Real World Health Care Blog

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It Takes a Community for Effective Disease Prevention and Management

To help stem the tide and high cost of persisting disparities in U.S. health care, providers are leveraging Community Health Workers (CHWs) as critical players in improving health outcomes by successfully linking “vulnerable” patient populations to better care. Living in the communities where they work, CHWs understand what is meaningful to those communities, communicate in the language of those they serve, and incorporate cultural buffers to help patients cope with stress and promote health outcomes.

As the CDC reports, growing evidence supports the involvement of CHWs as a critical link between providers and patients in the prevention and control of chronic disease:

  • They help high-risk populations, especially African-American men in urban areas, to control their hypertension.
  • They enable diabetic patients to reduce their A1C values, cholesterol triglycerides and diastolic blood pressure.
  • Their interventions improve knowledge about cancer screenings as well as screening outcomes.
  • Their interventions help patients reduce the severity of asthma.

Many Americans – especially those with low incomes, have no insurance or face other socio-economic barriers to primary care – often distrust the health care system, or lack the resources and awareness needed to take charge of their health. As a result, they wait until health issues and chronic disease escalate enough to drive them into the emergency department, where they receive short-term solutions that drive up the total cost of health care.

CHWs are changing that, community by community. Examples of CHW programs – both at home and abroad – abound. One is Penn Medicine’s IMPaCT Program.

IMPaCT (Individualized Management for Patient-Centered Targets) pairs patients in need of extra support with relatable neighbors and peers (people who have shared language, ethnic and geographic backgrounds) to assist them in navigating the medical system and identify the underlying causes of illness.

“Lower income patients tend to poorly manage chronic disease and have worse health outcomes than other patient populations,” explains Dr. Shreya Kangovi, Director of the Penn Center for Community Health Workers, which houses the IMPaCT program. “They are less likely to get preventive care and more likely to end up in the hospital. This scenario leaves health care practitioners frustrated, because they can’t move the needle on health outcomes. And it makes it difficult for the health system to meet its quality targets.”

Dr. Kangovi notes that many patients served by IMPaCT didn’t have a relationship with a primary care physician prior to joining the program.

“There is a lot of focus today on reducing hospital re-admissions,” she says. “But before we can reduce re-admissions, we need to make sure patients have a substitute for the emergency department.”

She shared the story of “Ben,” a young man with a bad case of lupus and no insurance. Ben had been visiting Penn’s Emergency Department regularly for lupus flare-ups. There, he received steroids and pain medications before being sent along his way. Thanks to IMPaCT, Ben was set up with a primary care doctor who understands his health problems, and placed Ben on a better medication regimen. Not only does Ben now feel better, he has more trust in the health care system that he sees as an ally, she says.

IMPaCT currently serves about 500 patients via two programs – one for hospitalized inpatients and one for primary care outpatients. The program’s CHWs meet with patients upon admission to the hospital to set short-term goals and identify pathways to solving their clinical and socioeconomic hurdles. They advocate for patients during their hospitalization, then work with them during discharge and beyond to get them connected to resources in their community. On the primary care side, patients work with their IMPaCT partner over six months to break long-term health goals down into smaller, achievable steps.

“Once patients leave the hospital, real-life issues intervene,” Dr. Kangovi says. “IMPaCT’s community health workers address these health and life issues on the ground, and do so much better and at a much lower cost than clinically trained personnel.”

Are CHWs making a difference where you live? How are they helping to reduce costs and improve access to health care?

Categories: Access to Care

National Patient Safety Program Cuts Bloodstream Infections to Save Lives and Money

Central-line catheters are lifesavers. They’re used in hospitals to deliver therapy where needed and when needed for patients with a wide range of conditions.  Unfortunately, central line-associated bloodstream infections (CLABSIs) result in thousands of deaths each year and billions of dollars in added costs to the U.S. health care system, according to the CDC.

But there’s one collaborative program that has cut CLABSIs in intensive care units by 40 percent, preventing more than 2,000 infections, saving more than 500 lives and avoiding more than $34 million in health care costs. The program, funded by the Agency for Healthcare Research and Quality (AHRQ), used the Comprehensive Unit-based Safety Program (CUSP) to achieve these landmark results.

CLABSIs occur when germs enter the bloodstream through the central line (also known as a central venous catheter), which is placed in a large vein in a patient’s neck, chest or groin to give medication or fluids or to collect blood for medical tests. Such lines are commonly used in intensive care units and can remain in place for weeks or months.

