Last week (January 26, 2012), The Centers for Medicare and Medicaid Services (CMS) and  HHS’ Office of the National Coordinator hosted the first “Care Innovations Summit” in Washington, D.C. to “showcase innovative work in care delivery and payment.” The Summit brought together leading innovators from inside and outside the healthcare industry to encourage and promote knowledge-sharing, “matchmaking,” and engagement to drive transformation of our healthcare system. The three-fold goals of all healthcare transformation efforts are: the promotion of “better care and better health at lower cost.”  

James L. Holly, MD, SETMA’s CEO attended the Summit and the preceding November, 2011 Leaders and Innovators meeting hosted by Healthcare Information and Management Systems Society (HIMSS).  HIMSS CEO, Stephen Lieber described the November meeting,  “The HIMSS Leaders & Innovators program brings together healthcare senior executives who will help drive leadership, innovation and overall strategic discussion and direction around current topics facing anyone in healthcare.  Executives have the authority and the vision to transform healthcare.”

Center for Medicare and Medicaid Innovation (CMMI) - Introduction

“Welcome to the Center for Medicare and Medicaid Innovation. Established by the Affordable Care Act, the Center for Innovation is a new engine for revitalizing and sustaining Medicare, Medicaid, and the Children's Health Insurance Program (CHIP) and ultimately for improving the health care system for all Americans. The Innovation Center has the resources and flexibility to rapidly test innovative care and payment models and encourage widespread adoption of practices that deliver better health care at lower cost.

“Our Mission: better care and better health at reduced costs through improvement. The Center will accomplish these goals by being a constructive and trustworthy partner in identifying, testing, and spreading new models of care and payment. We seek to provide

• “Better health care: by improving all aspects of patient care, including Safety, Effectiveness, Patient-Centeredness, Timeliness, Efficiency, and Equity (the domains of quality in patient care as defined by the Institute of Medicine).
• “Better health: by encouraging healthier lifestyles in the entire population, including increased physical activity, better nutrition, avoidance of behavioral risks, and wider use of preventative care.
• “Reduced costs: by promoting preventative medicine, better record keeping, and improved coordination of health care services, as well as by reducing waste, inefficiency, and miscommunication. These efforts will reduce the national cost of health care and lower out-of-pocket expenses for all Medicare, Medicaid, and CHIP beneficiaries.”

The Federal Government’s commitment to Innovation and particularly to innovation which effects real change in healthcare is serious.

SETMA and Innovation

SETMA has been involved in healthcare transformation and innovation since its founding in 1995.  Recently, multiple organizations have recognized SETMA innovation including Healthcare Informatics magazine, eHealth Initiative, Agency for Healthcare Research and Quality and others.  Like excellence in healthcare, innovation in healthcare is not a destination.  Like Dr. Mark Wilson was fond of saying, “Excellence is not a stop sign where you arrived, but a direction in which you are going.”  So transformation is a journey. 

During the CMMI Summit, Dr. Holly responded to some of the presentations.  In the introduction to the conference, reference was made to the participants.  Repeatedly, the names of companies who make products were mentioned.  Dr. Holly’s comment was:

“....(he) discussed "companies," "companies," "companies!!!"  Companies WILL NOT, companies CANNOT, transform healthcare. Providers and Patients WILL make this transformation happen!!!

“Healthcare reform can be top down and with enough pressure and regulation, reform can bring temporary change, but sustainable, permanent, self-perpetuating change requires transformation. Transformation comes from internalized values and personal passion, which operates independent of reform and which will in fact find reform slow, ponderous and inadequate.

“Real change will require a dynamic partnership between government, private companies, academics and practicing healthcare providers. To imagine success while functionally ignoring the last group will result in either failure or at best partial success.

“Top down will not work. Collaboration, dynamic partnership, between all four groups will get us where we want to be and it will keep us there.  The best which reform demands cannot match what transformation will produce.”

Subsequently, the Summit did focus on healthcare providers and their essential participation in innovation and transformation, but subtle suggestions of reliance upon organizations and “companies,” and of government for the success of this process remained.  SETMA agrees that companies and government must be partners with providers in the process, but SETMA also believes that if the critical responsibility of, role of and contribution of healthcare providers to innovation and transformation is overlooked, the probability for success will be lessened. 

SETMA has longed believe that the proper goal for healthcare is transformation which comes from an internalized passion for excellence and a self-sustaining perseverance rather than reformation which comes from external pressure and an artificial design for healthcare. Notwithstanding, those who want to change healthcare are incredibly gifted.  They are insightful and they are driven.  In collaboration with practicing healthcare providers, they will contribute to real and lasting change in health, in care and in the cost of care.  Without that collaboration, everyone will be frustrated.

Care Transitions

At the CMMI Summit, Farzad Mostashari, MD, the National Coordinator for Health Information Technology within the Office of the National Coordinator for Health Information Technology at the U.S. Department of Health and Human Services announced an innovation challenge designed for the use of “simple, IT-enabled processes to make care transitions, especially hospital discharges, safer for patients and easier for caregivers.”

The Coordinator commented that the “scheduling of follow-up appointments and post-discharge testing before leaving the hospital helps ensure safer and more effective transitions. Unfortunately, most patients across the country continue to leave the hospital without confirmed appointments and many providers remain frustrated by a highly manual and unreliable system. The Discharge Follow-Up Appointment challenge will focus on promoting effective care transitions.”  Dr. Mostashari added, “This challenge is an enormous opportunity for software developers to develop solutions, and pursue models that can be adopted across a community...Scheduling post-discharge follow-up appointments is critical, but not easy for patients or providers and we’re excited by the possibilities that will stem from this challenge.”

