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Improving Quality and Reducing Waste: The Virginia Mason Production System

The Virginia Mason Production System (VMPS) is a management method that seeks to continually improve how work is done within the medical center. Using this method, Virginia Mason (VM) identifies and eliminates waste and inefficiency in the many work processes that are part of the health care experience, making it possible for VM staff to deliver the highest quality and safest patient care. By streamlining repetitive and low-touch aspects of care delivery, staff members are freed to spend more time talking with, listening to and treat­ing patients. Using this methodology, VM has successfully implemented many improvements in their medical center.

The patient safety alert system at Virginia Mason, for example, has created a culture in which safety problems are quickly identified and addressed, increasing patient safety at the medical center and decreasing medical claims.VM nursing teams used VMPS to redesign their flow of work so they could focus more on patient care, and hospital emergency staff created a process that allows the team to treat more patients faster and with more efficiency.


Longer version:

Adopting VMPS in 2001 required a paradigm shift from thinking errors, inefficiencies and defects are to be expected, to believing that achieving zero defects in health care is not only possible, but also urgently necessary. VMPS uses a variety of strategies to accomplish the elimination of defects and waste, but all begin with an understanding that the medical staff who do the work know what the problems are and have the best solutions. Staff work together in one- to five-day workshops and events to brainstorm, test and implement improvement ideas. Long-term follow up ensures that changes are ingrained into the work and are actually used by the staff. Successes include:

Patient Safety Alert System.
VM used VMPS principles to develop a Patient Safety Alert (PSA) system requiring all staff who encounter a situation likely to harm a patient to make an immediate report and “stop the line” (i.e., cease any activity that could cause further harm). Since the PSA system was implemented, patient safety at VM has increased, and medical claims have dropped.

Getting Back to Nursing.
VM nursing teams used VMPS to redesign the flow of work so they could focus more on patient care. Instead of caring for patients throughout a unit, nurses now work as a team with a patient-care technician (PCT) in “cells” (groups of rooms located near each other). The cell model made it easier for nurses to monitor patients and quickly attend to needs, and communicate with each other. This reduced the number of steps walked per day from 10,000 to roughly 1,200.

Express Treatment in the Emergency Department.
Emergency departments are a major entry point for hospitals and can be a bottleneck. ED patient care is typically more expensive and involves longer wait times. Using VMPS, the ED team at Virginia Mason learned to predict appropriate staffing levels for times of greatest demand. A “team sort” process using standard clinical assessment tools to quickly identify and sort patients’ care needs was implemented. Those requiring minimal services receive express treatment and are discharged without going to patient-care beds, creating capacity for patients who require more extensive services. This work helped Virginia Mason decrease the number of hours the ED was closed and unable to receive new patients by more than 90 percent over two years. In 2011, VM will move its ED into more efficient space and the team sort process will allow the team to care for more patients.

Keywords: Care teams, ED care, eliminating waste, emergency room care, patient safety alert, prevention, safety, value, Virginia Mason Medical Center, Virginia Mason Production System, work process improvement, zero defects

For More Information:

Michelle Peterson
Director, Communications and Public Relations
Virginia Mason Medical Center
100 Ninth Ave, MS GB-ADM
Seattle, WA 98101
(206) 583-6581
michelle.peterson@vmmc.org
http://www.VirginiaMason.org/

Kaiser Permanente’s Healthy Bones Program Results in Reduction in Hip Fractures

According to recent information from the National OsteoporosisFoundationand the Office of the Surgeon General, osteoporosis is a major medical problem. The disease currently affects 8million women and 2 million men in the United States. Kaiser Southern California has a fully integrated Healthy Bones Program in place at all eleven of its medical centers. Using its electronic medical records system is capable of tracking dual X-ray absorptiometry scans, fragility fractures, and the medications used to treat or prevent osteoporosis, Kaiser’s multidisciplinary team prevented 970 hip fractures in calendar year 2007 (2544 hip fractures were predicted and the actual number was 1574), a reduction of 38.1%.

