step for a description of the
Johns Hopkins model.) This interest is likely to increase
along with the introduction of accountable care organizations, which may allow providers to share in the savings more efficient models of care produce.
The Johns Hopkins Model
Johns Hopkins developed its hospital at home program
as a means of treating elderly patients who either refused to go the hospital or were at such risk of hospitalacquired infections and other adverse events that physicians kept them at home out of concern for their safety.
Early trials of its model (described in the box below)
found the total cost of at-home care was 32 percent less
than traditional hospital care ($5,081 vs. $7,480), the
mean length of stay for patients was shorter by one-third
(3.2 days vs. 4.9 days), and the incidence of delirium
(among other complications) was dramatically lower (9%
vs. 24%).4 One study of the program also found no difference in rates of subsequent use of medical services or
readmissions. And patients and family members’ satisfaction was higher in the home setting than among those
offered usual hospital care, reflecting the convenience of
the model.
Payment a Significant Barrier
Despite these dramatic results and the refinement of
portable imaging equipment and drug delivery systems
that facilitate home-based care, the dissemination of the
model in the U.S. has been slowed by lack of payer acceptance. By contrast, the state government in Victoria,
Australia, reimburses for at-home care at the same rate
it reimburses for inpatient care. Without that “hospitals
would not be engaged enough to bother,” says Michael
Montalto, M.D., Ph.D., director of the “Hospital in
the Home” program at both Royal Melbourne Hospital
and Epworth Hospital. (In Australia, the state derives
Hospital at Home Programs: Step by Step
•
•
•
•
•
•
•
An emergency department or community physician identifies a patient who is sick enough to be hospitalized but
stable enough to be treated at home. Narrowly defined eligibility criteria help distinguish patients who need intensive
services and/or multiple visits from specialists—and therefore should be treated in hospital settings—from those
whose needs may be met at home by visiting physicians, nurses, and other clinical staff. Conditions with defined treatment protocols, such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), communityacquired pneumonia, and cellulitis, are a natural fit.
The suitability of the home is assessed to confirm it has air conditioning, heat, and running water.
Responsibility for care is assigned to a physician.
A greeter meets the patient in the emergency department or elsewhere to discuss the program, arrange transportation, and deliver the biometric and communication devices that will be needed to oversee care.
A caregiver meets the patient at home and a physician—either in person or via video—explains the treatment protocol. Orders are written and clinical staff, including respiratory therapists, physical therapists, and other caregivers
arrive as needed to administer intravenous medications and fluids, provide nebulizer treatments, and conduct tests,
including ultrasounds, X-rays, and electrocardiograms. Meals are arranged if necessary. The patient’s vital signs are
monitored electronically.
The physician visits the patient daily, or in some models, communicates with the patient via telemedicine equipment.
To capture any decline in the patient’s condition when clinicians are off site, providers monitor patient using telemedicine equipment.
Once the patient is stabilized and well enough to return to activities of daily living, he or she is handed off to his or
her primary care physician. In one model, providers maintain oversight of the patient for at least 30 days, to ensure
he or she is keeping appointments and is not suffering any adverse consequences. During this period, the physician
provides updates to the patient’s primary care physician.
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August/September 2011
Quallity Matters
a financial benefit from reducing or eliminating the
need to build new hospitals as demand for acute care
increases.)
In the U.S., the Centers for Medicare and Medicaid
Services (CMS) and most private payers do not pay for
hospital care delivered at home and generally restrict
payments for telemedicine—an essential element of
the model—to very limited circumstances, restricting
the possibility of implementation to a handful of providers who control all or some of their funding. These
include two Veterans Health Administration hospitals—one in Portland, Oregon, and the other in New
Orleans (which implemented the program out of necessity when Hurricane Katrina knocked out the Veterans
Administration Medical Center there) and Presbyterian
Health Care System in Albuquerque, New Mexico, an
integrated delivery system whose health plan supports
the program. (The Presbyterian program is described in
more detail in the accompanying case study).
That may change as more insurers, such as Aetna, consider implementing the model. “I don’t know exactly
how we are going to do it,” says Randall Krakauer, M.D.,
national medical director of Aetna’s Medicare program
who over the years has had several conversations with
Bruce Leff, M.D., the geriatrician and health services researcher who developed it . “One possibility would be to
implement it in collaboration with provider groups,” he
says, but that would require a certain scale. “We need a
relatively large membership base [of patients] to support
one of these operations.”
An Entrepreneurial Approach
Recognizing the potential to meet this need for infrastructure, one venture capital–backed health care firm is
working to build a hospital at home program as a standalone service that can be marketed to hospitals, insurers,
and physicians. The company, Tennessee-based Clinically
Home LLC, plans to provide at-home hospital services
through dedicated physician groups.
