Perspectives on the Acute Care Continuum

The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions. 

Bringing the Future of Healthcare to the Underserved

10/15/2015 12:39:44 PM | 5 comments

A recent study out of Harvard suggests that hospitals in low-income areas are more likely to be penalized under Medicare's value-based reimbursement programs. But one California health district is beating the odds with innovative programs and an integrated mindset.


The Rapid Pace of Change

Kaweah Delta Health District is based in Tulare County in California's Central Valley. It's one of the poorest counties per capita in the state. Many residents are employed in low-paying agricultural jobs, quite a few are migrant workers and relatively few hold high school or college degrees.
All hospitals in the Central Valley have seen patient volumes rise since implementation of the Affordable Care Act (ACA) in 2014, but none on the scale of Kaweah Delta. Emergency department (ED) volumes have swelled by 500 to 1,000 patients per month. Inpatient beds have been filled near capacity every day but one for the past thirteen months. The patient mix has also changed, with the hospital seeing more acute and complex cases.
Several overlapping factors are probably driving the growth in Kaweah Delta's patient population; with healthcare reform likely a major factor. In 2013, 24 percent of Tulare County residents lacked health insurance. A year later, after ACA implementation, that number had dropped to 14 percent. These newly insured patients are less fearful of debilitating costs and more likely to seek care — even if it means a trip to the notoriously expensive ED.
The local physician shortage is another factor driving patients toward the hospital. The Central Valley has long been underserved for both primary and specialty care. The wait for primary care now ranges from three weeks to six months depending on the payer. So patients often have no practical option for care other than the ED.
Finally, the district has grown to meet the needs of the community, adding new service lines like neurosurgery, stroke care and (coming soon) maternal fetal medicine. It's also becoming a regional referral center for trauma, stroke and cardiovascular care. These offerings have attracted walk-in patients, referrals and transfers from across the region.
To preserve access to care, Kaweah Delta needed to find ways to ease ED crowding, decrease inpatient length of stay (LOS) and manage population health in a way that minimized preventable admissions. This required innovation, openness and a collaborative mindset. Above all, the district needed physician champions who could spark change and keep it moving forward.

A Multipronged Approach

In transforming care delivery, the Kaweah Delta leadership found a valuable partner in CEP America. We currently staff the district's EDs and urgent care centers and were recently chosen to manage its family medicine residency. We are excited to support the hospital's goals and provide leadership for the following initiatives:
Urgent care integration. CEP America emergency and urgent care physicians work together to counsel patients toward the appropriate level of care. We've successfully funneled many lower-acuity patients toward urgent care, which relieves the burden on the ED and reduces patients' out-of-pocket costs. (On the other hand, as our market share has increased, we've also seen more high-acuity patients transferred from urgent care to the ED.)
Family medicine residency and clinic. Under CEP America's guidance, this program will hopefully create new opportunities for access and integration. Our plan is to enroll patients who lack access to primary care into the resident-staffed family medicine clinic. The program will accept all comers, including self-pay patients.
We hope that patients will utilize the clinic for non-emergent, preventative and post-acute care. This will help to reduce preventable admissions and readmissions. And because the patients form an identified population, the clinic will also serve as a vehicle for population health management.
Telehealth. CEP America is currently working with Kaweah Delta's leadership to possibly implement a 24-7 telehealth program that will further integrate the emergency medicine, urgent care and family medicine service lines. The proposed call center will be staffed by a multidisciplinary team that includes a resident, pharmacist, case manager and social worker.
The team will help direct patients to the appropriate level of care as well as troubleshoot any health issues that arise. For example, if a patient is having trouble filling a prescription, they might help to arrange for home delivery of the medication, explore affordable alternatives and/or help the patient access needed care.
Integrated delivery network. I'm excited to be personally co-chairing this initiative, which is driven by a team of hospital-based physicians from across the district. Together, we identified the system's 18 most costly DRGs and found that variability of care was a major factor driving resource utilization.
To address the problem, we've begun creating clinical pathways for each condition that promote consistent, evidence-based care. Our first six pathways were just approved, including those for CHF, COPD and sepsis.
Medicare Advantage pilot. I'm also proud to serve on the clinical advisory committee for this program, which manages four to five thousand patients in a capitated, risk-sharing arrangement between the local IPA, health district and Humana. Through increased care coordination, we've been able to decrease LOS by one day over the average for the Medicare population. Lessons learned in this program will be used to help develop integrated delivery networks for all Kaweah Delta patients.

Success Stories

The experience of Kaweah Delta demonstrates that population health management and value-based care can succeed with any population. Leveraging the strategies above (and many more), the system has managed to serve the needs of the newly insured while maintaining excellent ED throughput times (relative to EDs of similar size and acuity).
To me, the partnership between Kaweah Delta and CEP America underscores the importance of physician engagement. It has been exciting to see CEP America physicians helping to lead this transformation, either as contracted partners or members of the larger medical staff. Our physicians recognize that we have to be ready for the future of the marketplace, and that the entire system needs to work toward the same goal for the benefit of the patient. That's why it's so important that we come to the table with solutions that help our hospital partners move forward.

Wes Fields

Great summary of why the Kaweah Health Care District is one of the more important test beds for integrating acute and primary care in California, if not America.
12/21/2015 11:16:51 AM

Joe Ginejko
Great job demonstrating how a partnership between the hospital and the physicians can co-design solutions to our many issues in delivering the best care to our patients. Keep up the innovative work!
10/17/2015 1:47:35 PM

Tom Sugarman
Really impressive work Scott! You and your team are showing how physician leadership and engagement can lead to tangible improvements in access and quality of care, especially in underserved areas.
10/16/2015 10:03:09 AM

Rick Newell
Great piece! Scott, you and your team in partnership with Kaweah are doing amazing work that is benefiting patients in the entire region. Hopefully other health systems will be able to mimic Kaweah to transform care delivery in other regions as well.
10/16/2015 9:09:47 AM

savoy brummer
Nice article. These issues are facing lower demographic hospitals across the country and we need more conversations regarding solutions.
10/16/2015 8:40:07 AM