The Acute-Care Continuum: The Future of Hospital-Based Care

Since the passing of the Patient Protection and Affordable Care Act in 2010, there has been a swelling of efforts by healthcare providers to manage what is often referred to as the "continuum of care" for patients. Physicians and health systems are engaged in a number of different structures and agreements that aim to essentially achieve the same thing: manage care for patients across all care settings and — perhaps more boldly — from birth to death.


Broader than the reform law itself, the "triple aim" of healthcare — better care, lower cost and a healthier population — is driving much of this effort to coordinate care across the continuum. This new model of integrated, coordinated care is emerging because successfully reducing costs, waste, variation and duplication, while improving outcomes is nearly impossible to achieve under the current delivery model. Radical new ways of delivering care are required, and as a result, healthcare providers are creating different types of structures in attempt to integrate various healthcare services so that care across the continuum can be successfully managed.


One of the most striking changes for hospitals and health systems as they work to create, or align with partners to create, an integrated continuum of services is their growing foray into ambulatory care. Hospitals have long provided outpatient services, but for most systems, investments in primary care and ambulatory facilities have expanded significantly in recent years.


While the elevated importance of ambulatory care has grabbed most of the trade headlines, an important aspect that may be overlooked in efforts to coordinate care is the need to coordinate care within the acute-care setting — that is, within the hospital itself.  According to a March 2013 RAND study, inpatient care currently represents 31 percent of the nation's healthcare costs, meaning that improved care coordination and waste reduction efforts in this setting could have a considerable impact on overall healthcare spending.

Lack of coordination inside the hospital

While much attention is paid to care coordination among various sites of care (outpatient, inpatient, post-acute, etc.), less attention is paid to care coordination efforts inside the hospital. Many assume that because all care at a hospital occurs within thehospital, it is inherently coordinated. This is far from the truth, says Wesley Curry, MD, CEO of CEP America, a physician practice that staffs hospital-based services at facilities throughout the U.S.


Emergency physicians, hospitalists, anesthesiologists, radiologists, intensivisits and skilled-nursing providers all interact regularly as they care for patients receiving services across the acute-care continuum. Without formal pathways for handoffs, communication and patient care coordination, outcomes can suffer. For example, a study presented at the 2013 American Thoracic Society International Conference found delayed transfer to the intensive care unit increases mortality rates in hospitalized patients. Of the patients transferred to the ICU within 6 hours of the critical Cardiac Arrest Risk Triage score, 27 percent died during admission. Researchers determined that for every hour the ICU transfer is delayed, the risk of mortality increases by 7 percent.


Coordinating the acute-care continuum

Coordination along the acute-care continuum simply requires physicians and providers in various hospital-based specialties work together to drive best practices and ensure communication. While this sounds simple, hospital politics can sometimes get in the way.


Nate Kaufman, managing director of Kaufman Strategic Advisors, has seen how challenging acute-care coordination can be in his work with clients across the country. "Professional staff is probably one of the most undermanaged groups at hospitals and health systems," he observes. "To make the continuum work, you need to have ED, radiologists, hospitalists and intensivists all in sync, and in many cases it's just the opposite. They may have different care philosophies, and they may have conflicting business objectives."


Some hospitals are now attempting to provide better patient care coordination and improve collaboration among hospital-based physician specialties by using a single physician staffing group to provide multiple hospital-based physician staffing services. Dr. Curry says the number of hospitals where CEP America provides both ER and hospitalist services jumped from 4 to 15 in just one year. In fact, today, some of  the largest providers of hospitalist services are physician management groups, which predominately provide emergency physician staffing, says Dr. Curry.


This shift is due in part to the need for improved coordination, but also due to financial incentives. According to Mr. Kaufman, a growing number of for-profit staffing groups will eliminate subsidies paid for ER and/or hospitalist physician staffing if a hospital agrees to contract with the provider for two or more hospital-based services. The potential savings are significant: An average subsidy for a hospitalist has been reported to be as much as $140,000, according to Dr. Curry.


