We all know it: Our healthcare system is a mess. Readmissions cost our industry up to $41.3 billion for patients readmitted within 30 days of discharge, according to the Agency for Healthcare Research and Quality (AHRQ). Talk of “innovation” has been smoldering over the past couple of years; something about this system has to change. We are on the verge of an era of transformation where hospitals execute an organizational overhaul in their care delivery methods.
Why Do We Even Need Hospital Transformation?
With more and more research, we find the patients who come back again and again to the hospital are often the same ones. Upon further scrutiny this makes perfect sense: These patients are the ones who are most at risk, often with chronic conditions and confounding factors in their lives and a lack of proper support.
However, this is how progress works: A suboptimal pattern emerges from the data, and we learn how to break it. What habits have hospitals fallen into that allow these patients to slip through the cracks?
Currently, when discharging patients from the ED, many hospitals hand the patient a piece of paper with a referral for whatever services providers have decided the patient needs. The patient walks out the door, the hospital loses contact, and there is no confirmation that the patient follows through. Often they do not, and they are back again with the same problem (or complications) a few days down the road.
An excerpt from the University of Colorado Memorial Hospital Health Midpoint Report sums up the problems: “Current gaps include the inability to share care plans real-time, to quickly identify high utilizers without reviewing all visits in the electronic health record, and to determine if patients followed up on recommended social services or healthcare agency referrals (if external health system). Also, partners identified the inability to visualize primary care notes that are not in CareEverywhere, and failure to share data on individuals with substance use disorder secondary to 42 CFR regulations. Finally, the regional accountable entity has access to the patient’s risk scores and complex care plans for COUP patients (Client Overutilization Program). However, at this time there is no venue to share such care plans and risk stratification scores. Also, it is challenging to identify Medicaid members who receive home-based community services as they use the hospital because the care management staff does not have access to such information in a timely fashion.”
Why is this a problem? The accumulation of all these repeat patients costs the healthcare industry billions of dollars. Poor care coordination and subpar care transition management after hospitalization account for $25 to $45 billion in wasteful spending every year.
We need to start supporting our patients where they need it. Confounding factors like homelessness, poverty, and mental health can prevent a patient from following through on their referrals and continuing to get the care they need. A significant facet of helping support care transitions is about social support to get the patient where they should go.
As the healthcare industry shifts into value-based care, many state Medicaid offices are now also fining hospitals that cannot show how they are providing community engagement.
Roadblocks to Closing the Feedback Loop
There are many roadblocks to making these transformations a reality. Some of the largest:
- Convincing Physicians to Learn New Workflows
Though physicians tend to be supportive of new care models, countless hurdles need to be overcome—for example, the needs of individual patients, properly negotiated physician reimbursement models, and the (temporary) productivity loss in having to learn a new workflow. Though it is in everyone’s best interest to move the healthcare industry away from acute settings and toward models focused around health promotion, disease prevention, and addressing social determinants of health, the current system in which physicians work, with the workload these providers carry, provides a daunting setting. After all, physicians cannot solve poverty. However, with the proper hospital transformation setup, physicians and patients can become part of a program that helps address those societal issues.
- Adequate Funding and Targeted Incentives
The crux of problems with funding and targeted incentives is that these societal issues and determinants are difficult to measure. It is a risk to switch from volume to a value-based model, but it’s a risk that’s worth it. Population health programs have the potential to “bend the cost curve,” but it cannot happen without adequate funding, correctly targeted incentives set by the CMS, and the proper investment in the right technologies to enable the transformation.
- Care Coordination
Healthcare systems all over the world struggle with care fragmentation, but the problem is much more prevalent in the United States. This poor coordination causes delays in care, incorrect care, unnecessary complications, and needless tests and procedures. Frequently, delays and wrong actions are caused by poor communication, difficulty sharing care plans, and multiple caregivers trying to coordinate efforts across organizations. A health system that is not well coordinated cannot deliver high-quality care.
- Lack of Enabling Technology
Technology can enhance the sharing of information across organizations by creating and communicating a unified care plan, listing those involved in a patient’s care, and centralizing the medical information and other problems that come attached to a patient. However, few have the right compliances to make this all happen. Interoperability is critical, and the technology must successfully perform thoughtful and useful analysis when the data is received. Finding the right technological fit for your hospital is not easy.