Thanks in part to CUSP, progress is being made to protect people from these infections. In fact, nearly 60 percent fewer bloodstream infections occurred in hospital ICU patients with central lines in 2009 than in 2001. This decrease in infections saved up to 27,000 lives and $1.1 billion in excess medical costs. More recently, CLABSIs dropped 41 percent from 2008 to 2011, up from a 32 percent reduction in 2010.

CUSP Programs, like the one used in the AHRQ project, are being used by a number of state health departments to help prevent CLABSIs. CUSP combines clinical best practices with an understanding of the science of safety, improved safety culture and an increased focus on teamwork. It helps clinicians understand how to identify safety problems and gives them the tools to tackle those problems.

“In the CLABSI project, we learned that the principles of CUSP worked to make care safer, and that clinical teams could sustain those improvements over time,” said Jeff Brady, MD, MPH, Associate Director, Center for Quality Improvement and Patient Safety. “The CUSP toolkit, which is a free resource on AHRQ’s web site, is designed to help clinical teams improve any safety problem, not just CLABSIs or infections.”

Indeed, Dr. Brady notes that new projects are already underway to apply CUSP principles to other safety problems like perinatal care and other settings of care, like ambulatory surgery. In addition, AHRQ is developing a CUSP toolkit module to address patient and family engagement – a resource slated for introduction in the late spring.

The bottom line: CLABSIs are preventable and we have the replicable tools we need to protect more patients.

How are health care providers in your area preventing CLABSIs? Are there steps patients can take? If so, what are they?

Hospitals, Physicians Embrace Strategies To Reduce Cost of “Frequent Flyer” ER Visits

Pardee Memorial Hospital in Hendersonville, N.C., shaved nearly $405,000 from its Emergency Room (ER) expenses over a one-year period thanks to an integrated program that its founder calls a “patient-centered medical home on steroids.”

The program, Bridges to Health, helped its uninsured participants reduce their ER visits from an average of seven per year (at a typical cost of $14,004 per person) to three per year (at an average cost of $2,760 per person). Another indicator of success: 10 participants secured employment and six previously homeless members found places to live by the end of the first year.

It’s estimated that non-urgent Emergency Department (ED) visits cost the U.S. about $4.4 billion annually. At Pardee Memorial Hospital alone, 255 frequent users (“frequent flyers”) of the ED racked up more than $3 million in unpaid medical bills. Frequent flyers account for up to 40 percent of total ER visits nationwide.

Bridges to Health decreases ER expenses by providing this patient population with primary care, behavioral health services and a nurse case manager through bi-weekly health clinic visits.

“Many of these people just went to the ER because they were in pain or scared,” said Dr. Steve Crane, a family physician who started the program. “You see them going back so many times because their real issues are not supposed to be treated in the ER and are not taken care of.”

The Pardee Bridges to Health free clinic integrates medical checkups and group therapy, with doctors providing treatment and patients offering one another tips ranging from how to obtain legal assistance to saving money on food and shelter. In this way the program addresses the two main problems seen in these patients: lack of social support and access to regular primary care.

Although the results of the program are promising, Dr. Crane cautions that the patient group is small and that it only works for participants who attend the clinic meetings.

Another example of how hospitals can lower frequent flyer ER visits is in the story of Providence St. Peter Hospital (Olympia, Washington). The first step was to join a special community program called the Emergency Department Consistent Care Program and CHOICE, a unified program involving five area hospitals and a non-profit regional coalition of health care providers.

This collaborative effort resulted in ER visits among frequent flyers shrinking by about 50 percent, for a cost savings of nearly $10,000 per patient. That translated to a $2.2 million reduction in ED and inpatient expenses over two years at Providence St. Peter’s alone.

This program flags patients who visit the ED at least twice in one month or four times in six months then examines their cases for narcotic dependency, mental health issues and other factors. The program team uses that data to identify patients, then develops individual care plans and offers the assistance of primary care physicians, clinicians and specialists skilled in the patients’ particular needs.

What’s key to the success of the program? It effectively coordinates efforts with other hospitals in the area, according to its administrative coordinator, ensuring that frequent flyers get a consistent message wherever they go.

What approaches should be pursued to provide more efficient care systems while decreasing readmissions for frequent flyers? Encourage more doctors to keep their offices open longer? Leverage mental health coalitions that focus on continuity of care instead of short-term fixes?

Tell us what you think.

Categories: Cost-Savings

Walgreens Unveils Solutions to Boost Medication Adherence

How can health professionals enable their patients to take medications more consistently as prescribed?

