Competing health care systems and complex patients An inter professional collaboration to improve outcomes and reduce health care costs lable at ScienceDirect Journal of Interprofessional Education &[.]
Trang 1Competing health care systems and complex patients:
An inter-professional collaboration to improve outcomes
and reduce health care costs
Lauran Hardin, MSN, RN-BC, CNLa,b,*, Adam Kilian, MDa,c,
a Trinity Health-Michigan d/b/a Mercy Health Saint Mary's, Grand Rapids, MI, USA
b National center for Complex Health and Social Needs, Camden, NJ, USA
c University of Utah Health Care, Salt Lake City, UT, USA
d Cherry Health Services, Inc., Grand Rapids, MI, USA
a r t i c l e i n f o
Article history:
Received 10 July 2016
Accepted 20 January 2017
Keywords:
Cross continuum care collaboration
Competing health systems
Integrated care
High need patient
High frequency patient
Complex patient
Chronic patient
Emergency department
Individualized care
Decrease readmissions
Preventable hospitalization
Cost reduction
Root cause
Inter-professional team
Interorganizational team
Integrated behavioral health
Overuse
Overutilization
Super utilizers
a b s t r a c t
Background: High-need, high-frequency patients overutilize acute care services, a pattern of behavior associated with many poor outcomes that disproportionately contributes to US healthcare costs Purpose: Our objective was to reduce healthcare costs while improving clinical outcomes through optimizing healthcare delivery and inter-professional collaboration for complex patients
Method: To do so, we partnered with a competing health care system to address fragmentation in the patients' plans of care contributing to patterns of high utilization
Discussion: Our collaborative approach was associated with a reduction in healthcare utilization and costs for this population, as well as an increase in operating margin
Conclusion: Collaboration between neighboring competing health systems that share a select group of complex patients is an effective way to stabilize care, decrease health care system overutilization, improve healthcare delivery, and reduce the costs of associated care Our intervention model provides a useful model for inter-organizational collaboration in healthcare
© 2017 The Authors Published by Elsevier Inc This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/)
Introduction Background Interest in high-need, high-cost (HNHC) patients has
inten-sified in recent years as healthcare systems increasingly focus limited resources on high-risk patients to prevent the unnec-essary use of costly services.1,2To meet the needs of HNHC pa-tients, many organizations are developing specialized intensive management programs, offering enhanced clinical access, care coordination, medication reconciliation, support during transi-tions from hospital to home, and referrals to social and com-munity services.3e6
Funding: This work is supported by an Innovation Grant funded by Trinity Health.
The funding organization(s) had no role in the design and conduct of the study; in
the collection, analysis, and interpretation of the data; or in the preparation, review,
or approval of the manuscript.
Conflicts of interest: The authors declare that they have no conflicts of interest.
* Corresponding author National Center for Complex Health and Social Needs,
800 Cooper St, Camden, NJ, 08102, USA.
E-mail address: lhardin@camdenhealth.org (L Hardin).
Contents lists available atScienceDirect
j o u r n a l h o m e p a g e : h t t p : / / w w w j i e p o n l i n e c o m
http://dx.doi.org/10.1016/j.xjep.2017.01.002
2405-4526/© 2017 The Authors Published by Elsevier Inc This is an open access article under the CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/ ).