The Clinically Home model was designed in collaboration with Johns Hopkins (Leff serves as chair of the company’s clinical advisory board and the health system has
an institutional consulting agreement with the company.) Both the Clinically Home and Johns Hopkins models supply the equipment and staff necessary to manage
www.commonwealthfund.org
intravenous lines, perform diagnostic tests, and provide
other services in the home and rely heavily on physicians
and nurses to manage care. But in the Clinically Home
model, physicians do not make house calls. Instead, they
engage with patients, as well as nurses and nurse practitioners making home visits, using two-way biometrically
enhanced video that enables physicians to see, but not
touch, their patients.
This approach introduces some complications. It requires
using providers who are comfortable treating patients
without face-to-face contact, as well as consistent and
continuous communication among team members who
operate in a virtual manner. Montalto also points out
the lack of a physician presence in the home may inhibit
patient confidence. The patients “stay at home through
the acute episode because they are confident to do so. I
think with no face-to-face [contact with physicians] at
all, there are going to be some circumstances in which
patients will bail,” he says.
Another significant difference between the two models
is that in the Clinically Home version, the admission
eligibility criteria and protocols that physicians and other
caregivers use to ensure care is standardized and safe
include approximately 100 diagnostic-related groups
(DRGs). Among them are asthma exacerbation, early
sepsis, seizure disorders, and gastrointestinal conditions
or diseases. Its founders believe that with the expanded
list of DRGs, the model has the potential to vastly increase the number of patients treated at home and deliver
care at half of traditional hospital costs. The larger savings ensue from eliminating physician house calls. “You
really start to leverage economies of scale when you have
a doctor who is covering a hospital at home program
across wide swathes of geography,” Leff says.
Clinically Home has been testing its approach at
Advocate Health Care, an integrated delivery system in
Oakbrook Terrace, Ill., that participated in a clinical trial
of the program at its own expense. That trial focused on
a single hospital that was at capacity and whose emergency department frequently had to turn away ambulances.
The patients in the program and in the control group
suffered from DVT, asthma, pneumonia, CHF, and
COPD, among other conditions.
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Quallity Matters
Leff says that trial, completed in October 2010, significantly reduced readmissions, increased patient satisfaction rates, and cut costs beyond the savings he achieves
in a model that relies on physician house calls. Scott
Powder, Advocate’s senior vice president of strategy and
growth and a board member of Clinically Home, said he
could not be specific about results until the publication
of trial results, but says, “we learned the model works.”
Physician Resistance and Other Challenges
While Clinically Home prepares to offer a standalone
service, some health systems are launching their own
hospital at home programs using internal resources.
Carilion Clinic, a Roanoke, Virginia–based integrated
delivery system, is attempting to test one in Tazewell, a
small community in eastern Virginia. But two months
into the program, they haven’t been able to recruit a
single patient because physicians—both in the community and in the hospital’s emergency department—are
reluctant to refer patients, even though they support the
concept in principle, says Lisa Sprinkel, senior director
of home care and hospice services, who oversees the program. “They want to make sure their patients are cared
for. I [also] think there’s some hesitancy from a legal perspective (e.g. malpractice risk),” she says.
Time constraints are another barrier. Physicians who
refer patients to the program must screen them carefully
and make arrangements to introduce them to the concept of at-home hospital care. For many, it’s simply easier
to admit patients. “One of the biggest lessons learned
is [that] the engagement of the emergency department
physicians is critical because they are the ones who actually have to make the biggest adjustment in their decision making,” Powder says.
August/September 2011
Montalto still finds this to be a problem, even after 17
years of practice with at-home care. “We still get a lot of
people who won’t refer patients to us [because they] feel
that we are an inferior choice to coming into the hospital.” Presenting the program as a seamless hospital unit
helps. “It gives them confidence to at least try us,” he
says. Having 24-hour coverage, presenting details of the
program at meetings, and writing papers that demonstrate the effectiveness of the program are also essential,
he says.
The chief financial officers (CFOs) of hospitals may
also present a challenge, especially those who remain
unconvinced that the beds freed by treating patients at
home will be filled with patients needing more complex
and intensive services. “When you don’t have backfill
opportunities, it is a little bit harder sell to the CFO of
the hospital [that] you are going to walk away from a
$10,000 or $12,000 admission,” Powder says.
And finally, there are concerns about patient safety and
gaming, the latter of which occurred in Australia when
some hospitals began referring patients who only needed
subacute care to the at-home program. Auditing programs, establishing accreditation programs, and reinforcing inclusion criteria may address these concerns. And
with rigorous quality assurance and improvement programs, more providers may consider the model. “”I think
it could be an adjuvant to what we are already doing in
health care to produce higher value,” says John Combes,
M.D., senior vice president of the American Hospital
Association. Gaining the full support of payers may take
more time. Michael Montijo, M.D., president and COO
of Clinically Home, says payers will want additional evidence of improvement in quality, reductions in readmission rates and costs, and improved safety. He’s confident
that will come with additional testing. “Once they feel
comfortable with that and put it into their underwriting,
the game changes,” he says.