Personalized counseling from pharmacists and prescription refill reminders are two effective ways now shown to fuel better drug adherence, according to research from Walgreens presented March 15 at the World Congress Summit in Philadelphia.

Walgreens’ community pharmacy programs – in addition to successful intervention models – are equipping patients with powerful tools to self-manage their health.

One finding, for example, revealed that individuals receiving in-person counseling from their pharmacist saw 7.2 percent higher adherence than those with more conventional pharmacy care. Meanwhile, one of Walgreens’ pilot programs demonstrated that patients who receive prescription refill reminders (also called automated refill reminders or ARR) are more likely to consistently take medications for chronic conditions.

“In order to improve medication adherence among patients, providers need to understand the key challenges and contributors to non-adherence, and how to address them,” said Jim Cohn, Walgreen Co. spokesperson. “The research findings demonstrate how programs at the community pharmacy level designed to target common barriers to adherence, such as the challenge of learning a new medication therapy or simple forgetfulness, can significantly improve patient health and outcomes.  Ultimately, these types of pharmacy initiatives can help providers do their part to ensure more people get, stay and live well.”

Walgreens isn’t alone in recommending evidence-based approaches to enhance adherence outcomes. The Medication Adherence Project’s (MAP) 2010 Training Package also offers strategies for both providers and pharmacists that stress individualized patient engagement, with solutions that include writing 90-day instead of 30-day prescriptions, prescribing generics, communicating directly with providers, and more.

Securing increased medication adherence will not only go far in helping patients live longer and healthier, but will deliver considerable savings for the health care system too.

How do we know? Underscoring the benefits of adherence, MAP cites “lower disease-related medical costs” for diabetes and hypercholesterolemia in addition to related “reductions in health care costs.”

The New England Health Institute (NEHI) also provides compelling evidence in its October 2012 Issue Brief that reducing medication non-adherence, which contributes to hospital readmissions, helps lower hospitalizations and saves on associated expenses, noting: “One study found that one-third of adverse drug events resulting in a hospital admission were related to non-adherence. The aggregate cost of hospital admissions related to medication adherence has been estimated to be roughly $100 billion per year and estimates of the share of hospital admissions related to non-adherence are as high as 10 percent.”

Successful strategies generating increased medication adherence are clearly worth pursuing and replicating, both to strengthen the quality of health services and to lower the cost of care.

Now we want to hear from you. As a medical professional, what approaches do you incorporate to encourage patients to properly take their meds? If you’re a patient, what has worked for you?

Making Costly – and Deadly – Medical Errors and Unnecessary Hospital Visits Something Only Grandparents Can Remember

“She died from a breakdown in the system. She died from a breakdown in communications.”

These heartbreaking words, from patient safety advocate Sorrel King about the loss of her young daughter Josie King, are words that no one should ever have to say or hear.

Her 10-year commitment to end hospital errors led to a $1 billion war on errors, funded through the Affordable Care Act.  The resulting Partnership for Patients program has already signed up more than 8,000 partners – including organizations and individual medical care providers – in a shared effort to save thousands of lives, prevent millions of injuries and take important steps toward a more dependable and affordable health care system.  According to the Centers for Medicare and Medicaid Services (CMS), the participants include:

  • Hospitals and national organizations representing physicians, nurses and other frontline health care and social services providers committed to improving their care processes and systems, and enhancing communication and coordination to reduce complication for patients.
  • Patient and consumer organizations committed to raising public awareness and developing information, tools and resources to help patients and families effectively engage with their providers and avoid preventable complications.
  • Employers and States committed to providing the incentives and support that will enable clinicians and hospitals to deliver high-quality health care to their patients, with minimal burdens.

In the April 2011 announcement launching the program, Health and Human Services Secretary Kathleen Sebelius shared two goals of the Partnership for Patients:

  1. To reduce preventable injuries in hospitals by 40 percent by the end of 2013, preventing 1.8 million injuries and saving 60,000 lives.
  2. To cut hospital readmissions by 20 percent, saving 1.6 million patient complications that force them to return to the hospital.  Achieving this goal by the end of this year would mean more than 1.6 million patients will recover from illness without suffering a preventable complication requiring re-hospitalization within 30 days of discharge.

{For a video of Ms. King explaining her work and Secretary Sebelius announcing the Partnership for Patients program, please click here.}

According to CMS, a recent study by the Office of the Inspector General (OIG) (PDF) found that 13.5% of hospitalized Medicare beneficiaries experience adverse events resulting in prolonged hospital stay, permanent harm, life-sustaining intervention, or death. Almost half of those events are considered preventable.

