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A Closer Look at Failures and New Initiatives

Half in jest but partly in truth learned during stints in Boston hospitals, Kate Reed notes that being an ambulatory services planner is something like being "a mushroom farmer" because "it wasn't until the last couple years that anyone cared about ambulatory."
An RN/MBA and also former clinic administrator at Virginia Mason Medical Center in Seattle,
Kate Reed

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Panel moderator Kate Reed, RN, MBA: Being an ambulatory services planner used to be something like being a mushroom farmer.
Reed was moderator of the "Outpatient Restructuring" panel at the 2012 Wharton Alumni Health Care Conference.

"Ambulatory was always in the worst, under-resourced facilities," she told the audience. "So, I'm delighted that in the new world of accountable care that people are suddenly saying, 'Oh, we better get really good in how we provide outpatient care.'"

"All our future success in ambulatory care depends on several very large buckets of activities, including access to primary care and preventive services and coordination of those services," Reed said. "We've developed these extraordinary specialists and built their specialties into pretty rigidly defined silos that are now a challenge to the coordination of care."

Reed's comments were only the first from a panel whose members all acknowledged serious deficiencies in the health care system's traditional approach to dealing with outpatient populations.

"Most of the care that [our industry has] provided has been absolutely centered around the conveniences of the infrastructure and the capital we've built," said Gary Gottlieb, President and CEO of Partners Healthcare, whose various hospitals are teaching affiliates of the Harvard Medical School. "We've been hyper-capitalized for the better part of the last century and a half, building health care institutions that were driven first by epidemics and the isolation of populations, and later driven by reimbursement systems and science that created giant infrastructures that required themselves to be fed in the way that, right now, appears more hyper-capitalized than ever before."

"The mission," said Gottlieb about the reorganization going on in his own facilities,
A 3:49 video excerpt of Gary Gottlieb's remarks at the Wharton Health Care Management Alumni conference. Or, click here for larger video format.
"is focused on trying to bring the best and the brightest people to care for the sickest and neediest population and somehow to try to use innovation to re-inform care."

"We've been a magnet for magnificent young people," Gottlieb continued, "and if we abandon the communities that we serve in and around our institutions I can tell you those young people will run from us. You know, I was the president of the Brigham and Women's Hospital for eight years and over that time there were about 100,000 babies born. And the fact that the infant mortality rates for the babies of black women in Boston within two and a half miles of that hospital were two and a half to three times higher than for white women is a failure of my leadership and therefore all we do in this regard has to make those changes as well."

Payment as accountability tool
"We're all living in an environment that's evolutionary as it relates to health care payment," said Gottlieb. "And I think health care payment has to be a tool to create accountability. The fee-for-service environment is failing to create accountability and it promotes fragmentation. But it's not an evil center of provider-induced demand. At the other extreme is the evil of provider-induced barriers to access that is equally difficult. In the 1990s it created a tremendous polarity with primary care doctors on one hand and specialists and institutions on the other trying to create barriers to access. That was a failure society wouldn't tolerate. So somehow within the spectrum of all this there is a sweet spot and we're trying to figure out how to embrace it."

Similarly, Matthew Cook, Vice President of Strategic Planning at the Children's Hospital of Philadelphia (CHOP) is trying to figure out how best to reinvent ambulatory care, which is no small feat in a health system as large as his. CHOP operates the country's largest network of pediatric ambulatory care facilities, annually handling 700,000 primary care, 450,000 specialist, and 88,000 emergency department visits.

Currently, CHOP is working to push more of its high-level ambulatory care further into its extensive local networks from its headquarters hospital in Center City. "We've actually sacrificed growth at the main campus here for the growth of our community partners," Cook said.

Most intractable problem
He admits that access to care is one of CHOP's most intractable problems. Its latest efforts to improve access have it rethinking the physician space. "We're asking how can we take capacity or patients from the primary care physician and move those down to the nurse practitioner at the same time we move some specialty care patients over to our primary care physicians so that we can free up some demand for our specialty care or our subspecialists."

The outpatient area in which CHOP has achieved the most success so far is asthma, the chronic disease that is the leading cause of hospital admissions among children. In a two-year initiative in its inner-city clinics underwritten by Aetna and other insurers, the hospital revamped its entire approach to dealing with asthmatic pediatric patients.

"There was a lot of heavy care coordination accomplished by nurses and nurse practitioners," said Cook. There were also greatly increased pre-visit patient assessments by RNs, innovative methodical use of electronic records to detect patient ED visits. Those visits triggered followup nurse phone calls to the family to better understand how that incident could have been prevented or diagnosed earlier. One goal of this part of the program was to risk-assess the patients and assign them to a severity class that would inform management of their care by everyone involved.

Evidence-based medicine
"Our telephone time went up 300%," Cook said. "But we standardized treatment. We got physicians to agree on the medical dosage and care plan. We ensured all the points of evidence-based medicine were completed."

Over two years, the asthma effort more than halved the referrals of primary care physicians to allergy or pulmonary specialists. "That was a fairly dramatic shift," Cook said. "And it allowed the allergy and pulmonary specialists to see more chronically ill patients that could not be cared for by primary care physicians."

The initiative also saw a decrease in asthma patients going to the emergency department as well as a decrease in asthma patient admissions to the hospital, he said.

But Cook notes such successes do not come easily or without some friction. "The one thing we really learned is that it can be challenging when you're trying to change behavior that's been ingrained in somebody's practice for 25 or 30 years."

Looking forward, Cook said CHOP is working to re-envision and reinvent other parts of its basic systems.

"We have ambitions for our integrated IT platform as many organizations do," he said. "We're in the process of trying to integrate both claims and clinical data and provide real time support to our clinicians. We're trying to improve our analytics so that we know how to price differently as we move from fee-for-service to value based or risk based reimbursement. And then finally, we're really trying to integrate the care model across the region, across disciplines and make it much more collaborative in nature.

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Hoag Levins is a journalist and managing editor of The LDI Health Economist.

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