After his presentation, Dr. Mostashari and Dr. Holly had a brief discussion of SETMA’s work in Care Transitions.  SETMA’s performance for 2009, 2010 and 2011 in performing the Physician Consortium for Performance Improving 18-point quality data set for Care Transitions is posted on SETMA’s website under Public Reporting.

Dr. Mostashari asked, “What is the secret sauce which makes your program successful.”  During the conference Dr. Holly sent the following note to Dr. Mostashari:

“Your question about ‘Care Transition’ set me to thinking. I mentioned that SETMA had discharged 25,995 patients from the hospital in 2009, 2010 and 2011 and that 99.1 percent of those patients had received a ‘Hospital Care Summary and Plan of Care and Treatment Plan’ at the time of discharge.  This document, which replaces the old ‘Discharge Summary; includes:

1. Reconciled Medication list
2. Diagnoses
3. Follow-up care with made-appointments, addresses, phone numbers and provider names
4. Laboratory and procedures results

“SETMA's ‘care transitions,’ which begins at admission (care needs assessed particularly whether or not the patient lives alone) includes:

1. Tracking of PCPI's 18-element quality metric set
2. Conference with patent and family at the time of discharge
3. 12-30 minute Care Coaching telephone call by SETMA's Care Coordination staff the day following discharge
4. A provider follow-up visit with an interval dictated by the patient's risk stratification the interval range is 1-6 days

“What is the ‘Secret Sauce”

“Farzad, you asked, ‘what is the secret sauce,’ which can be exported to others in regard to successfully implementing a "care transitions" program.  I think the following is the answer:

1. The program requires a team. The "Hospital Care summary and Plan of Care and Treatment Plan" is completed by a Hospital Care Team which also conducts the discharge conference,
2. The program requires "Truth Tell" -- first you have to determine where you are.  The link above is to a slide deck which contains candid discussion where SETMA needs improvement.
3. The program requires "Goal Setting" -- a goal is like a GPS which tells you where you want to be; the truth is where you are. Quality metrics are points of reference which shows you whether you are moving toward your goal before you get there.
4. The program requires continued training of health care providers. One a month, SETMA's clinics are closed and all providers attend training.  In January, the training was on Care Transitions and was presented by the CEO, the head of SETMA's Hospital Care team who is an RN and the Director of SETMA's Department of Care Coordination who has no academic medical training but who ran a Psychiatrist’s practice for twenty years.

“The program requires buy-in by all providers in a Medical-Home setting.   This is the ‘secret sauce’ lavished over the foundation of a robust EHR and multiple, integrated care teams.  It works and it is reproducible.”

The Conference is Over

On Saturday, January 28th, the realities of “Care Transitions” continue to face SETMA and healthcare providers everywhere.  The week of the CMMI Innovation Summit was the first week during which SETMA began participating in a program to care for uninsured and unassigned patients who present for care to the emergency department of one of Southeast Texas’ major hospitals. 

Because these patients do not have a relationship with a provider or a practice and because many do not have the resources to obtain the care they need, they present unique challenges.  The following note was sent to SETMA’s hospital care team and providers:

“With 23 admissions yesterday, please make sure HEDIS and immunizations are completed on all uninsured and unassigned patients  It is critical that all Care Transition issues are completed and that the Hospital Care Summary and Post Hospital Plan of Care and Treatment plan is given to each at the time of discharge including a reconciled medication list

“A follow-up care coordination call must be arranged for each and our standards for follow-up visits must be maintained for all patients cared for by SETMA.  If the patient is to be followed up at their request somewhere other than SETMA, a copy of their Hospital Care Summary and post Hospital Plan of Care and Treatment Plan MUST be sent to that follow-up point as well as being given to the patient.”

The Challenge is Not!

On Monday, January 30th, the imperative for Care Transitions and Care Coordination became real and personal again.  Because of SETMA’s commitment to treat all patients with the same standards and caring as we treated everyone; SETMA’s CEO made morning rounds on the uninsured patients admitted to SETMA’s service at the hospital.  He wanted to make sure that the standard of excellent care was maintained and to assess the complexity of the post-hospital care needs of these patients.

To say the least, it was an emotionally difficult morning.  It is impossible to maintain cool objectivity in policy making decisions when you are faced with good people with difficult problems that they cannot solves.  This review showed that SETMA’s providers and the hospital were maintaining excellent standards but that the needs of these patients are overwhelming.  All patients needed immunizations, which were given.  SETMA’s commitment to screening all patients between ages 13-64 for HIV had been maintained.  But these patients had had little screening and preventive care, in their life. They had no resources through which to get future care.  They needed dental care, routine care, nutrition help, financial support, family support and the list goes on and on.  They need mental health support, smoking cessation assistance, some needed drug rehab and all need a place where they can receive compassionate, affordable care. They all need a medical home.

SETMA does not have the answers to all of these problems but we do have a commitment to make sure that everyone for whom we assume care is given excellent care.  The social, political, economic, and sociological challenges for the uninsured are enormous.  In fact, they are bigger than the government, or any one person can solve.  Ultimately, these problems are only solvable when we, acting like our “brother’s keeper,” assume responsibility for the needs of those who approach us and when we respond to those needs, not as an act of charity, but as acts of brotherhood.  They are solvable when all “patients” are our mothers and fathers, our brothers and sisters, our sons and daughters, our own loved ones.

How we deal with the most vulnerable members of our society tells us more about whom and what we are than all of the lofty ideals we might espouse.  It is easy to argue that people are responsible for their own circumstances.   In the abstract, we can ignore those around us, as long as they remain anonymous.   But, when the needy take on a face, a name and a need, we are faced with a mirror through which we can see our own soul clearly.