A recent article in the Journal of the American Medical Association showed that specific community-wide quality improvement activities are proven to reduce hospital readmissions.

Do you want to find providers and hospitals near you who have signed the pledge? It’s as easy as clicking here.

Do you want to learn more about the specifics of what actions will be taken to reduce accidents and re-admittance, and the studies conducted to determine the solutions?  Check out Altarum Institute’s blog post on the topic.

Taking the Digital Leap Saves Community $20+ Million in Preventable Health Care Costs

Hospitalizations dropped by almost 3,000 people over a two-year period in Cuyahoga County, Ohio, thanks to a variety of quality changes and investments in electronic health records (EHR). This tool collects and shares critical health information about individual patients and populations across health care settings.

The nearly 11 percent drop in hospitalizations for common cardiovascular conditions (diabetes, high blood pressure, heart failure and angina) was reported in the 10th Community Health Checkup by Better Health Greater Cleveland, a regional health improvement collaborative that works with health care systems, health plans and employers to foster quality health care that’s more affordable.

Why does this decline matter? Because it shows that through efficient use of EHR, primary care is getting better in this community and has implications for advancing the quality of patient-centered care across health systems.

The report demonstrates that practices leveraging EHR are finding that they can more effectively measure care and identify opportunities to enhance service as a result: “The changes are helping people change the course of their health, and they’re adding up to measurable impact on the community – in health, care and cost.”

Better Health also notes that EHR makes a huge impact for the better when it comes to health outcomes for patients: “We have documented large differences between our EHR- and paper-based systems in terms of achievement and improvement of our standards in diabetes and high blood pressure.”

Indeed, a 2011 paper published in the New England Journal of Medicine confirms this trend, finding a 35 percent higher achievement for composite care standards for diabetes patients treated by practices using EHR compared with practices using paper-based systems. EHR sites were also associated with a 10 percent greater improvement of care and a 4 percent improvement among outcomes.

“EHRs have been well shown to improve patient safety, especially through e-prescriptions and clinical decision support,” says Dr. Tim Kowalski, President, Health Action Council Quality Forum. “They also help to improve care coordination via medication reconciliation, enhancing the exchange of health information and through the use of patient registries. And, they help to reduce redundancy via awareness of previous evaluations and various test results.”

Dr. Kowalski adds: “As health care purchasers we are demanding that health care providers demonstrate quality improvement, customer experience improvement and cost-effective care when we consider which provider groups to feature to our employees and their dependents. As we move from a world of fee for service payment to population health outcome-based compensation, this will become increasingly important.”

Have you seen examples – beyond those demonstrated by Better Health – where care is improved and costs are reduced when EHR are incorporated in the system? Tell us more.

Categories: Cost-Savings

Will Consolidation Change Health Care for the Better?

The Cleveland Clinic believes it will, especially when it produces better patient outcomes and improves care across a spectrum of services.

As part of the recent wave of hospital mergers and acquisitions designed to improve quality and lower costs, Cleveland Clinic recently entered a long-term strategic alliance with Community Health Systems (CHS), a for-profit provider that operates 135 hospitals nationwide. While the two organizations will remain independent, they will “both [remain] committed to discovering novel strategies to improve care, reduce costs, enhance access to health care services and develop new approaches to care delivery.”

In discussing the alliance, CEO and President of Cleveland Clinic, Delos M. Cosgrove, MD, notes that thriving in today’s health care environment will require new ways of doing things. He calls medicine a “team sport.”

We couldn’t agree more. All effective strategies that successfully remove obstacles to quality, affordable care should be on the table in today’s health care environment. The Cleveland Clinic’s consolidation with CHS will lower expenses and improve the quality of care by:

  • Improving patient outcomes and reducing costs by creating a framework that enables physicians to share best practices while capturing, reporting and comparing data.
  • Enhancing quality and data infrastructure by assessing CHS-affiliated hospitals and applying the expertise of the Cleveland Clinic’s Heart and Vascular Institute to related programs.
  • Sharing best practices and creating synergies that encompass telemedicine initiatives, second opinion services for physicians and patients, complex care coordination and other areas in care and cost containment.

We look forward to watching the alliance between Cleveland Clinic and Community Health Systems as they continue to reframe health care.

Have you seen examples of successful collaborations that are improving access to care and/or reducing health care costs? Share them with us.