Notes
1
B. Leff, L. Burton, S. L. Mader et al., “Hospital at Home: Feasibility and Outcomes of a Program to Provide Hospital-Level Care at
Home for Acutely Ill Older Patients,” Annals of Internal Medicine, Dec. 2005 143(11):798–808.
2
M. Montalto, “The 500-Bed Hospital That Isn’t There: The Victorian Department of Health Review of the Hospital in the Home
Program,” The Medical Journal of Australia, Nov. 2010 193(10):598–601.
3
Leff, Burton, Mader et al., 2005.
4
Ibid.
www.commonwealthfund.org 4
August/September 2011
Quallity Matters
Hospital at Home Program in
New Mexico Improves Care
Quality and Patient Satisfaction
While Reducing Costs
By Vida Foubister
Summary: An integrated delivery system in Albuquerque, New
Mexico, has been able to better meet the needs of its patient
population by offering those who need acute care and meet specific criteria the option of being treated in their homes instead of
the hospital. The program has reduced the average length of stay
and cost of care and improved patient satisfaction.
Issue
U.S. hospitals face bed shortages that are expected to
intensify as the population ages. To ensure access to care,
health care system leaders have begun to look for creative
ways to care for patients. “Hospital at Home,” a program
designed to provide acute care services in the homes of
patients who might otherwise be hospitalized, has been
demonstrated to increase the quality of care patients receive, improve their satisfaction, and reduce the cost of
hospital care by at least 30 percent.1 Despite its promise,
broader adoption of the model by health systems across
the country has been limited by payment policies that
restrict reimbursement to care provided in the hospital
setting. This case study profiles the work of one health
system that launched a Hospital at Home program with
the support of its health plan.
Organization and Leadership
Presbyterian Healthcare Services (http://www.phs.
org/) (PHS) is an integrated delivery system based in
Albuquerque that provides care to more than 750,000
patients throughout New Mexico. Presbyterian’s network
includes eight hospitals, a medical group with 34 locations statewide, home care services, and inpatient and
outpatient hospice programs. Its managed care organization, Presbyterian Health Plan, provides commercial
health insurance, Medicaid, and Medicare products to
more than 500,000 members.
The Hospital at Home program was developed by leaders of Presbyterian Home Healthcare, the health system’s
home care and hospice agency, who include Lesley Cryer,
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R.N., the agency’s executive director; Karen Thompson,
clinical director of special programs and Hospital at
Home; and Scott Shannon, M.B.A., director of finance.
They worked with Bruce Leff, M.D., professor of medicine at Johns Hopkins University School of Medicine
(Johns Hopkins), who developed the Hospital at Home
model. The system’s executive and senior vice presidents
were also engaged in the development of the program.
Objective
Presbyterian Healthcare Services introduced its Hospital
at Home program to achieve better clinical outcomes, increase patient satisfaction, and reduce costs. The program
was also expected to address the hospital’s need for increased capacity, a need that will persist after the opening
of its new hospital in October. (The emergency department of this facility has already opened and is admitting
patients to the Hospital at Home program). Demand
in the area has increased both with local hospital closures and the growing number of patients with chronic
disease—a population health system leaders project will
double by 2030.
The health system’s Hospital at Home program, implemented in October 2008, is based on a care model
developed at Johns Hopkins. Through that program,
clinicians evaluate patients arriving at the emergency
department who require admission for community-acquired pneumonia, exacerbation of chronic heart failure,
exacerbation of chronic obstructive pulmonary disease,
cellulitis, and other conditions to determine whether
their illnesses could be treated at home.
Those who meet specific criteria for home treatment are
given the option of being admitted to the program. If
they agree, the patients are then transported home with
any necessary medications and equipment; a nurse arrives at the home within one hour to ensure continuity
of care for patients who have arrived at the hospital with
acute care-level medical needs; and the nurse and other
clinical staff, including physicians, make subsequent
visits as need. Upon discharge from Hospital at Home,
the nurse gives patients follow-up instructions and sends
detailed information to their primary care physician.
At Johns Hopkins, where the Hospital at Home program was developed, it resulted in measurably improved
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Quallity Matters
outcomes, reduced iatrogenic complications, increased
patient and family satisfaction, and lower costs of care. 1
Targeted Population
Presbyterian currently offers the Hospital at Home program to three populations of patients who live in the
Albuquerque area: those arriving at the emergency departments of Presbyterian Hospital, Kaseman Hospital,
and Rio Rancho Hospital; those who are referred from
physician offices, urgent care, and the health system’s
home health agency; and patients who are transferred to
the program from the hospital. The latter category includes patients who have transitioned from the intensive
care unit to a step-down unit.
