Report from Tallahassee Memorial HealthCare on Enhancing Continuity of Care

The Challenge: Patients with multiple chronic conditions often rely on a combination of inpatient and outpatient services for their care, frequently moving back and forth between these two parts of the health care system. And yet, it’s during “handoffs” — hospital admissions and discharges — that mistakes, miscommunication, and loss of continuity tend to occur. Chronically ill patients can benefit the most from aggressive coordination of care. Leaders at Tallahassee Memorial HealthCare, in partnership with their counterparts at the area’s largest health plan, recognized that improving communication between their two organizations, particularly about patients with complex care requirements, could improve care and possibly reduce costs as well.
The Background: Tallahassee Memorial Hospital (TMH), located in Tallahassee, Florida, is a 770-bed acute care and extended care not-for-profit hospital that is part of Tallahassee Memorial HealthCare. As the largest hospital in the area, TMH serves a significant percentage of the Tallahassee area’s 600,000 residents. Capital Health Plan (CHP) is a not-for-profit, single-site, mixed-model health maintenance organization with 110,000 members. About 95 percent of Tallahassee’s physicians contract with CHP.
The hospital and the health plan have had a strong working relationship for many years. Winnie Schmeling, PhD, RN, TMH’s now semi-retired Vice President of Organizational Improvement and Planning and executive-in-charge of Pursuing Perfection, is a founding board member of CHP, and works very closely with its leaders to shape the delivery of health care in the Tallahassee community.
Together the two organizations wanted to explore ways to improve communications about patients with multiple health problems, particularly when these patients enter and leave the hospital. And they also recognized that with more aggressive outpatient care, and improved coordination of care, they might be able to reduce the need for some hospitalizations. With the Pursuing Perfection project and grant money as a catalyst, TMH and CHP set to work on better ways to manage many of the system’s sickest patients.
The Situation: Tallahassee Memorial HealthCare has a long history of working to improve care processes. Chosen in 2001 as a Pursuing Perfection grantee, the hospital has focused improvement efforts on medication safety, reducing mortality, care for patients with acute myocardial infarction (AMI), and care at the end of life. These efforts have been effective. For example, TMH’s work on improving care for patients whose conditions contribute most to hospital deaths — AMI, heart failure, stroke, and pneumonia — has resulted in a 23 percent reduction in overall mortality between 2001 and 2004.
But improving the health of patients outside the hospital walls requires more organized and systematic communication between the hospital and primary care physicians than has been the norm.
“Traditionally, the type and depth of communication between the primary care physician and the hospital has been determined by the individual practice style of the physician,” says Nancy Van Vessem, MD, Capital Health Plan’s Chief Medical Officer. “Sometimes there is wonderful communication. But sometimes there isn’t.” A discharge sheet, usually handwritten by a nurse and signed by a physician, has typically — but not always — been given to patients upon discharge, with instructions to take it to their primary care physician on their next visit. Many of these sheets never make it there.
Meanwhile, on the outpatient side, in June 2003 Capital Health Plan had opened a unique new clinic designed to improve care for its sickest patients. “We knew what these patients needed,” says Van Vessem. “They needed better, more frequent access to outpatient care and better coordination of care. We surveyed the patients and they confirmed our thinking.”
So, using sophisticated diagnosis-based software, the health plan identified its sickest patients, and then, with the permission of their primary care physicians, contacted these patients and offered them a spot in the new clinic.
Called the Center for Chronic Care, the clinic is designed specifically for patients with multiple chronic conditions who don’t fit neatly into existing programs for single diagnoses such as diabetes or congestive heart failure. The Center is headed up by Internist and Gerontologist John Agens, MD, who provides primary care.
“For some patients it was hard to think about changing to a new primary care physician, even though they could keep all their same specialists,” says CHP’s Van Vessem. “But for many patients, especially those who felt their health had been worsening under the usual system of care, the prospect of more organized care and better access was worth it.”
Jim Carraway fits Van Vessem’s description. At 53, retired after working for the state of Florida for 30 years, Carraway suffers from a rare neurological disorder called Charcot-Marie-Tooth, which causes progressive nerve and muscle degeneration. During the past several years Carraway has also had a stroke, six heart bypass operations, a defibrillator implanted, several surgical procedures on his feet, and been diagnosed with diabetes. “For the past two years I pretty much didn’t do anything,” he says. “I was either in the hospital or in rehab.”
According to Van Vessem, the approximately 220 patients now being seen at the new Center for Chronic Care are “on average ten times sicker than the average health plan member.” She says they see Dr. Agens about three-and-a-half times more frequently than patients in the “usual” care system, and the visits are more comprehensive.
Jim Carraway’s wife Sarah has noticed a difference in the care her husband receives at the Center and, more importantly, in his overall health. “Dr. Agens is interested in every detail of what is going on with Jim,” she says. “Every time Jim’s in there, they go over every little thing. And compared to where he was three or four years ago, he’s doing much better.”
The difference lies in a comprehensive, planned approach to care that seeks not only to address the whole patient at every visit, but to engage the patient more fully in self-management as well. Part of the intake process for patients seen at the Center is a detailed multidisciplinary review of medications, diet, and functional status, as well as a depression screening.