Excerpts from The Journal of Bone and Joint Surgery article:
http://www.ejbjs.org/cgi/content/full/91/Supplement_6/79

“According to recent information from the National OsteoporosisFoundationand the Office of the Surgeon General, osteoporosis is a major medical problem. The disease currently affects 8million women and 2 million men in the United States. An additional 34 million Americans have low bone mass. Each year, an estimated1.5 million individuals in the United States experience a fragility fracture secondary to osteoporosis, resulting in an annual cost of 18 billion dollars. With the rapidly aging U.S. population, the problem of osteoporosis is now reaching epidemic proportions. There are 75 million baby boomers entering the stage in their lives when they are most at risk for osteoporosis. One-half of all women and one-third of all men will sustain a fragility fracture during their lifetime.

Knowledge That What the Orthopaedic Surgeon Does Improves Bone Health

The literature has shown that orthopaedic surgeons have not done enough to aggressively diagnose and treat osteoporosis. It is important for orthopaedic surgeons to know that an aggressive osteoporosis disease-management program can decrease the rate of osteoporosis-related hip fractures by 25% to 50%. One such program is described below.

Background of the Kaiser Southern California Healthy Bones Program

Kaiser Southern California (Kaiser SCAL) is a health-maintenance organization in Southern California that is made up of eleven medical centers with 3.2 million members. Kaiser SCAL has an electronic medical records system that is capable of tracking dual X-ray absorptiometry scans, fragility fractures, and the medications used to treat or prevent osteoporosis. Kaiser SCAL has a fully integrated Healthy Bones Program in place at all eleven of its medical centers. The Healthy Bones Program was established by having orthopaedic surgeons serve as champions in a large multidisciplinary team comprised of healthcare providers from the following disciplines: endocrinology, family practice, internal medicine, rheumatology.

Results

Since the SCAL Healthy Bones Program was adopted, we have seen our annual dual X-ray absorptiometry scan utilization rate rise from 21,557 per year in 2002 to 78,262 per year in 2007, a 263% increase. The annual dual X-ray absorptiometry scan utilization rate in men was 1549 in 2002, and it increased to 15,700 per year by 2007, a 914% increase. The annual number of patients receiving anti-osteoporosis medications rose from 33,208 per year in 2002 to 84,155 per year in 2007, a 153% increase. The annual number of men who received anti-osteoporosismedications in 2002 was 2663, and that number increased to 9310 a year by 2007, a 250% increase. There was a large variation in the reduction in hip fracture rates at the eleven SCAL medical centers during the study period. The reduction in hip fracture rate varied from 31.0% to 54.3%. The overall hip fracture rate reduction was 38.1%. That translated into preventing 970 hip fractures in calendar year 2007 (2544 hip fractures were predicted and the actual number was 1574).

Keywords: Osteoporosis, Kaiser Permanente Southern California, Healthy Bones, electronic medical records, orthopaedic, bone loss, hip fractures, bone loss, multidisciplinary team

FOR MORE INFORMATION:

Jean Sud
Senior Manager, Public Policy & Communications
Kaiser Permanente, The Permanente Federation
1 Kaiser Plaza
Oakland, CA 94612
tel. 510.271.6317
Jean.L.Sud@kp.org
www.kaiserpermanente.org

Kaiser Permanente’s Joint Replacement Registry Improves Patient Outcomes While Reducing Costs

Within the US, over 600,000 total hip and total knee replacements are performed each year. By the year 2030, that number is projected to exceed 4 million. Annual hospital costs associated with these procedures are projected to exceed $65 billion by 2015. The projected increases in the demand for total joint replacements and the costs associated with these procedures will challenge our already overburdened US health care system. Kaiser Permanante’s Total Joint Replacement Registry helps its surgeons and patients make informed decisions about which implant to use or in which patients the risks and potential costs of failure make surgery unwise.


Excerpted from The Permanente Journal article:

“Within the US, over 600,000 total hip and total knee replacements are performed each year. By the year 2030, that number is projected to exceed 4 million. Annual hospital costs associated with these procedures are projected to exceed $65 billion by 2015. Although patients who undergo total joint arthroplasty (TJA) are often of retirement age, recent studies have shown that patients below age 65 represent 35-45% of all TJA recipients in the US. As TJA is marketed more as a lifestyle operation than as a final option to retain mobility for end-stage arthritis, the proportion of patients below age 65 may increase.

