Re-engineering the way we deliver healthcare: we have to do better!

Illustration: Lee Sauer

In thinking about next week’s CV Transforum conference, a lot comes to mind on the need to re-engineer the way we do things. And from my work assisting groups who are thinking about the different alternative payment models, and helping programs develop their care team models, I have many stories that illustrate the need for change. Today, before I get into the problem areas, I want to start with a story that shows how things can go right.

I received a call from a friend whose mother, with a history of CAD, had an episode of chest pain that seemed all too familiar with her previous angina. The friend described it as exertional and had been progressing with less and less activity over the previous several weeks. This woman was the caregiver for her terminally ill husband and didn’t have time to be sick. It was a Wednesday, and I was in the office and had easy access to the cardiologist who had been taking care of her. Based on the symptoms and review of the last visit, he recommended a nuclear stress test. So I called down to our testing department and they had an opening the next morning. Her stress test was performed and was found to be abnormal. Since I was in the office that day and had the opportunity to check in, I got the test read before she even left the office. Finding it abnormal, I reviewed it with her cardiologist who recommended Left Heart Cath. I called the physician in the cath lab and he had an opening that afternoon. The patient was already NPO and they could take her if she came straight to the hospital. This was Thursday afternoon. Her cath was performed and they found 3 vessel diseases and recommended a surgical consult. Again, having the ability to check in on her, I called the surgeon’s nurse and they assured me that they could see her that day. The surgeon agreed and she was placed on the surgical schedule for the following day. The surgery went well and she was discharged home the following Tuesday without complication or issue.

What I want you to take from this story is the timeline and the degree of care coordination required to create that timeline. In less than a week, this woman went from symptoms to surgical revascularization and home without having an acute event to trigger the episode. My ability to follow through and use connections with the provider team was key in this; my question for you all to think about is: why can’t we create such a scenario for every patient who comes through our doors or calls us on the phone? In my opinion, several areas of our delivery design—access, care coordination, and shared care—need a major overhaul. In this case, any one of these could have slowed this process to a ‘crawl.’

Access

Access is more than just the next available appointment; it should encompass how your phones are answered, the ease of management for urgent needs, and the communication of test results, medication refills, physician-to-physician calls, and so much more. I believe that this is one of our biggest challenges for several reasons. One, the resources required to manage phones, schedules, triage, etc. are often seen as non-revenue-generating roles within the ambulatory practice. Yet, every missed call or long wait could mean revenue lost. So it may not be a revenue-generating role, but it certainly can be a revenue-losing role if not managed appropriately. Second, in our fee-for-service world, we are incentivized to maintain full or even overfull schedules, where we find ourselves unable to do today’s work today. How many of you are doing work in your offices every day that should have been done 2-3 months ago, with backlogs and recalls that are more than what your capacity allows? This scenario creates competition between holding slots for new patients and getting the established patients seen, as well as an ability to manage urgent needs by bringing them in. We do a lot of reactive telephonic care, which can be slow, cumbersome, and a patient dissatisfied.

In our fee-for-service world, we are incentivized to maintain full or even overfull schedules, where we find ourselves unable to do today’s work today.

Care Coordination

We spend a lot of time talking about coordination of care, but are we really that good at it? In this example, care was passed from the primary cardiologist to the imaging cardiologist to the interventional cardiologist and then to the surgeon—all within 48 hours. There were phone calls, test reports, and patient information that needed to pass through with hand-off. Support roles including team-based nursing, imaging support, pre-procedure preparation, and surgical coordination and preparation were required. This doesn’t just happen. Coordination of the right folks with the right processes and protocols is essential. Protocols include protocols for RN triage to manage patient calls that include symptom changes, protocols for abnormal test results to be managed in real-time with follow-through, and protocols for pre-procedure and pre-surgical preparation. These protocols require development by physicians and administrative leadership to drive out as much unnecessary variation as possible to create highly reliable processes by competent team members that drive high-quality results. To put it simply, the fewer ways there are to do things, the more likely they will be done correctly. When a system of care is in place, timelines like the above can happen the majority of the time.

Shared Care

This is where the scenario begins to get complex. I think everyone agrees that access and care coordination are very valuable. So, how do your physicians share care within your program, especially with the growing sub-specialization that we see in cardiology? Shared care means that a group of physicians holds themselves responsible for providing the highest quality care in all the elements such that they trust each other to take part in the care of their patients. This requires both economic and clinical alignment. This is the piece that allows the primary cardiologist to identify a need, allow a partner to read the ordered imaging study, and allow a third partner to perform the cath. I often hear the argument around continuity of care at a patient level and its value—does that mean that all care is provided by that physician or does it mean that physicians hand-off portions of the care in an environment of communication and respect to maintain a holistic approach to patient care? If the above scenario needed to be managed by the primary cardiologist to include evaluation, test interpretation, cath performance, and referral, that timeline in some cases could be 1-2 weeks or more. Back to my point about doing today’s work today. Certainly, there are trade-offs and if the collaborative environment, trust between partners, and processes/protocols aren’t in place, a more traditional single-physician approach is required. This is not easy work and it takes time for sure.

In conclusion, I want you to think about all the times you have bypassed your normal operations to get a friend or family member plugged into your program. What were the things that you knew would slow things down, and what is required to create a program where you are confident enough to have that same friend or family member utilize the normal patient flow and assure that their needs will be met? I know these issues are not uncommon, as we see them often in the practice assessments we do across the country. Frankly, with all of the pressures related to reimbursement, narrow margins, and incentive misalignment, our system works just the way we have it set up. I look forward to seeing many of you at the conference next week, where we will see examples of this work, learn from each other, and get a better understanding of how our new reimbursement models can incentivize us to put better care systems in place.