To enroll in the program, patients must meet the following criteria:
1. They are being treated for chronic heart failure
(CHF), chronic obstructive pulmonary disease
(COPD), community-acquired pneumonia
(CAP), cellulitis, complex urinary tract infection
(UTI), dehydration, nausea and vomiting, deep
vein thrombosis (DVT), and stable pulmonary
embolism (PE).
2. They are determined to be sick enough to be
hospitalized but do not need the intensive
care unit (ICU), a determination made using
research-based criteria from Johns Hopkins
for the first four disease categories and criteria
that Presbyterian and Johns Hopkins developed
together for the others. These determinations meet
criteria for hospitalization established by Milliman
and Interqual.
3. They live close enough to the three Albuquerque
hospitals participating in the program to be able
to return to the emergency department within 30
minutes, if needed.
4. The patient is covered by Presbyterian Health
Plan or chooses to pay for the Hospital at Home
service, as the program is not covered by other
payers.
Process of Change
Presbyterian began in 2007 by convening 12 multidisciplinary teams and giving each a charter with specific
deliverables and a timeline for achieving them. The
teams spent the first nine months of 2008 creating the
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processes necessary to roll out the model, with each
team focused on one of the following areas: marketing/
communication, pharmacy, emergency department, physician care, quality, billing/financial, vendor contracting,
clinical nursing, intake and scheduling, human resources,
legal, and documentation/coding.
One obstacle the human resources team encountered
was hiring a lead physician for the program. “We went
through three rounds of interviewing before we found
a Hospital at Home doctor,” says Cryer. “It seemed way
too risky to physicians who were used to working in a
hospital setting.” (The health system has since hired two
more physicians for Hospital at Home and is in the process of training them to work within the new model.)
While the clinical teams worked to build staff acceptance
of the model, the marketing and communications team
was tasked with building patient awareness and acceptance of treatment at home. They developed a commercial featuring a patient receiving care through Hospital
at Home, which ran on television for three months, and
promoted the program through billboard advertising.
However, they are finding that many patients are learning about the program through word of mouth. Patient
acceptance of the program is high; about 90 percent of
eligible patients agree to be admitted.
Using this multidisciplinary process helped to create
“incredible buy-in for the program,” says Cryer, as it created institution-wide awareness of the new care model.
“It’s really the only way we were able to create this virtual
hospital in a nine-month period.”
The Care Model
Once admitted to the program, patients are transported
home and seen by a nurse within one hour, and are visited once every day by a physician. A registered nurse
comes one to two times per day, as does an aide. These
visits are supplemented by telemedicine-based video
monitoring. Through shared staffing arrangements with
departments whose clinicians are cross-trained in hospice
and home care, the program is able to provide patients
with round-the-clock physician and nursing coverage.
Their care follows specific pathways, which were developed initially by Leff and have since been modified and
expanded for the needs of Presbyterian’s population.
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August/September 2011
Quallity Matters
If needed, Hospital at Home patients have access to
social workers; rehabilitation services, including occupational therapy, physical therapy, and speech therapy;
and nutritionists. In addition, contracted vendors, with
whom the system had existing relationships through its
health plan, provide patients with any necessary equipment, oxygen, medication, infusions, diagnostic services,
and transportation. Similar to the hospitalist model, the
Hospital at Home program discharges patients when
they are stabilized and the lead physician provides a
detailed summary of the patient’s treatment to their
primary care physician. In some cases, patients that continue to need care, albeit at a lower level, are discharged
to regular home care.
Quality Measurement
Concurrent with the development of the patient
care services, quality measures were created to enable
Presbyterian to evaluate the outcomes of Hospital at
Home patients and compare them with those of patients
admitted to its hospital facilities. These outcomes include
patient and family satisfaction, illness-specific clinical
quality measures, hospital readmission rates, and total
cost.
Payment Model
The rollout of the program depended heavily on the system’s ability to create a mechanism to pay for the service,
as Medicare does not cover it.
Presbyterian had been tracking its costs per Hospital at
Home episode of care and those managing the contracting were confident that the discounted rate would enable
the program to break even. The health system chose to
contract as this rate as it believes the Hospital at Home
care model benefits patients.
Results
Within the first year, the Hospital at Home program admitted 125 patients with CHF, COPD, CAP, or cellulitis. Because CAP and COPD were found to be less
prevalent in the summer months, five more diagnoses—
complex urinary tract infection, dehydration, nausea and
vomiting, DVT, and stable PE—were added in January
2010. Presbyterian worked with Hopkins to develop
enrollment criteria for these new diagnoses and by July
2010, 261 patients had been admitted to the program;
this number reached 439 by the end of June 2011.