The projected increases in TJA demand and the costs associated with these procedures will challenge our already overburdened US health care system. One potential method to address this pending crisis is through comparative safety and clinical effectiveness research aimed at reducing the need for TJA revision surgery. Registries are one example of clinical effectiveness studies that can help surgeons and patients make informed decisions about which implant to use or in which patients the risks and potential costs of failure make surgery unwise. These studies can also identify the relative value of TJA over alternative treatments or the effectiveness of one implant brand or design over another. Although implants vary widely in cost, there is little evidence to support the use of new, more expensive designs instead of more established, traditional designs.

The goals of the Kaiser Permanente (KP) Total Joint Replacement Registry (TJRR) are: 1) to monitor revision, failure, and rates of key complications (e.g., infection, venous thromboembolic disease such as blood clots and embolism, and mortality); 2) to identify patients at risk for poor clinical outcomes following TJA; 3) to identify the most effective techniques and implant devices (best practices and implant constructs); 4) to track implant usage and costs; and 5) to monitor and to support implant recalls and advisories in cooperation with the US Food and Drug Administration.”

Link to full journal article: http://xnet.kp.org/permanentejournal/sum08/joint-replacement.html

Keywords: clinical effectiveness, total hip replacements, total knee replacements, joint replacement, total joint replacement registry, total joint arthroplasty, TJA, Kaiser Permanente, KP, Southern California, registries

For More Information:

Jean Sud
Senior Manager, Public Policy & Communications
Kaiser Permanente, The Permanente Federation
1 Kaiser Plaza
Oakland, CA 94612
tel. 510.271.6317
Jean.L.Sud@kp.org
www.kaiserpermanente.org

Information Technology Supported Care Teams Significantly Improve Care for Patients with Heart Disease

Kaiser Permanente Colorado has significantly reduced the mortality rate for patients with heart disease, which is the nation’s number one killer for both women and men. Using team-based medical best practices and computer-supported care registries, doctors and clinical care teams reduced overall mortality by 76 percent and cardiac mortality by 73 percent. Coronary Artery Disease is the dangerous buildup of plaque inside the coronary arteries. Cardiac mortality refers to all deaths related to heart events.


Excerpt from Kaiser Permanente case study:
http://xnet.kp.org/future/ahrstudy/032709cardiac.html

“Kaiser Permanente Colorado has significantly reduced the mortality rate for patients with heart disease, which is the nation’s number one killer for both women and men. Using team-based medical best practices and computer-supported care registries, doctors and clinical care teams reduced overall mortality by 76 percent and cardiac mortality by 73 percent. Coronary Artery Disease is the dangerous buildup of plaque inside the coronary arteries. Cardiac mortality refers to all deaths related to heart events.

The ability of clinical care teams to coordinate their efforts in cardiac care is greatly enhanced by the availability of electronic health information—which provides instant access to patient information—and evidence-based clinical care guidelines and protocols.”

Keywords: CAD, care coordination, care teams, cardiac care program, chronic care, collaborative care, colorado, communication, coronary artery disease, electronic medical record, evidence-based medicine, health information technology, integrated care, Kaiser Permanente, KP Healthconnect, patient support, population health, preventive care, safety, treatment, value

FOR MORE INFORMATION:

Jean Sud
Senior Manager, Public Policy & Communications
Kaiser Permanente, The Permanente Federation
1 Kaiser Plaza
Oakland, CA 94612
tel. 510.271.6317
Jean.L.Sud@kp.org
www.kaiserpermanente.org

Depression Care Curbs Rate of Suicides at Henry Ford

A quality improvement initiative for the Health Alliance Plan members who receive care at Henry Ford Medical Group resulted in dramatically bringing down the rate of suicide in its 200,000 patient population. Over 9 consecutive quarters, there were no suicides among the patients of the Perfect Depression Care Program of the Behavioral Health Services division of Henry Ford, in stark contrast to the 230 suicides expected in an average population of 100,000. The goal of the initiative was to completely redesign care delivery around the six aims outlined in the Institute of Medicine’s Crossing the Quality Chasm report–safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity—in order to reduce the number of suicides to zero. The belief held by the program is that perfect depression care would result in no suicides—not just a reduced risk of suicide.