Journal of Interprofessional Education & Practice 7 (2017) 5e10
Trang 2The most complex HNHC patients have a constellation of
chronic disease, psychiatric diagnoses and substance use disorder
Patients in this group are often dually eligible, having both
Medi-care and Medicaid, and they represent one of the highest cost
groups in the healthcare system.7The complex needs of the
pop-ulation are often beyond the management capabilities of a typical
primary care practice Stabilization in the population requires an
integration of disciplines traditionally separated by specialty and
regulations that divide medical, psychiatric, and substance use
in-formation into disconnected documentation systems.7e9
Rationale for our intervention
In response to the needs of this population, the Cherry Health
Durham Clinic (CHDC) e part of the Cherry Health System e
created an integrated Primary Care and Behavioral Health Medical
Home (BHMH) specifically designed to meet the needs of patients
with co-occurring disorders The CHDC opened in 2011 and
in-cludes a Primary Care Physician, Physician Assistant, Psychiatrist,
Nurses, Health Coaches, and Supports Coordinator all in one office
Patients are able to receive services in one location with integration
of psychiatric and medical records Health Coaches provide support
for on-going chronic disease management including
evidence-based therapies for psychiatric and substance use disorders The
Supports Coordinator addresses housing, insurance, and access
issues for further stabilization Due to the comprehensive nature of
services, the clinic receives some of the most complex patients in
the city including patients with extreme healthcare utilization
(>100 visits per year), complex psychiatric conditions such as
Munchausen Syndrome, and very complex social situations such as
homelessness, active domestic violence, and significant trauma
In 2012, Mercy Health Saint Mary's (MHSM)e part of the Mercy
Health System e began to investigate the HNHC population
accessing the hospital system A Complex Care Center was created
by a Clinical Nurse Leader (CNL) to provide clinical intervention,
process improvements, and analysis of patients accessing the
hospital Population analysis of high frequency patients in the
system revealed an unexpected finding of patients assigned a
medical home with a competing healthcare system but utilizing the
Mercy Health hospital system for care One group included the
Cherry Health System patients and this led to a new approach to
care coordination We realized that to stabilize their care we would
need to collaborate with our competitors
Rather than focusing solely on improving care within the four
walls of our own organization, we began to look at how we could
collaborate across systems to bring the best of both organizations to
the table to serve the needs of patients.10The general aim of our
model for inter-organizational collaboration was to create a
con-tinuum of care across organizational boundaries to deliver
inte-grated healthcare to HNHC patients to reduce their need to
overutilize healthcare resources Just as previously addressed by
Loehrer et al, creating an effective linkage across the care
contin-uum required“overcoming challenges related to the historic
frag-mentation of healthcare service delivery, in which provider
organizations may not share a common mission, orientation to the
goals of care, or information exchange platform.” Although we
initially faced significant challenges to create the partnership,
focusing first on the patients helped build bridges to improve
outcomes for both organizations
Challenges of inter-organizational collaboration
Collaboration between organizations is often problematic due to
different organizational logics and cultures,11conflicting
legisla-tion, knowledge and value bases, and conflicting economic and
other interests of the organizations involved.11e16 Yet, increased collaboration among different healthcare systems to prevent and manage chronic disease has been recognized as being critical for successful care of these patients.17e20 The Centers for Disease Control and Prevention (CDC) and the Public Health Accreditation Board (PHAB) have reinforced the vision for more unified chronic disease approaches across healthcare systems: two of CDC's four key chronic disease practice domains call on public health to improve the services provided by health care systems,18and health care system collaboration is now required by PHAB for health departments' accreditation, and the movement toward collabora-tive chronic care continues to grow.19In spite of the existence of many integrated care programs worldwide, ample literature pub-lished about inter-professional team-based care,21e24and growing emphasis on these issues, there has been little published on inter-organizational team-based care in the setting of competing health systems
Specific aims The objective of this article is to describe our approach to inter-organizational collaboration on a shared population of HNHC patients, illuminate challenges involved and how to overcome them, share findings from the clinical impact of our collaboration, and describe the model that has been successful in our area The purpose of this article is to share the framework of our model, thereby providing a guide for facilitating inter-organizational collaborative practice among competing health care systems to improve patient outcomes and quality of patient care