Though the implementation of Hospital at Home was
not without its challenges, the program appears to be
a success. Its performance indicators are all equal to or
better than those measured at the hospital facilities. In
2010, patient satisfaction, as measured by a Hospital at
Home Consumer Assessment of Healthcare Providers
and Systems (CAHPS) survey developed with Press
Ganey, was 94.5 percent. In the first six months of 2011,
among the 100 patients admitted to the Hospital at
Home program, only one was readmitted to the hospital
within 30 days for the same diagnosis.
The health system relied on its relationship with the
Presbyterian health plan to do so; the plan reimburses
providers using a bundled rate that covers the full continuum of costs, including physician fees and ancillary
costs for services provided by contracted vendors, such
as oxygen or diagnostic tests. Presbyterian is able to do
this because a high percentage of its patients are covered
by its health plan and only about 40 percent of its home
care patients are covered by Medicare, as opposed to
80 percent to 90 percent of patients in most home care
agencies nationally, says Cryer.
The program also has a lower average length of stay and
lower cost per episode than the hospital facilities. The
average length of stay for Hospital at Home patients is
3.5 days; the length of stay for comparable inpatient admissions is 5.4 days. And the Hospital at Home variable
costs per stay are $1,000 to $2,000 less than comparable
inpatient costs per stay by diagnosis. These savings ensue
from lower costs for diagnostic testing—including labs
and radiology—and pharmacy; less clinical service consumption; cost avoidance due to prevention of complications and rehospitalization; and flexibility in the staffing
model.
In addition, the system agreed to be reimbursed at a
discount of the Medicare Prospective Payment System,
which determines payments based upon Medicare
Severity-Diagnosis Related Groups (MS-DRG),
sweetening the pitch to its health plan, says Shannon.
All clinical outcomes are equal to or better than those
found among Presbyterian facility patients with 100
percent of patients meeting the indicators for: receipt of
pneumonia and influenza vaccination; antibiotics within
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Quallity Matters
six hours of diagnosis for CAP; and receipt of angiotensin-converting enzyme inhibitors (ACE inhibitors) and
angiotensin receptor blockers (ARB) for CHF.
Next Steps
Beginning in April, Presbyterian began work on a modified Medical House Calls program, which uses physician
home visits to increase the intensity of patient care in the
home setting. “What we’re attempting to do is prevent
patients from deteriorating so much that they have to
go into the hospital,” Thompson says. This, in turn, is
expected to prevent the iatrogenic complications—such
as falls, delirium, infections, and exposure to medication
errors—that so often go hand in hand with hospital admissions for many of these patients.
In addition to increasing the number of house calls, the
system also plans to increase physicians’ presence with athome patients through use of telemedicine, especially for
patients discharged from Hospital at Home and home
care.
Implications
Presbyterian is committed to creating a community of
early adopters and, to that end, has worked with Johns
Hopkins to provide guidance to about 30 organizations
interested in establishing similar programs. “Just having
New Mexico able to do this isn’t going to convince CMS
to pay for it,” says Cryer. The interested groups tend to
August/September 2011
be other integrated health systems or systems that own
hospitals, employ doctors, and/or have home care agencies. Many of the organizations have close ties with a
payer that enable them to negotiate innovative payment
approaches.
Payment, however, remains a critical barrier. Presbyterian
has worked to create a replicable bundle of care that
covers all services, with Hospital at Home as a standalone benefit with one co-payment per admission. This,
however, is only offered through its own health plan.
Commercial payers have expressed interest in purchasing the Hospital at Home service as a product, but
before these health plans can offer it to their members,
Presbyterian must first test the bundled payment model
that it has developed with its own health plan.
The model also depends heavily on strong connections
with physicians throughout a care system. Those leading
Hospital at Home programs need to constantly remind
emergency department physicians, hospitalists, and primary and specialty care practitioners in the community
to consider their services for patients requiring acutelevel care and must maintain close relationships with
caregivers to ensure their commitment to the program.
“This is such a new concept and no one has a reference
point to it,” says Thompson. “We had to learn as we did
it: ‘What does a Hospital at Home patient look like?
How do you get them to look to Hospital at Home as an
alternative?’ “
For Further Information
Lesley Cryer, R.N., executive director of Presbyterian Home Healthcare at [email protected]; Karen Thompson,
clinical director of special programs and Hospital at Home, [email protected]; and Scott Shannon, M.B.A.,
director of finance at [email protected].