Excerpted from:
Depression Care Effort Brings Dramatic Drop in Large HMO Population’s Suicide Rate
Tracy Hampton, PhD
JAMA. 2010;303(19):1903-1905.
http://jama.ama-assn.org/content/303/19/1903.extract

“While physicians and other health care workers may not be ableto predict which of their patients will attempt suicide, theycan implement preventive strategies that markedly lower therisk of such tragedies. Now, one pioneering program has demonstratedthe importance of pursuing 2 key approaches at once: carefullyassessing patients for risk of suicide and adopting measuresto reduce the likelihood that a patient will attempt suicide.

The example comes from a quality-improvement initiative that succeeded in substantially bringing down the rate of suicide in a population of about 200 000 members of a large health maintenance organization (HMO). Through the second quarter of last year, the Perfect Depression Care program of the Behavioral Health Services (BHS) division of the Henry Ford Health System resulted in 9 consecutive quarters without any suicides, a dramatic contrast to the annual rate of 89 suicides per 100,000 members at baseline and approximately 230 suicides per 100,000 individuals expected in a patient population . . .”

Keywords: care team; depression; Henry Ford Health System; Michigan; Perfect Depression Care Program; prevention; quality improvement; rate of suicide;

FOR MORE INFORMATION:

Dwight Angell
Director of Public Affairs
Henry Ford Health System
One Ford Place
Detroit, Michigan
tel.313-876-8709
Dangell1@hfhs.org
www.henryfordhealth.org

New Tools Empower Patients to Make Decisions

Studies show that if patients are given information about all of the options available to treat their condition in a palatable manner, they are much happier with their medical decision and the outcome. Patients also tend to choose less aggressive treatments. This can improve patient safety and health outcomes while bringing down the cost of care. At any given time, between 20,000 and 30,000 Group Health patients are considering a preference-sensitive procedure. To assist their patients and doctors in making treatment decisions, the health system uses tools such as videos to involve and inform their patients.


New Tools Empower Patients to Make Decisions, by Michael Soman, MD, April 19, 2010
http://ghcview.org/?p=110

Sometimes science does not have all the answers. Treatments for conditions from back pain to breast cancer sometimes involve weighing different options with pros and cons for each. Often these treatment decisions are best determined by the patient’s preference as she weighs the impact on her life of surgery, pain, and daily functioning.

At Group Health we have identified a list of preference-sensitive conditions and have begun a more formalized approach to involving the patient in these treatment decisions. Part of experience for patients is watching a carefully balanced video presentation developed with scientific rigor by the Foundation for Informed Medical Decision Making. In a video for cardiology, a patient learns the pros and cons of getting angioplasty. In general surgery, another video educates breast cancer patients about the differences in lumpectomy versus mastectomy.

Patients are encouraged and given time to fully discuss all of their questions and concerns with their doctor. It is a decision made together – shared between patient and doctor. This, unfortunately, is a very different experience in many doctors’ offices and hospitals across the country where patients can feel rushed and under some pressure to follow the doctor’s orders. Although most doctors mean well, surgeons tend to promote the treatment that they feel they do well – and that supports their business.

Studies show that if patients are given all the information in a palatable manner, they are much happier with their decision and the outcome. Patients also tend to choose less aggressive treatments. This can improve patient safety and health outcomes while bringing down the cost of care.

At any given time, between 20,000 and 30,000 Group Health members are considering a preference-sensitive procedure. Researcher David Arterburn from the Group Health Research Institute is carefully tracking the results of this program, looking at improvements in the patient experience as well as whether the process reduces the number of more aggressive treatments.
We don’t whether these new tools will reduce costs at Group Health. But we know from our experience at Group Health that ensuring patients are fully informed and involved in decisions about their care is worth the investment of materials and time.

Keywords: care coordination, communication, David Arterburn, Foundation for Informed Decision Making, Group Health Cooperative, Group Health Research Institute, integrated delivery system, medical home, patient support, physician primary care, shared decision making, treatment, value, Washington

FOR MORE INFORMATION:

Stephen Tarnoff, MD
Associate Medical Director, Strategy & Business Development
Group Health Cooperative
320 Westlake Ave. N., Suite 100
Seattle, WA 98109-5233
tel.206.448.5006
tarnoff.s@ghc.org
www.ghc.org

Diabetic Care Management at Intermountain Healthcare

Diabetes is the sixth leading cause of death by disease in the US. But caring for diabetic patients is remarkably simple. Most health care providers understand what needs to be done to keep diabetics well, but it is difficult and time-intensive to get the patient to participate in the process — and it’s easy for things to fall through the cracks. To care effectively for diabetic patients, a care management model must be put in place and followed consistently in order to keep diabetic patients healthy. Intermountain Healthcare’s system makes it easier for the health provider and the patient to do the right thing.


