Interdisciplinary Rounds: The Key to Redesigning Care for Value

The days of solo-physician rounding are numbered, and value-based care is hastening the end. Instead, interdisciplinary rounding is taking hold.

"We believe that healthcare is now — and will be in the future — a team-based sport," said Dennis Deruelle, MD, vice president and national medical director for the Bundled Payments for Care Improvement initiative at TeamHealth. "It will be delivered in teams and if you can't work well in teams, then you won't succeed in the future of healthcare."

This content is sponsored by TeamHealth.

Interdisciplinary team rounds are dedicated interactions that occur on a regular, ongoing basis throughout the patient stay between the physician and other members of the care team, which may include nurses, physical therapists, pharmacists, case managers and family members or caretakers.

IDT rounds are becoming more common because they build a strong foundation for the care coordination that is essential to success in value-based care models such as CMS' BPCI and Comprehensive Care for Joint Replacement programs. They also help make care more efficient and cost effective by allowing for fluid decision making with the most accurate, up-to-date information available.

It's not just about the physician-patient relationship anymore

The traditional healthcare delivery system centered on the one-physician to one-patient theory, but that model has become increasingly obsolete in an era of team-based medicine and outcomes-based reimbursement. The one-to-one relationship is simply not reflective of care teams today — nor should it be, according to Dr. Deruelle.

"As we look at shared decision making in healthcare, we really look at it between the patient and the doctor. We discuss it and design it and look at that relationship as a one-to-one relationship," Dr. Deruelle said. "But the reality is healthcare is delivered by teams of teams, and in particular the team around the patient — their caregivers, family members and the patient — that team is not always present for rounds."

Care coordination is enhanced significantly when all the important decision makers — including the patient and their family members — are present to discuss care, answer questions and troubleshoot potential barriers to post-acute treatment. For example, a physician may tell a patient that returning directly to the home is the best post-discharge option. The physical therapist supports the idea, and the decision appears to be made. However, if the case manager and family members were not present during the decision-making process, they may have information that precludes the patient going home. By the time that additional information is available, the care team may already be blindly planning for a care pathway that is unachievable.

IDT rounds can help improve clinical decision making by giving caregivers access to more patient information, thereby reducing the need for course corrections and ultimately making care more efficient. "IDT rounds provide an opportunity for key members of the team to get together in real-time to communicate, to make decisions and to interact in a unique way that cannot be replicated by a series of phone calls or uncoordinated hallway conversations," Dr. Deruelle said.

Coordinated communication is essential to successful care redesign

Hospitals are seeing increasing value in using IDT rounds to enhance post-acute care coordination under value-based reimbursement models.

"When we undertook care value redesign, we looked at all the key touch points of a patient's stay in the hospital, including their discharge, possible readmission and possible second readmission," Dr. Deruelle said. "In doing the care redesign, we identified interdisciplinary rounds as a key touch point for communication and setting the stage for the appropriate setting after the hospital."

By improving communication between providers, IDT rounds can help support three integral components of value-based medicine, according to Dr. Deruelle.

  1. Post-discharge planning. The first element influenced by IDT rounds is the decision about where a patient should go after they leave the hospital. IDT rounds provide a forum for all the caregivers involved in a patient's care, including nurses, physical therapists and family members, to jointly discuss next sites of care and evaluate the patient's individual post-acute needs early on in the discharge planning process. This can help the care team identify the optimal next site of care and design care around that setting as soon as possible.
  2. Medication management. Medication management is the second element of value-based care that can be enhanced by IDT rounds. Dr. Deruelle recommends including a pharmacist on the rounds when possible to discuss medications on a daily basis, particularly in discussions surrounding discharge. Studies have shown involving a pharmacist during the rounding process can improve patient care and reduce costs. For example, a 2003 study demonstrated the rate of preventable adverse drug events can be reduced 78 percent when a pharmacist is involved in rounds. A 2010 study demonstrated hospitals can save $16 for each hour a pharmacist works reviewing patient cases while on rounds with a hospitalist.
  3. Patient hand-off. The last element of care redesign where IDT rounds come into play is the hand-off and discharge process. Having the patient and their family or caregivers present during the rounds, particularly as they approach discharge, can make a world of difference in closing gaps in care that occur during care hand-offs. "The last few IDT rounds during the hospital stay provide an excellent opportunity to tighten up that plan and make sure it's achievable from everyone's standpoint on the team," Dr. Deruelle said.

IDT rounds can help optimize a key cost-saving opportunity — the post-acute care setting

Improving communication between stakeholders is crucial to develop effective care plans that account for patients' individual needs. This not only helps produce better patient outcomes, but can also reduce the costs of post-acute care.

Outside of implants and supplies, the post-acute setting represents the No. 1 opportunity for hospitals to lower costs within bundled payment programs. Almost half of overall savings associated with the CJR bundled payment program implemented at San Antonio-based Baptist Health System was attributed to post-acute care spending reductions, according to a study published in JAMA Internal Medicine in February 2017. When included in the bundle, average post-acute spending declined by more than $2,440 per case, primarily due to lighter use of inpatient rehabilitation and skilled nursing facilities, according to the study.

IDT rounds can help hospitals reduce post-acute spending by enhancing communication between caregivers. With the teams of teams present during IDT rounds, all the key players know as soon as possible what barriers are present to certain next sites of care, and can work to eliminate those obstacles if possible. According to Dr. Deruelle, the goal for every patient is to go home. "We believe patients should go home if they can go home," Dr. Deruelle said. "We don't accept that a skilled nursing facility is any safer in and of itself than a home discharge if the right support can be provided."

In fact, studies have shown patients who receive home-based care may achieve the same quality results as those who go to an inpatient rehabilitation facility, and often at a lower cost. For example, patients who were sent home after a knee surgery and received at-home physical therapy experienced no difference in complication rates within six months of surgery compared to peers who were sent to an inpatient rehabilitation facility, according to a 2015 analysis of data on more than 2,400 patients who received knee surgery at New York City-based Hospital for Special Surgery from 2007 to 2011.

"Many patients believe they will do better after knee replacement if they have rehabilitation at an inpatient facility because they will receive more physical therapy," Douglas Padgett, MD, the lead investigator of the study, said in a statement. "However, in terms of early complications and outcomes at two years, we did not find an advantage."

Providers must be engaged in the process to drive outcomes

To ensure IDT rounds are successful, hospitals must approach the care redesign process thoughtfully. It is a significant shift in thinking to consider responsibility for patient outcomes extends beyond discharge and that it's everyone's responsibility — not just that of the physician, nurse or family.

To help this new mindset sink in, it is essential to gain buy-in from IDT round leaders. Physicians ideally lead the rounds, sometimes with a nurse co-leader, according to Dr. Deruelle. The key to gaining clinician support is to demonstrate that IDT rounds are not added work — they ensure the patient is at the center of their care and ultimately improves value.

Dr. Deruelle advises hospitals to remember the education component of care redesign — including both content creation and dissemination. Content needs to be available "so there is a full and complete understanding of what the outcomes are that we want to achieve, why we want to achieve them and why care redesign and IDT rounds will help us get there," he said. Tool kits and modules should be available electronically, but training should always begin in-person. If affiliated hospitals and staff are included in the training process, that's even better, he said.

"At the end of the day, one of the most powerful messages is that these models can help improve value for patients," Dr. Deruelle said. "It really gets our providers engaged because they know we are doing it for the right reasons."

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