Staff members use this information, in combination with the patient’s medical history and personal goals, to create a care plan that patients can review continuously and modify as their health changes and/or improves.
Jim Carraway says this approach works. “At the end of every visit, Dr. Agens goes over the goal sheet and we set goals and expected outcomes for the next visit, like lose five pounds or keep your blood pressure at this level,” he says. “He names them, and it is motivating, because you know someone is paying attention.” Using Agens’ patients as a pilot group, the health plan and the hospital are working together to meet three primary aims: improve outcomes, reduce costs, and improve communication between the two organizations when patients move in and out of the hospital.
The Solution: Winnie Schmeling says the ultimate goal is for the hospital and the health plan to use the same comprehensive electronic communication system for their shared patients, but right now different information systems make that a challenge. In the interim, the Center for Chronic Care has created a simple electronic spreadsheet of its patients that the hospital has entered into its system. This way, a “red flag” goes up in the hospital’s computer system whenever a patient of Dr. Agens comes to the emergency department or elsewhere in the hospital. “It sounds simple, but it’s a major accomplishment,” says Schmeling.
That “red flag” is the signal for the hospital staff that this is a patient with a complex history and complex medical needs. “We know these patients have a care plan that can be helpful to us,” says Schmeling. Currently, patients who carry their care plan with them — or a family member with access to it — can give it to the hospital staff. Eventually, staff will have electronic access to those plans, with patients’ permission.
“We also want to be especially sure these patients get evidence-based care and get their medications carefully reconciled both at admission and discharge,” says Schmeling. Of course this is the goal for all patients in the hospital, she adds.
Work is underway to build an electronic patient identification system that will notify hospital staff electronically when Center for Chronic Care patients are admitted to the hospital; a computer-based medication reconciliation program; a “Healthcare Passport” that will allow patients to store pertinent health information in both a web-based and a paper-based format; and a physician resource intranet site that will include the health plan’s drug formulary. “It’s important for physicians to understand the health plan’s preferred drug list, because the non-preferred drugs carry higher copayments. We know that for some patients there is a connection between copays and compliance. We’ve found that some readmissions are the result of patients not filling prescriptions because of the cost,” says Schmeling.
Meanwhile, when patients seen at the Center for Chronic Care are hospitalized, Dr. Agens is in close contact with the hospitalist who cares for them, and receives detailed discharge information from the hospital. “He is very engaged in this effort, and his is a great practice through which to explore issues between inpatient and outpatient communication. Ultimately we want to create effective, systematic communication for all our patients,” says the health plan’s Van Vessem.
Guiding the work is a chronic care steering committee, composed of physicians, nurses, and other health care professionals from the health plan and the hospital, as well as some patients, including Jim and Sarah Carraway. “They are trying to look at things from the patient’s point of view, and they want our input on how to serve us better,” says Jim Carraway. “At first I wasn’t sure what to say. I’d never been asked before.”
The Results: Capital Health Plan has measured the difference the Center for Chronic Care is making. So far, doctor’s visits and drug spending for these patients have increased, but emergency department visits and inpatient days have decreased. Specifically:
  • Primary care physician visits have increased 250 percent
  • Pharmacy costs have increased 22 percent
  • Inpatient days have decreased 40 percent
  • Emergency department visit rates have decreased 37 percent
  • Claims costs (what CHP pays to a range of providers, including hospitals, physicians, and outpatient diagnostic services) have decreased 18 percent
Clinical results are equally encouraging. For example, the Center’s patients with blood pressure control at 135/85 or less doubled from 40 percent to 80 percent in one year. The number of patients appropriately on ACE inhibitors increased from 60 percent to over 90 percent. Patient-reported scores measuring functional status and ability (for example, “I can walk to the mailbox”) have also improved.
On the hospital side, gains are less direct but still important. “It’s true that reducing admissions reduces revenues for the hospital,” says Schmeling. “This is just one example of perverse incentives in the system. If someone is readmitted because we haven’t provided the best care, we get paid again. That’s not the kind of thing we should be trying to do. While our revenues may be reduced when there are fewer Center for Chronic Care admissions, we create additional capacity for other patients. This is important because we presently operate under huge capacity constraints.”
Schmeling says that the idea is for the health care system, including her hospital, to scale its resources to the real needs of the community. “We shouldn’t try to optimize our business based on underuse, overuse or misuse,” she says. “The business case for quality is that we should operate so we do well when we do what patients need. . . and do it right.”
What Team Members Say: “The Center for Chronic Care is making a good business case for quality. They are demonstrating that when you do care right, it is cheaper. This benefits the entire health system, as well as the patients we serve.” — Winnie Schmeling, PhD, RN, former Vice President of Organizational Improvement and Planning and executive-in-charge of Pursuing Perfection
“Patients with multiple needs require more attention. And according to our patient surveys, they are very happy to be getting what they need. Here’s a typical survey response from a patient in the Center for Chronic Care: ‘I used to be hospitalized almost monthly. Now I feel 200 percent better.’” — Nancy Van Vessem, MD, Chief Medical Officer, Capital Health Plan
Learn more about Pursuing Perfection at Tallahassee Memorial HealthCare.
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