Diabetic Care Management at Intermountain Healthcare Diabetes is the sixth leading cause of death by disease in the US. But caring for diabetic patients is remarkably simple. Most health providers understand what needs to be done to keep diabetics well, but it is difficult and time-intensive to get the patient to participate in the process — and it’s easy for things to fall through the cracks. To care effectively for diabetic patients, a care management model must be put in place and followed consistently in order to keep diabetic patients healthy. Here’s how Intermountain Healthcare does it:

  1. When a diabetic patient is identified (in one of its 140 clinics, 21 hospitals, or among its 400,000 health plan members), this is noted in Intermountain’s advanced computerized electronic patient record.
  2. This electronic record then follows the patient wherever they go in the Intermountain system and identifies them to caregivers as diabetic.
  3. Patient education is provided in the physician office as well as in regular, consistent mailings. Care managers (typically nurses) are assigned to help individual diabetic patients and make outreach phone calls.
  4. Most of Intermountain’s hospitals and large clinics offer diabetic education classes as well as diabetic educators who visit the patients in their hospital room. There are multiple Diabetes Education Centers that have more than 20,000 patient visits each year.
  5. Patients are strongly encouraged and frequently reminded to get tests and screenings related to their diabetes. This helps them keep their blood sugar in control and avoid other complications.
  6. Intermountain’s health plan sends quarterly diabetes reports to physician offices listing the names, screening statuses, and lab results of diabetic patients. If patients have not been filling their diabetic medication prescriptions, the physician is notified so he can follow up with the patient. This report also allows physicians to see how his/her diabetes patient management compares to other physicians.
  7. Clinical teams of physicians, nurses, pharmacists, diabetes educators, and computer specialists meet monthly to measure and refine the process.

How does diabetic care at Intermountain compare to the U.S.? Two examples:

  • Intermountain ranks above the national average in getting patients to do annual extensive HbA1c (blood sugar) testing, with 90 percent participating appropriately.
  • Only 22 percent of Intermountain patients have poor HbA1c control compared to the national average of 29 percent. Poor control can contribute to a variety of other health problems.

It’s important to note that it’s unlikely any health care organization will achieve perfection. Much of this process depends on personal involvement by the patient, and some patients are more motivated than others.

Keywords:care teams, care management, care coordination, communication, diabetes, electronic medical record, EMR, evidence-based medicine, health information technology, Intermountain Healthcare, Salt Lake City, Utah, safety, treatment, value

FOR MORE INFORMATION:

Dave Green
Communications Manager
Intermountain Healthcare
36 South State Street
Salt Lake City, UT 8411
tel. 801.442.2844
dave.green@ihc.com
www.ihc.com

TeleStroke: Using Technology to Facilitate Care

Approximately 60 percent of stroke patients access their initial medical care within three hours of the onset of symptoms. The TeleStroke program of Cleveland Clinic is a distance health application that will address the issues surrounding time-critical therapeutic intervention.

TeleStroke uses videoconferencing and image transfer to connect Cleveland Clinic stroke specialists with stroke patients located within a 200-mile radius of Cleveland. The TeleStroke program provides 24/7 professional consults to bedside physicians at outlying hospitals for diagnosis and recommendation for treatment and/or transfer. When necessary, these consults — in coordination with existing staff and critical care transport — may result in transfers to Cleveland Clinic for a range of stroke interventions not available at most regional hospitals.

The well-coordinated operations between specialists at Cleveland Clinic and the frontline physicians at regional hospitals are key to the program’s success.Stroke is a significant medical burden, ranking as the third leading cause of death in the U.S. and the leading cause of long-term disability, with more than 700,000 strokes in the U.S. per year. However, significant barriers slow treatment to a large number of patients with non-hemorrhagic stroke: emergency room physicians and non-stroke neurologists are reluctant to administer the proper medicine due to potential complications; and a shortage of neurologists delays acute and consultative care. Therefore, TeleStroke provides an urgent and compelling alternative to having a stroke neurologist always present at the bedside for treatment of acute strokes.