Process of collaboration with a competing health system Here we outline the inter-organizational infrastructure and practices that we considered integral for facilitating effective cross continuum collaboration between competing health systems to help shared HNHC patients (Fig 1) Details on patient identification and root cause analysis are described in a separate article.8 Patient identification and root cause analysis
Data analysis of the HNHC patients in the Mercy Health system built the case for collaboration by highlighting the need for improved care in the population The Complex Care Center utilizes
a tool called a Complex Care Summary to analyze root causes contributing to patient destabilization.8 Collecting information about the patient's cross continuum team identified natural partners for collaboration including the CHDC Reviewing root causes beyond the medical diagnoses (including psychiatric, social determinants of health and system barriers) enabled us to build a comprehensive foundation on which to create the person-centered plan of care Organizing our collaboration around patient specific situations gave us the opportunity to build the collaboration around shared purpose Both organizations wanted to improve outcomes; however, the complexity of the patients made it difficult
to achieve this in isolation
Engagement of the clinical partnership Patient-centered collaboration proved essential Many models
of inter-organizational collaboration begin with system leadership meetings and organizational infrastructure We found that by starting with the patient and their individual story we were able to quickly develop a shared sense of purpose to improve outcomes across organizations Rather than getting delayed by organizational
L Hardin et al / Journal of Interprofessional Education & Practice 7 (2017) 5e10 6
Trang 3politics and contracts, we were able to design the collaboration
around the patients and their direct needs This naturally built
bridges past competitive issues because we quickly learned that our
inter-professional collaboration made each of us stronger and more
able to meet complex patient needs
Shared infrastructure
We initially began one patient at a time but, as the population
grew, building structural elements to facilitate on-going
collabo-ration was important to consistently produce outcomes A Business
Associate Agreement (BAA) was developed and described how
in-formation sharing between entities would occur for healthcare
purposes HIPAA allows sharing of information for care
coordina-tion but this addicoordina-tional document was signed between our
orga-nizations to clarify the relationship.25Integrated patient consent
forms for medical and behavioral health information are another
emerging tool for facilitating care for complex patients.26 CHDC
utilizes this integrated consent form for their patient population
which adds support to collaboration across organizations.26Shared
plans of care embedded in the medical record also proved crucial
MHSM's created a tool called Complex Care Maps© to translate
important patient information into the medical record.8In a one
page succinct format, root causes of patient instability, key
strengths and challenges, the cross continuum team with contact
numbers, evidence based considerations and key notes in the EMR
are identified.8 This tool pops up with an alert the first time a
provider opens the medical record during the episode of care.8
Collaboration occurred between the MHSM's staff and the CHDC
staff to create Complex Care Maps© for their patients The hospital
staff began to call the CHDC staff directly from the ED and the
inpatient unit facilitating stronger integration and consistency of
care across settings
Facilitating effective team culture Clinical leaders of both interdisciplinary teams (MHSM CNL and CHDC MSW Director) needed to model collaborative behaviors and inter-professional respect to continue to build success within the teams We achieved this through adopting the facilitator role and shepherding the teams out of competitive waters and into collabo-rative focus on outcomes for the patient Leaders needed to take accountability for system failures in meeting patient needs and approach this topic with a sense of curiosity rather than blame For example, when we discovered that a root cause underlying destabilization of some patients was a change in psychiatric medi-cations during a hospitalization that were long established in the outpatient setting, the response needed to be one of constant pro-cess improvement Leaders investigated more information about the root cause and brought key team members together to create process improvement infrastructures and on-going communication
to prevent this from happening with subsequent patients
Leaders consistently made the teams aware of targeted out-comes by addressing frequency of healthcare visits and status
of progress in the shared plan of care If team members had not followed up on key elements, then leaders consistently held a sense
of curiosity and inquiry around what the barriers were to achieving this for the patient Facilitating the removal of those barriers, rather than punishing or blaming team members, proved to be a major key
to success and allowed the teams to learn how to collaborate with each other without high risk of failure
Ongoing management Extending services outside the walls of our institutions also facilitated a great deal of trust between organizations The MHSM's CNL attended collaborative rounds every 2 weeks at the CHDC to Fig 1 Concept map for inter-organizational cross continuum collaboration between competing health systems.
