The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions.
As Chief of Thoracic and Vascular Trauma at the Shock Trauma Center in Maryland, Dr. James O’Connor knows the difference between sick and well. With decades of experience at the leading statewide trauma program in America, Dr. O’Connor and his colleagues are actively engaged in expanding the critical care services for trauma patients to include Maryland’s sickest patients needing medical intensive care. As he recently explained to an expert panel gathered to assist the editors of Health Affairs to frame a special edition on ‘Reinventing Emergency Care,’ the reason is very simple. It is increasingly true that health care consumers have “one set of doctors when they are well, and another set when they are sick.”
Regardless of their specialty training, physicians are more and more likely to choose between practicing in office settings or hospitals. In some cases, full-time hospital practice for surgical subspecialists like Dr. O’Connor is a matter of necessity. Outside military theaters, no one would dream of doing an open-chest procedure outside the best equipped hospital available. Further, regionalization of advanced trauma care, speeding access to premier specialists like Jim and his colleagues at Shock Trauma, has been shown to save lives and improve medical outcomes.
The recent 60 Minutes broadcast – “The Cost of Admission”, and a comparable article in the NY Times, have raised a very controversial issue in emergency medicine and put this issue prominently in the public eye. The issue is: when is it inappropriate to try to influence physician behavior, and when do incentives become coercive?
Clearly, there are times when protocols, policies, performance goals, and even financial incentives can be helpful in getting physicians to adopt practices that are in patients’ best interests. The bottom line, though, is that if the goals of these incentives are not directed first and foremost to improving outcomes and providing cost effective, efficient, patient directed, quality driven objectives; such incentives deserve to be viewed with great skepticism, if not condemned outright. Unfortunately, the line between appropriate incentives and inappropriate incentives is not always easy to determine without a very thorough review. Thus, a protocol, or software driven set of admission criteria, that incentivizes providers to admit patients who rarely need to be admitted rather obviously steps over the line; but a protocol that encourages a physician to reconsider admission in patients who meet certain criteria in order to reduce the likelihood of an adverse outcome if the patient is discharged home could well be in patients’ best interests.
We take a look at 'post-hospital syndrome' discussed in The New England Journal of Medicine (January 2013). In addition, Health Affairs reports how a team approach could help with the physician shortage and The Hospitalist takes a look at CMS's Value-Based Payment Modifier (VBPM). Finally, we present 40 ED Performance benchmarks from Becker's Hospital Review.
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I am grateful for the privilege of reading about your experience. Thank
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