With the proper technology, though, many of the transformation roadblocks are reduced or eliminated.
Software like Julota’s, for example, has enabled technology to lower readmissions and help hospitals with their transformations by allowing the sharing of information across organizations. Julota’s product electronically links hospital EDs to community services. Now the ED can send electronic referrals to organizations like behavioral health clinics, food banks, home assistance programs, substance abuse centers, and charities.
There are already electronic referral platforms out there. The difference with Julota is that organizations can share and create care plans together. Julota allows actual data, health records, and care plans to be shared between partners. The integrations then allow sharing of primary notes. All of this is critical for current DSRIP (Delivery System Reform Incentive Payments) community engagement initiatives. Finally, the software allows case management to operationalize programs with specific protocols, assessments, required data, checklist items, and so forth, so patients can be tracked. This allows multiple team members and community resources to help patients progress to completion.
Helping your patient engage with the community is a win-win for the patient and your hospital because this engagement addresses the social determinants at the core of true population health. It facilitates care coordination.
HIPAA and other privacy regulations are respected because Julota is HIPAA-, CFR 42 Part 2 (behavioral health, substance abuse)-, and CJIS (law enforcement, jail facilities)-compliant. Julota has none of the interoperability problems you face with other software.
Just as Uber now includes safety features that allow you to send your route and location to other people, maybe we should have a similar tracking feature for an at-risk patient’s medical journey too. If a patient leaves with just a slip of paper or even just an electronic referral, the feedback loop is never closed—in fact, there is no feedback loop. Hospital transformation cannot happen until hospitals engage with community resources.
With the help of software like Julota, when a patient walks out the door, the hospital can get confirmation back when the patient arrives at their next scheduled destination and is put on a plan. Now hospitals, with Julota software, can prove their accountability.
These aspects also help with payer-provider collaboration, funding, targeted incentives, and, convincing physicians to learn new workflows. When the benefits are significant enough and the communication clear enough, the results help overcome other hurdles.
Don’t want to switch software for your current hospital usage? Great—you don’t need to. Julota does not replace any existing software system but can link to the hospital’s current electronic health record (EHR) like Epic or Cerner. Physicians do not need to spend lots of additional time learning a new EHR.
But perhaps more importantly, using software like Julota will enable hospitals to use the data to measure patients’ social determinants of health. This will not only help payers and providers communicate and delineate shared goals but ultimately lead to lower healthcare costs for all.
What Hospital Transformation Could Look Like
Some hospital transformations have already begun. A progressive hospital in the Pacific Northwest may prove to be the incubator and model for the country. With the help of Julota, PeaceHealth Peace Island Medical Center in San Juan County, Wash., has become a community hub, linking with most of its community resources. One such organization is the North County Regional Fire Authority (NCRFA). As one of PeaceHealth’s “spokes,” it operates a mobile integrated healthcare/community paramedicine program. Now EMS, fire departments, case managers, charitable organizations, clinicians, and physicians can come together to form a unified care plan for any given patient.
At PeaceHealth, when a patient comes into the ED with a nonemergency, staff can use Julota to quickly and electronically refer the patient to more than a dozen community resources. The hospital then gets electronic confirmation that the patient followed up and utilized those services, and all parties can share information to collaborate around the patient.
“In [my] 37 years of working in EMS,” said Darin Reid, the community resource paramedic program manager at NCRFA, who also runs the local MIH-CP program, “this was the first time I’ve seen all the local community organizations and services work together.”
Beth Williams-Gieger, director of administrative services at Peace Island Medical Center, said, “Peace Island Medical Center has embraced the community health needs assessment process as a means of realizing our mission. Our mission includes building a strong, healthy community by engaging with our community partners to identify disparities and prioritize community health needs. Julota provides our community with a common information exchange that allows us to track coordination of referrals to address social and economic health needs for our patients outside the hospital walls. Healthier communities enable all of us to rise to a better life. Julota is an important community connector technology that will assist us in creating a better future for our community.”
It is time to embrace the organizations and other community resources that are out there ready to help improve population health. The need is there—now the technology finally is too.
Written by Kevin Amell