L Hardin et al / Journal of Interprofessional Education & Practice 7 (2017) 5e10 7
Trang 4show respect for the importance of the cross continuum team and
to invest in on-going collaborative stabilization of patients When a
CHDC patient was admitted to the hospital, contacts were made
with the outpatient team and joint conferences were held in the
hospital setting This continued to reinforce the importance of the
primary care team as the“home” of the patient and stopped
frag-mentation in the plan of care by the inpatient team It also saved
significant time for the case management team in the hospital by
stopping“reinvention of the wheel” in the patient's care plan
Joint celebration of success
Capturing successes was important for continuing to motivate
the teams to attend to the challenging work of culture change
and retaining resiliency in the face of some of the most difficult
patient situations in the healthcare system Reinforcing the
principle that change occurs in iterations in complex populations
and acknowledging incremental shifts in outcomes as a win was
an important principle Traditional outcome measures such as
reduction in visits, reduction in length of stay, and adherence to
primary care appointments were reviewed Successes such as
MHSM's ED staff calling the CHDC staff during the moment of
care or CHDC staff visiting the patient in the hospital and
conferencing with inpatient staff were also acknowledged
Most importantly, leaders needed to model that successes
would be shared between organizations, rather than attributed to
one organization, to continue to foster the inter-organizational
partnership (Fig 2)
Impact
Utilization, cost, social, and healthcare access variables were
collated from the electronic medical record and cost accounting
system; a comparison of the 12 months prior to and the 12 months
after introduction of the collaboration was conducted This project
was deemed as a Clinical Quality Improvement Initiative by
the Mercy Health IRB, and as such was not formally supervised by
the IRB per their policies
Subject population and setting
Nineteen patients who regularly accessed care at MHSM's and
were patients of the CHDC between November 2012 and July 2015
were served during this collaboration Both agencies are urban
healthcare providers and are located 1 mile apart MHSM's has
greater than 80,000 annual ED visits and Cherry Health serves more
than 60,000 complex patients in a competing healthcare system The
population served had a prevalence of psychiatric diagnoses (100%),
substance use disorder (53%), history of suicidality (42%), and com-plex social determinants of health issues including history of trauma (58%) and current homelessness (16%) Surprisingly, the population was primarily less than 50 years old (68%) Many had a pattern of high frequency healthcare access for multiple years including 26% with four or more years of>3 healthcare visits (IP or ED)/year and 25% with greater than 2 years of frequency prior to intervention Outcomes of collaboration
In the 12 months prior to intervention, patients averaged 12.42
ED visits, 3.37 IP admissions, 14.21 Length of Stay (LOS) days, and 2.21 CT scans per patient per year In the 12 months after inter-vention, patients averaged 8.89 ED visits, 1.68 IP admissions, 7.21 LOS days, and 0.74 CT scans per patient per year This represents a decrease in average ED visits by 28%, IP admissions by 50%, LOS by 49%, and CT scans by 67% Of note, the population of 19 patients had
396 hospital visits (ED/IP/OP) in the 12 months prior to interven-tion CT scans are specifically called-out in the results section as the risk for over-testing in the population is high due to frequent healthcare access
Gross charges in the population decreased $721,654 dollars in the 12 months after intervention, representing a 51% reduction in gross charges Similarly, direct expenses decreased $211,129, rep-resenting a 54% reduction in direct expenses Operating margin improved $84,774 in the 12 months after intervention, representing
a 71% increase in operating margin despite the reduction in visits to the hospital
Lessons learned Recognizing and overcoming cultural barriers to inter-organizational collaboration
Despite the above infrastructures and practices designed to promote effective team culture, inter-organizational partnership can present unique challenges as barriers arise and it is important
to be aware of and overcome them
The well-known saying, “Culture eats strategy for breakfast”, attributed to Peter Drucker,27is a key concept when considering inter-organizational collaboration Competitors do not often come together to solve problems The business infrastructure that fuels competition is organized around preservation of financial resources Often, thefirst cultural hurdle that arises in collaboration
is mistrust and financial competition Starting with the patient story and the opportunity to improve quality and safety for a person helped to jump this hurdle
Healthcare providers overall have a shared cultural value to heal and improve patient outcomes Leaders needed to proactively model and address fears and misconceptions that quickly arose to test the strength of the commitment to collaborate For example, as the partnership became more visible in the healthcare system, a concern was brought forward that the CHDC was sending all of their complex and uninsured patients to MHSM's and directing their patients with insurance to another healthcare system This fueled the barrier of mistrust and fear aboutfinancial resources Leaders quickly investigated the rumor and brought forward data analysis that showed there was no diversion of patients occurring and the majority of patients served by the CHDC had marginal insurance This changed the rumor and helped people see that we actually had shared financial benefit from working together to stabilize these HNHC patients
A second key cultural barrier to overcome can be a lack of understanding the different functions and applications of team-based vs individual-team-based care delivery When you organize
L Hardin et al / Journal of Interprofessional Education & Practice 7 (2017) 5e10 8
Trang 5care around the patient story, key relationships quickly emerge.
