7 Key Steps in Developing New Options for Responding to Unplanned Acute Care
April 16, 2020
Sadie, a 76-year-old who lives alone and suffers from chronic renal stones suddenly developed acute flank pain resulting in four medical visits in one week. First to her primary care provider (PCP), second to the emergency department (ED), and a third visit to Urgent Care. Each time she was sent home and instructed to return to the ED if her pain worsened. When Sadie went back to the ED for her fourth visit that week, she was seen by an ED nurse with specialized training in geriatric emergency care, who took the time to understand her issues including poor monitoring for pain control, and her fear of living alone and using a new opioid prescription. After this last ED visit, Sadie was diagnosed with an acute renal cyst, pain control was achieved, and she was transitioned home (rather than being admitted) as part of an “Acute Care at Home” program that provides care from a home health nurse with oversight by her PCP. Because Sadie’s story is sadly common, new options are needed to better serve seniors (and lower healthcare costs).
Of the over $3.6 trillion spent on healthcare in the U.S., inpatient hospital care accounts for 31 percent of the total spend.1 EDs play a prominent role as primary entry points for hospital admissions.2 In an effort to lower healthcare costs and better match seniors to the right care, at the right time, and right location, the West Health Institute collaborated with the Institute for Healthcare Improvement in creating a learning and action network (LAN) to develop innovative responses to seniors’ unplanned acute health events. “Acute Care at Home,” which create pathways that disrupt the typical trajectory to hospital admissions, is one such response.
In 2018, our LAN engaged six Next Generation Accountable Care Organizations (ACO) to create, or improve upon, their ability to respond in new ways to unplanned acute events. New ideas focused on developing acute home-based care, including aspects of pre-engagement, intensive case management, and telehealth support. Through the year-long project we identified key learnings to achieve success, as well as guidance on how to approach common obstacles. Identifying and overcoming challenges through iterative testing using quality improvement principles was key. Based on the LAN learnings, in this two-part series, we share what organizations may want to consider in developing senior-focused solutions when unplanned acute needs arise.
Getting the Right Team │ While assembling the best people for your team is a critical first step, accurate selection of individuals isn’t always obvious. Once the LAN got started, we learned some ACO’s team members had the right titles but not the right skills, aligned incentives, or bandwidth to contribute. To the extent possible, rather than moving forward based upon assumptions and job titles, take some time early in the process to talk candidly with prospective team members to ensure any individuals you include have the appropriate skills, incentives, and time. A couple of the teams realized later than others that they did not have a finance contact at their organization to meet their program’s needs, which led to frustration and delays in program development.
Defining Patients who May Benefit│ Identifying individuals most likely to benefit from a new program can be challenging and often takes several iterations to get right. We found the most successful approaches used multiple sources of data that included both quantitative (e.g. risk scores, prior utilization and cost, disease burden, frailty) and qualitative (patients, caregivers, and clinicians) sources. Clinicians especially have important knowledge about patients that could otherwise be missed if they’re not directly asked. After much discussion, one of the ACO programs in the LAN determined their inclusion criteria should be at-risk patients aged 65 and older, within a specific geographic area, a Hierarchical Condition Category score of 2.0 or higher, and an Epic generated high-risk score of 40 or greater. Another LAN team opted to exclude patients needing more than four liters of oxygen or who didn’t have a caregiver in the home.
Engage All Key Stakeholders │ Engage key stakeholders early and often. LAN teams included stakeholders from the ED, risk management, primary care, geriatrics, finance, home health agencies, community paramedics and patients/families, as well as many others. Understand clearly the incentives driving each stakeholder group to discover mismatches in alignment. One ACO team did multiple leadership and stakeholder presentations to understand if there was mutual agreement to invest time and resources into their LAN program population of chronic obstructive pulmonary disease (COPD) patients. To build support, they tapped into several leaders that had championed a recent successful intervention with end stage renal disease patients. This engagement led to the formation of three subject matter expert workgroups that did deep dives into issues and set priorities for a successful program. Another ACO team conducted a focus group with seniors to understand what value means to them and found many helpful insights, including that seniors want and need a point of contact that can “pull it all together,” such as care coordinator. Everyone is driven by incentives; knowing the costs and burdens to each stakeholder is important for their ongoing engagement.
Do Your Paperwork │ Create workflow maps, communication infrastructure and clinical pathways. In our LAN, clinical interventions remained evidence-based, with many teams adapting existing order sets and protocols for use in the home or skilled nursing facility (SNF). The main focus in the LAN was on improving processes. Early on, consider how your communication needs will change when providing acute care in the home or SNF, and work towards standing up HIPAA-compliant communication channels that are compatible with existing communication and documentation infrastructure. Many of our teams used portals and secure chat within their Epic systems. If changes need to be made to electronic platforms, anticipate it as early as possible. We found this step can take months and may stall progress if enough time is not allocated for IT needs in the project plan. One team in the LAN used a paper chart for early testing while they waited for the alert to be built within their electronic health record system.
Measurement for Improvement │ Create a comprehensive measurement strategy. The data will signal how well your program is running and give solid data points about the progress of your program. In the LAN, we included both process and outcome measures, and tracked most measures at least monthly. In addition to measures such as inpatient admissions and ED visits, the LAN teams tracked costs through one of two approaches. The first was a per episode cost and the second was a utilization-based cost. For many of the teams, it was a key learning just to start the process of understanding how to measure the program’s financial aspects. Quality measures were also a key component of the LAN programs. One team implemented a process tracking measure and found ED screening for unmet needs were not happening as planned. As a result of rapid cycle Plan-Do-Study-Act (PDSA) testing, they improved the process and better served their patients.
Practice Makes Perfect │ Run multiple simulations to identify gaps and opportunities before going live. Discuss and analyze every simulation and use learnings to iterate your processes. Begin by talking through the process step by step and advance to real-time simulations, possibly even in patients’ homes. Simulations can uncover some of the unknowns and allow you to address issues prior to involving your first patient. One of the ACO teams ran simulations of multiple patients from each of the diagnoses eligible for their program over an 8-week period. They learned in their sepsis patient simulation the team’s preparation steps were inefficient and needed to be reworked. This was a finding that was much better to learn within the safety of a simulation and contributed to their success once the program was launched.
Embed Education │ Ensure appropriate education about your program. Testing new ways of responding to acute events involves changing attitudes, behaviors and procedures for multiple stakeholders. Our ACO teams found it helpful to develop a plan that educated while also honored stakeholders’ existing knowledge and culture. Once processes are stable, consider engaging with internal supportive services to embed education within the broader organizational efforts. One team looked at the timing of patient education and discovered their program pre-enrollment was most effective when patients were in a phase where they felt well. They had the capacity to understand and evaluate the program, whereas paradoxically, not feeling well was associated with a perception of not needing the program.
Transforming healthcare delivery that is both beneficial and sustainable necessitates planning out the work and optimizing efficiencies wherever possible to enable success. We hope the lessons from our LAN teams will be useful to others in their program development and improvement. Further detailed analysis and results from the work of the LAN teams will be available in the future.
- Centers for Medicare and Medicaid Services. National Health Expenditures Data Set. 2018. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical
- Schuur, JD, Venkatesh AK. The growing role of emergency departments in hospital admissions. NEJM. Aug 2 2012;367(5):391-393.