However, aligning across the acute-care continuum doesn't necessarily mean all physicians must come from a single group. "It's about working with physicians in each independent specialty practice to take leadership roles and do things within the hospital to better align the goals and communication of hospital-based groups," says Dr. Curry.


Additionally, some hospitals have chosen to employ physicians to improve coordinate and collaboration around hospital-based services. Integrated systems such as Kaiser and Geisinger, for example, have done this through employment. However, it should be noted that just because a hospital employs various hospital-based physician specialties does not mean the physicians or care will automatically be coordinated. It takes purposeful effort to acheive this.


Mr. Kaufman agrees. "The first step is to redefine the role of the CMO to become manager of hospital-based physicians and at least monitor and support the groups if they're going to stay as individual groups and hold them accountable," he says. "The second step is that contracts [with the individual hospital-based groups] need to be more specific in terms of performance and willingness to coordinate care."

Financial implications of acute-care coordination, or lack thereof

How well hospital-based physicians work together also significantly impacts a hospital's bottom line. CMS' Value-Based Purchasing program will eventually put up to 6 percent of hospital's Medicare payments at risk, and commercial payers are likely to follow with similar value-based adjustments.


The VBP "makes very clear who did and who didn't achieve performance standards," says Dr. Curry. However, the "who" he is referring to are individual hospitals. Within the hospital, it is very difficult to identify which physician group — ER doctors, hospitalists, etc. — are responsible for wins or losses, and this lack of clarity is a major challenge for hospital administrators. For example, which group is bringing down patient satisfaction ratings?


"Right now it's difficult for a hospital to know if hospital-based groups are providing value. It's really an anecdotal excersize," says Dr. Curry.


Mr. Kaufman agrees that it's difficult to objectively assess the performance of hospital-based physician groups. "Very few hospitals are able to measure care provided across the acute-care continuum," he says. "When they go to the group and say, 'there's a problem,' the group says 'show me the data,' and the data isn't clean."


There are a couple of ways hospital leaders can overcome this lack of accountability. If the hospital chooses to continue to contract with separate groups for hospital based-services, "there has to be significantly stricter supervision and contractual requirements," says Mr. Kaufman. Hospital leaders may also choose to either contract with a larger organization that can staff multiple hospital-based departments, or may choose to employ hospital-based physicians own their own.
"If one entity can control all of those physician services, they are essentially responsible for the hospital's metrics," which will make it easier for administrators to assess the physician group performance, says Dr. Curry.

The patient's perspective

Denise Brown, MD, medical of director at Dignity Health's Sequoia Hospital in Redwood City, Calif., who also serves as the vice president of practice development for CEP, agrees that lumping all hospital-based physician performance together can create problems for administrators and physicians. But it is an appropriate way to examine quality because it reflects a patient's experience at a hospital, she argues.


"Doctors get so peeved by HCAHPS questions that lump all physicians together," she explains. "The reason this is really appropriate is because it's the patient's experience.  [Patients] do lump all the doctors together, and they do lump all the nurses together." In patients' minds, there's no difference between the hospitalists and the ED physicians — they are all physicians who've treated them while they're in the hospitals.  


Mr. Kaufman agrees. "A system may have four different hospitals with four different ED groups," he explains. "The patient may think you're getting branded services anywhere you go in the system, but the care you're getting could be totally different depending on which hospital you go to and which group it contracts with."


Health systems may look to patients as providers of coordinated acute-care, but in many instances today, coordination is lacking even inside the walls of a hospital. Many providers are beginning to make changes to better coordinate this care and provide integrated, seamless inpatient services. However, the road to truly coordinated inpatient care will be a long one.


"The issue is when you are most critically in need of coordinated care — when you're entering the ER and going through the acute-care process — in many cases that's when you could be getting the least coordinated care," says Mr. Kaufman.

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