For example, the hospital staff may perceive that they are the key
driver of the plan of care but their contact with the patient is
limited to the silo experience of the time the patient is in the
hospital The long term relationship of a primary care physician,
psychiatric case manager, guardian or other discipline may be the
most effective role to have long-term communication and
coaching directly with the patient for a plan of care In order to
effectively work with a team approach, each person needed to be
ready to let go of being“the one” person to affect the plan of care
and face his/her own feelings of competition for credit in
improving outcomes For many providers, this is an unfamiliar
role and independence is more comfortable, but less effective for
the patient Leaders needed to continuously model the question
“who has the strongest relationship with this patient” and also
continuously facilitate hearing from every discipline on the team
what else they might collaboratively contribute to improving
outcomes for the patient
Afinal key cultural barrier to navigate is complexity avoidance,
sometimes also called approach-avoidance conflict A state of
ambivalence, anxiety, or fear can arise when confronted with a
complicated situation that is desirable to resolve but involves
addressing undesirable aspects of the human condition.28When
hearing of a burning building, it would be a rarefirst reaction to run
in among the flames and try to fix the problem; working with
complex patients is no different Ethical complexity and
long-term trauma were common in the population served in this
collaboration Leaders needed to model a state of support and
safety for providers to express their fears and uncertainty in
com-plex cases that touched on their own personal issues or were
beyond the team's capacity to understand how to resolve
Uncer-tainty partnered with curiosity needed to be an accepted state and
cultural value Leaders were charged with continuously bringing-in
additional resources to help solve complex situations and creating a
state of curiosity rather than failure when an immediate solution
was not apparent
Concluding remarks
Collaboration between neighboring competing health systems
that share a select group of complex patients is an effective way to
stabilize care, decrease healthcare system overutilization,
improve healthcare delivery, and reduce the costs of associated
care Our intervention model provides a framework for
inter-organizational collaboration in healthcare In health systems
around the world, the focus of current reform efforts is to achieve
higher quality, more cost-effective care.29 Policymakers and
leaders are beginning to converge on a core set of solutions, most
of which call for increased coordination among care providers
across professional boundaries.10
Next steps
After successful implementation with the CHDC, Mercy
Health has continued to seek additional partners for
collabora-tion within the Clinically Integrated Network as well as outside
of it Collaboration is designed around the complexity of patient
needs, utilizing the same framework but applying it in a range of
approaches from weekly rounds with a Federally Qualified
Health Center serving the homeless population to monthly
“huddles” for more stable populations Such relationships may
be facilitated by the creation offinancial incentives that reward
coordination, such as creating a payment mechanism/platform
to encourage competitors to form partnerships/relationships,
understand their shared patient population, explore the
breakdowns in care in their community, and implement com-plementary improvements in each setting of care.10The nation would benefit from learning about the experiences of additional approaches to cross-continuum collaboration as health reform continues to unfold.30
Acknowledgments Authors would like to acknowledge: Diana Mason, PhD, RN, FAAN and Jean Barry, PhD, RN, NEA-BC for serving as advisors Views expressed are those of the authors and not necessarily those
of MHSM's, CHDC, or the University of Utah
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