The Acute Care Continuum is the integration of urgent, emergent, inpatient and post-discharge care of patients with acute medical conditions.
My emergency department in Selma, Calif., recently faced a spacing emergency when the number of our ED patient beds was reduced from 24 to 10. We had no choice or advance notice and about a day to prepare. We had to act and adapt quickly, because certainly our volume wasn’t reduced to help us with our transition. With limited resources and no increase in staff, we had to achieve the same results working with less. To accomplish this, I tried to expand my own productivity, and at the same time I focused on building our team through communication, motivation, and integration.
We were not only able to continue to serve the same number of patients, but our turnaround time to discharge (TAT-D) actually fell from 125 minutes to 108 minutes. I believe that beds by themselves don’t make people efficient. Instead, being part of a team that communicates well and shares leadership, vision, and ambition is what promotes efficiency; and this is what enabled us to increase our performance during this challenge. We were able to galvanize enthusiasm and to shift the culture in the ED toward increased teamwork. We did not let the number of beds dictate to us how we would do our job.
What is medical reconciliation (MedRec), and why is it important within the acute care continuum? The Joint Commission (TJC) on Medication Management has stated in its 2012 list of goals that EDs must: “Maintain and communicate accurate patient medication information.” Dirk Stanley, MD, summarizes the medical reconciliation challenge nicely. He says it is obtaining from the patient the ‘home med list’ of what the patient usually takes, creating a current list of what the patient is taking at that moment, and then generating a new current med list of “what does the patient need to be on right now.” MedRec includes identifying omissions, duplications, contradictions, unclear information and changes and giving the new list to the patient when leaving the medical setting. Beyond its obvious value in patient care, MedRec is important to the ED because failure to adhere to a TJC National Patient Safety Goal can result in loss of accreditation.
Gaining a grasp of this workflow is inherently filled with uncertainty. For example, how can a provider even know for sure whether a patient takes the medications they state they take or if the patient is divulging all the medications they are taking? To meet the MedRec challenge, inter-department coordination and EMR utilization will be key parts of the solution. In a sense, the challenge and the accomplishments made in MedRec coordination can be seen as a microcosm of the future path towards breaking down department silos across the healthcare continuum to create efficiency and integration.
In 2013 and 2014 as part of the Patient Protection and Affordable Care Act (ACA) a “primary care payment bump” will become effective. This is a program where for two years primary care physicians (PCPs) will receive the Medicare level reimbursement for the Medicaid patients they see. This is not a small change, considering Medicaid rates have been estimated to be about 66 cents to the dollar when compared to Medicare primary care rates. In fact, the investment the Feds are making for this program is estimated to be $11 billion and will increase PCP Medicaid reimbursement by 34%.
Physicians eligible for this program are those with a specialty in family medicine, internal medicine, pediatric medicine, and obstetrics. The policy considerations behind this pay bump are consistent with the ACAs goal of expanding the availability of health care. Medicaid expansion is a critical component of how increased care will be provided across the country under the ACA.
Safety net hospitals serve vulnerable populations such as low income and uninsured patients (pdf). Studies show that the upcoming changes to Medicare reimbursement could greatly add to the financial troubles of safety net hospitals, and it appears that hospitals already on the financial edge could fail. The new way of determining Medicare payments that begin this October will be partially based on quality metrics such as patient experience surveys and readmissions, as opposed to the pay per service model of the past.
It makes sense to judge hospitals on the quality of care they provide. In terms of quality of care, some have made the case that there is little difference between safety net and non safety net hospitals. According to a study conducted by Joseph Ross for Health Affairs, care quality for Medicare enrollees at safety net and non-safety net hospitals was almost equal, and mortality and readmission rates were “broadly similar” for both. Safety net hospitals even face some increased challenges in readmissions such as their patients are often less likely to be able to afford medications, have access to doctors for check-ups, and are more likely to have trouble getting the needed transportation for follow-up care. Kaiser Health News recently reported that hospitals that have the largest share of low income patients are 2.7 times as likely to have high readmission rates.
I was recently working on a consultation gig and came across a report from the FTC and the DOJ entitled ‘Improving Health Care: a Dose of Competition’, which included a reference to the so-called Iron Triangle of Health Care. William Kissick initially proposed this concept in 1994 when he described medicine’s dilemma of infinite needs versus finite resources. The three vertices of the triangle are cost, quality, and access. As I read the description of the equilibrium established by this triangle of consequences, I visualized the three corners of this triangle, each connected by springs to the other two. Attempts to reduce costs in the system must, according to the theory, result in either reduced quality of care, or reduced access to care, or both. Likewise, improving quality either increases costs, or reduces access, and so on.
Is it possible to reduce costs and maintain or even improve quality and increase access? If you assume there is a lot of waste, fraud, and excess that increases costs but does not contribute to the quality of care, or a lot of inefficiency in resource utilization that undermines access; then perhaps the springs can be stretched a bit without pulling in the other corners of the triangle. Well, we know there is waste, and we know there is inefficiency, so it should be possible to rein in costs, or at least hold steady there, and still improve the effectiveness of our health care model (or any health care model, for that matter). The question is: will Obamacare achieve this goal?
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Great article Seth! As a non-clinician, I know that a call-back would mean the
Great article and really a good 'how to do it' in a way that makes sense and
Thanks, Seth, for highlighting the personal gratification that comes from
Rachel, thank you for sharing your unique method of coping that allows you to
Inspiring and thought provoking! Thank you for taking the time to share this