Children’s Hospitals Utilize Opportunity to Strengthen Ambulatory Strategy

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As children’s hospitals and large pediatric programs work toward recovery and stabilization, administrative and clinical leaders are assessing which elements of COVID-19 disruption and innovation are here to stay. Many children’s hospitals have begun to understand their continued volume depletion, attributing lost emergency department and inpatient volumes to the natural consequences of social distancing (e.g., reduced viral spread among pediatric patients) and additional reductions in inpatient utilization due to intentional strategies such as early discharge and outpatient shifts. 

Though outpatient shifts have been an ongoing trend impacting health care utilization for several years, the COVID-19 pandemic has accelerated site of care shifts to minimize time spent in a hospital and subsequent risk of infection exposure. In pediatrics, the outpatient shift has unique meaning and drivers depending on the acuity level of the condition or procedure.

High-acuity conditions at freestanding and academic children’s hospitals

Among high-acuity pediatric patients (e.g., medically complex patient population), outpatient shift began well before the pandemic driven by innovations in surgical approaches and family-centered models at elite and academic pediatric institutions. For high-acuity conditions, outpatient shift often refers to a status change rather than a true site of care change. In other words, patients receive a service in the hospital and are discharged after a short stay. The importance and utility of this approach is heightened light of the national pandemic today. Examples include:

Major procedure to treat a cardiac anomaly: Innovative hybrid operating rooms facilitate a shift to outpatient status as minimally invasive approaches and immediate access to imaging reduce surgical time and anesthesia. Hybrid operating rooms will remain in the hospital but allow for complex surgeries to be completed under outpatient status.

Epilepsy monitoring and Neurodiagnostics: Discharge following 24-hour electroencephalogram monitoring in the Epilepsy Monitoring Unit (EMU) has enabled the outpatient status shift for children with seizures. Though the EMU remains hospital-based, ongoing technology improvements to neurodiagnostics facilitate outpatient shift. 

Low-acuity, high volume surgeries in the community

On the other hand, care redesigns driven by COVID-19 likely played a more direct role in accelerated outpatient shifts among low-acuity conditions and procedures. More common general surgeries (e.g., ear tubes) that were already performed under outpatient status in the hospital were pushed to other ambulatory sites—such as ambulatory surgery centers and office—as children’s hospitals worked to address patient reticence to hospital-based care. Examples include:

ENT and Ophthalmology services: Review of a 2020 hospital-based dataset indicate slowest volume recovery in surgical subspecialties such as ENT and Ophthalmology. Our team suspects a key contributor is out of hospital shift to ambulatory surgery centers, and in some cases, the office setting.

Pre-pandemic infrastructure: Service areas in which physicians have established community settings outside of the children’s hospital campus were best prepared to drive, capture and sustain additional outpatient shifts. Similarly, those with virtual health infrastructure were most effective at keeping families engaged and drive shifts from in-person outpatient care to telemedicine, including hybrid care models.

Strengthening your ambulatory strategy

While agility and nimbleness were critical success factors for health care organizations in 2020, children’s hospitals have the opportunity to deploy organizational priorities and intentional ambulatory strategies in 2021. Administrative and clinical leaders can get started with these key action items:

Understand drivers of shift in your market—Unlike adult medicine where outpatient shift is driven by payment and policy or entrepreneurial physicians, children’s hospitals’ shifts tend to be driven by innovation and quality. Identify procedures in which outpatient shift enhances quality and patient-centeredness and drive operational improvements by collaborating with clinical and operational teams.

Assess your own and your competitors’ ambulatory footprint—Take inventory of the sites and services offered in the community and on hospital campus’. COVID-19-driven care shifts and utilization reductions may have long-term impacts on facility needs; for example, virtual health utilization may reduce the number of exam rooms required to meet in-person visit demands. Reconsider space needs and ensure your digital infrastructure aligns with site of care optimization.

Bring providers into the fold—Independent physicians may have alternative payment incentives than employed subspecialists. Ensure provider affiliations enable care to be delivered as designed by the children’s hospital with quality front and center.

Unlike adult medicine in which care shifts are largely determined by the Centers for Medicare & Medicaid Services, children’s hospitals have the ability drive their own site of care shifts that support their quality and operational goals. Recovery from the COVID-19 pandemic presents ongoing challenges, but it also presents children’s hospitals with the opportunity to redesign care pathways and reconnect with your communities through ambulatory strategy.

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