Note
1
B. Leff, L. Burton, S. L. Mader et al., “Hospital at Home: Feasibility and Outcomes of a Program to Provide Hospital-Level Care at
Home for Acutely Ill Older Patients,” Annals of Internal Medicine, Dec. 6, 2005 143(11):798–808.
www.commonwealthfund.org 8
August/September 2011
Quallity Matters
News Briefs
NQF Releases Child Quality Health
Measures
The National Quality Forum (NQF) endorsed 41 quality measures that cover prenatal to adolescent care and
include important areas of wellness and development for
children such as perinatal and neonatal care, chronic illness care, care for hospitalized children, and child health
outcomes. The standards, which are designed to help
the Centers for Medicare and Medicaid Services, states,
health plans, and providers track trends and opportunities for improvement, are available for comment as part
of a 30-day public appeals process that ends Sept. 13.
Pentagon, VA Developing Common
Medical Record
The U.S. Department of Defense and the U.S.
Department of Veterans Affairs are moving forward with
plans to develop a common data sharing network, according to the Washington Post. The federal government
will invest as much as $4 billion to combine clinical
data from the two systems into an “Integrated Lifetime
Electronic Record.” The end product is likely to rely on
open-source technology, which would enable private hospitals to make use of it.
Physicians Want Review Process
Established for Publicly Reported Data
The American Medical Association (AMA) urged the
Centers for Medicare and Medicaid Services (CMS) to
provide physicians with more time to review individual
data before reports on physician performance are made
www.commonwealthfund.org
available to the public. CMS plans to make Medicare
claims data available to as yet undefined entities for the
development of quality, efficiency, and performance reports. The reports are also designed to provide physicians
with individual feedback. According to a proposed rule,
Medicare would give physicians 30 days to review and
appeal performance results. The AMA is seeking 90 days
to review claims and additional time to request corrections. Separately, the U.S. Government Accountability
Office (GAO) recommended CMS improve its approach
to physician quality reporting in part by sampling physicians about the reports’ usefulness and reliability. “CMS
faces challenges incorporating resource use and quality
measures for physician feedback reports that are meaningful, actionable, and reliable,” the GAO noted.
Funding Available for Health
Improvement Projects
CMS announced in late June that it will award up to
$500 million to hospitals and providers to improve care
by reducing preventable injuries and complications related to health care–acquired conditions and unnecessary
readmissions. The funding, which is part of the public–
private Partnership for Patients program, will be awarded
by CMS’ Innovation Center. The program has established a goal of reducing incidence of harm in hospital
settings by 40 percent and hospital readmission rates by
20 percent within three years. Contractors applying for
funding are expected to design programs to teach and
support hospitals in making care safer; conduct training
for providers; provide technical assistance for hospitals
and clinical providers; and establish a monitoring system
to measure progress.
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Publications of Note
Hospital Board-Level Quality Scorecards
Inconsistent, Incomplete
A study designed to identify and evaluate the measures
hospital boards use to assess performance on quality
and safety efforts found wide variation in how the hospitals conveyed that performance to their boards. The
scorecards the hospitals used contained a mix of process
measures that were nationally defined and outcomes
measures that were not. In addition, the metrics on
board scorecards frequently included efficiency measures,
patient satisfaction measures, and human resource/staffing measures under the mantle of quality and safety. The
researchers say the results of the study raise substantial
concerns about how well hospital leaders and boards
identify measures to assess operations and track quality improvement and hazards. C. A. Goeschel, S. M.
Berenholtz, R. A. Culbertson et al., “Board Quality
Scorecards: Measuring Improvement,” American Journal
of Medical Quality, July/August 2011 26(4):254–60. Low Health Literacy Associated with Poor
Health Outcomes
Researchers conducted a systematic review of evidence
to understand the relationship between levels of health
literacy and use of health care services, health outcomes,
and costs, as well as disparities in health outcomes. They
found low health literacy—as measured by a patient’s
reading level—was associated with more hospitalizations;
greater use of emergency care; lower receipt of mammography screening and influenza vaccine; poorer ability to
interpret labels and health messages; and, among elderly
persons, poorer overall health status and higher mortality rates. The relationship between health literacy level
and other outcomes was less clear, primarily because of
a lack of studies and relatively unsophisticated methods
in available studies. N. D. Berkman, S. L. Sheridan, K.
E. Donahue et al., “Low Health Literacy and Health
Outcomes: An Updated Systematic Review,” Annals of
Internal Medicine, July 2011 155(2):97–107.
Dutch Model Has the Potential to
Significantly Increase Access to AfterHours Care in the U.S.
Commenting on a journal article that described the
Netherlands’ system for providing after-hours care to
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patients, the authors of this commentary suggested the
U.S. would benefit from implementing a similar system.
In the Netherlands model, cooperatives of 40 to 250 primary care physicians make triage nurses with physician
backup available by phone for patients during evenings
and weekends. Nurses responding to urgent patient requests follow triage protocols and offer advice ranging
from self-care to emergency department referral. Using a
similar system, the U.S. could increase the percentage of
physicians providing after-hours care, a percentage that
declined from 40 percent in 2006 to 29 percent in 2009.
Implementing such a program would require support
from government and private payers. It would also require primary care practices to assume some risk for the
cost of emergency department visits to ensure their continued focus on cost-containment methods, the authors
said. D. Margolius and T. Bodenheimer, “Redesigning
After-Hours Primary Care,” Annals of Internal Medicine,
July 2011, 155(2):131.
Health Information Technology Program
Increases Patient Monitoring
A survey of registry capability among physicians participating in the Massachusetts eHealth Collaborative—a
four-year, $50 million health information technology
program—found physicians who participated in the
program increased their ability to generate registries
for laboratory results and medication use. The analysis
also suggested that physicians who used their electronic
health records more intensively were more likely to use
registries, particularly in caring for patients with diabetes, compared with physicians reporting less avid use of
electronic health records. M. Fleurant, R. Kell, J. Love et
al., “Massachusetts e-Health Project Increased Physicians’
Ability to Use Registries, and Signals Progress Toward
Better Care,” Health Affairs, July 2011 30(7):1256–64. Waiting Times in Emergency Department
Affect Outcomes for Low-Acuity Patients
A study assessing the impact of waiting times on adverse
outcomes among patients in Ontario, Canada, found
patients who presented to the emergency department
during busy periods were at greater risk of later admission to the hospital and death. For patients of low acuity
(i.e. lower triage status) whose mean length of stay in the
emergency department was greater than one hour but
less than or equal to six hours, the adjusted odds ratio for
death was 1.71 while the odds ratio for admission to the
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Quallity Matters
hospital was 1.66. The study also found that reducing
the mean length of stay in the emergency department by
an average of one hour could have potentially decreased
the number of deaths in lower-acuity patients by 261, or
12.7 percent. In contrast, patients who were well enough
to leave without being seen were not at higher risk of
short-term adverse events. A. Guttman, M. J. Schull, M.
J. Vermeulen et al., “Association Between Waiting Times
and Short Term Mortality and Hospital Admission After
Departure from Emergency Department: Population
Based Cohort Study from Ontario, Canada,” British
Medical Journal, published online June 1, 2011. Team Work Improves with Focus on
Patient-Centered Care
This study was designed to identify the determinants
of collaborative capacity, which is the likelihood that
providers will collaborate as if they were members of an
egalitarian team even in the absence of a formal team
structure. The researchers found that clear task direction, specifically an emphasis on patient-centered care,
is significantly associated with higher levels of task interdependence, higher quality of staff interactions, and
collaboration. The study collected data from staff in 45
units from nine hospitals and seven health care systems
in upstate New York. The study also found that measures
for team structure and collaboration do not vary significantly between hospitals, only by unit and occupational
group. The researchers concluded that collaborative
capacity is somewhat constrained by a rigid hierarchy of
health care occupations and division of labor. However,
collaborative capacity may be improved at the unit level
through an emphasis on patient-centered care and a
context that supports providers’ work. D. B. Weinberg,
D. Cooney-Miner, J. N. Perloff et al., “Building
Collaborative Capacity: Promoting Interdisciplinary
Teamwork in the Absence of Formal Teams,” Medical
Care, Aug. 2011 49(8):716–23. Present-on-Admission Diagnoses Improve
Mortality Rate Calculations
This study found that the comprehensive use of diagnoses identified as “present on admission” improves methods for comparing hospital mortality rates. The study examined 91,511 discharge records for patients with heart
failure from 365 California hospitals for patients discharged in 2007. G. J. Stukenborg, “Hospital Mortality
Risk Adjustment for Heart Failure Patients Using Present
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on Admission Diagnoses: Improved Classification and
Calibration,” Medical Care, Aug. 2011 49(8):744–51.
Barriers to Innovation Identified
In this commentary, Victor R. Fuchs and Arnold
Milstein outlined several barriers to the diffusion of more
cost-efficient care models. Among them: the unwillingness of insurers to standardize coverage benefits and administrative transactions; the reluctance of employers to
make inefficient models of care financially unattractive to
employees; the opposition to reform from legislators who
seek campaign contributions for stakeholders who benefit from inefficient arrangements; hospital administrators who resist efforts to reduce hospital occupancy; and
physicians who resist practice changes for financial and
nonfinancial reasons. V. R. Fuchs and A. Milstein, “The
$640 Billion Question—Why Does Cost-Effective Care
Diffuse So Slowly?” New England Journal of Medicine,
June 2011 364(21):1985–7. Proposal to Reduce Medicare Spending
Outlined
In this commentary, Alain C. Enthoven outlines a plan
for aligning growth in Medicare spending with growth
in the gross domestic product (GDP). His strategy calls
for reducing beneficiaries’ demand for a fee-for-service
model of care by offering standardized health plans that
are distinguished by their provider networks. To encourage cost-conscious choice of plan, beneficiaries would
pay the difference between the price of the least costly
plan and the plan of their choice. Enthoven believes this
would compel insurers to compete on value for money.
Enthoven’s plan also calls for the government to pay
the price of the least costly plan. He also recommends
linking beneficiaries’ premium support payments to the
growth in GDP and using global prospective payments
to give providers the incentive they need to reduce the
cost of care. A. C. Enthoven, “Reforming Medicare by
Reforming Incentives,” New England Journal of Medicine,
published online May 26, 2011. New Framework for Increased
Collaboration Among Children’s Hospitals
Hospital executives and pediatric department chairs
from 14 children’s hospitals worked together to develop
a framework for integrating quality and safety improvement programs across their institutions. The framework
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Quallity Matters
encourages: 1) alignment of quality priorities and resources across the organizations; 2) education and training for physicians in the science of improvement; and
3) professional development and career progression for
physicians in recognition of quality-improvement activities. The framework can be used to assess the institutions’
level of integration, plot a path toward further integration, track progress, and identify potential collaborators
and models of advanced integration. F. Howard Levy, R.
J. Brilli, L. R. First et al., “A New Framework for Quality
Partnerships in Children’s Hospitals,” Pediatrics, June
2011 127(6): 1147–56. Factors That Led to Success of a
Collaborative CLABSI-Prevention Program
Researchers analyzed the methods and results of the
Michigan Intensive Care Unit (ICU) project, which dramatically reduced rates of central line–associated bloodstream infections (CLABSIs), to determine how and why
such programs are successful. They found the project
achieved its effects by among other things: 1) generating
pressures for ICUs to join the program and conform to
its requirements; 2) creating a densely networked community with strong horizontal links that exerted normative pressures on members; 3) reframing the infections as
a social problem and addressing it through a professional
movement that combines “grassroots” features with a
vertically integrated program structure; 4) using several
interventions that functioned in different ways to shape
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a culture of commitment to doing better in practice; and
5) harnessing data on infection rates as a disciplinary
force. M. Dixon-Woods, C. L. Bosk, E. L. Aveling et al.,
“Explaining Michigan: Developing an Ex Post Theory of
a Quality Improvement Program,” Milbank Quarterly,
June 2011 89(2). Developing EHRs That Improve Quality
and Efficiency
In this commentary, the authors argue that meeting
federal meaningful use regulations for electronic health
records (EHRs) will not produce the comprehensive
functionality needed to improve quality and efficiency.
To go beyond the regulations, they recommend that
providers develop systems that speed the communication of critical test results, enhance transitions in care,
improve test result tracking, and provider robust and
complex real-time decision support to providers. Broad
integration between systems is also necessary to ensure that information, including laboratory, pharmacy,
billing, and ordering information, can be transferred
between systems without manual entry. S. K. Abbett,
D. W. Bates, and A. Kachalia, “The Meaningful Use
Regulations in Information Technology: What Do They
Mean for Quality Improvement in Hospitals?” Joint
Commission Journal on Quality and Patient Safety, July
2011 37(7):33–6. 12
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Editorial Advisory Board
Special thanks to Editorial Advisory Board member Paul Schyve for his help with this issue.
Eric Coleman, M.D., M.P.H., associate professor of medicine, University of Colorado
Susan DesHarnais, Ph.D., M.P.H., program director of healthcare quality and safety, Thomas Jefferson University
Don Goldmann, M.D., senior vice president, Institute for Healthcare Improvement
Thomas Hartman, vice president, quality improvement, IPRO
Charles Homer, M.D., M.P.H., president and CEO, National Initiative for Children’s Healthcare Quality
Rosalie Kane, Ph.D., professor of public health, University of Minnesota
Gordon Mosser, M.D., associate professor, School of Public Health, University of Minnesota
Christopher J. Queram, M.A., president and CEO, Wisconsin Collaborative for Healthcare Quality
Michael Rothman, administrator, Division of Cardiology, Johns Hopkins University
Paul Schyve, M.D., senior vice president, Joint Commission
Bruce Siegel, M.D., research professor, Department of Health Policy, George Washington University; chief executive officer,
National Association of Public Hospitals and Health Systems
Editorial Team 2011
Anne-Marie Audet, M.D., vice president, Program on Quality Improvement and Efficiency
Sarah Klein, B.A., editor
Douglas McCarthy, M.B.A., contributing editor
Martha Hostetter, M.F.A., managing editor, [email protected]
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