Keywords: access,coordinated care, Cleveland Clinic, Ohio, stroke, telemedicine

FOR MORE INFORMATION:

Megan Pruce
Senior Manager, Communications & Public Affairs
Cleveland Clinic
tel. 216- 445-7452
prucem@ccf.org
www.clevelandclinic.org @ccf.org

Controlling Elective Inductions at Intermountain Brings Benefits to Mothers and Newborns

A few years ago, Intermountain noticed a striking trend that was part of a larger national phenomenon. Women and their doctors were more frequently choosing to induce labor and increasingly, those inductions were happening at 37 or 38 weeks gestational age. Intermountain’s medical research team was concerned that early inductions might have negative health consequences for babies and moms. Armed with statistical information from their own hospitals and using standards from the American College of Obstetrics and Gynecologists, Intermountain instituted a new guideline to limit labor inductions before 39 weeks unless a consulting physician agreed that an earlier induction was medically necessary. Today, there is strong support for the best practice protocol throughout all of Intermountain’s labor and delivery units.


Elective Inductions

Utah has the highest birthrate in the nation, so it may not be surprising that close to 33,000 babies are delivered every year at Intermountain Healthcare, a Salt Lake City-based system of nonprofit hospitals and clinics. In fact, labor and delivery is the most common admission for Intermountain’s 18 hospitals that offer the service. But beyond delivering lots of babies, Intermountain Healthcare also has a national reputation for quality improvement efforts, which are supported by a sophisticated electronic medical record system.

A few years ago, Intermountain noticed a striking trend that was part of a larger national phenomenon. Women and their doctors were more frequently choosing to induce labor and increasingly, those inductions were happening at 37 or 38 weeks gestational age. Intermountain’s medical research team was concerned that early inductions might have negative health consequences for babies and moms. When they analyzed the data from births at Intermountain’s hospitals, they found that women who deliver before babies reach 39 weeks gestational age tend to have longer and more complicated deliveries. Researchers also found a statistically significant increase in the number of newborns with medical complications.

Specifically, the data showed that of babies delivered at 37 weeks gestational age, 8.85 percent were admitted to the neonatal intensive care unit. The number dropped to 4.51 percent of babies delivered at 38 weeks and then bottomed out to 3.34 percent at 39 weeks. The percentage of NICU admissions climbs slowly for babies born at 40 weeks gestational age and beyond. So according to Intermountain’s statistics, hitting the magic 39-week mark seemed to significantly cut the chances of a baby being sent to the NICU.

But that wasn’t all the research found. Babies also were more likely to struggle with respiratory distress syndrome if physicians electively induced labor before 39 weeks. The data showed that if delivery occurs at 37 weeks, 1.92 percent of babies were affected. At 38 weeks the percentage drops to .68 percent and bottoms out at .42 percent at 39 weeks, before slightly climbing again at 40 weeks. The need for newborns to be on a ventilator was also significantly reduced if delivery occurred at 39 weeks gestational age.

Armed with statistical information from their own hospitals and using standards from the American College of Obstetrics and Gynecologists, Intermountain instituted a new guideline to limit labor inductions before 39 weeks unless a consulting physician agreed that an earlier induction was medically necessary. Today, there is strong support for the best practice protocol throughout all of Intermountain’s labor and delivery units.

In 1999, approximately 28 percent of all inductions at Intermountain’s hospitals occurred before 39 weeks. Today, that percentage is near two percent. And with the significant drop in early elective inductions, Intermountain has also seen a 90-minute drop in the average length of labor in electively induced patients, with fewer cesarean sections (about 21 percent compared to the national average of 31 percent) and other medical complications associated with deliveries. The guidelines benefit new babies and their moms. And as icing on the cake, the protocol has also saved patients millions each year.

Keywords: early elective inductions, evidence-based medicine, labor and delivery, labor induction, Intermountain Healthcare, neonatal, NICU, quality improvement, Salt Lake City, Utah, safety, treatment, value

FOR MORE INFORMATION:

Dave Green
Communications Manager
Intermountain Healthcare
36 South State Street
Salt Lake City, UT 84111
tel. 801.442.2844
dave.green@ihc.com
www.ihc.com

Enhancing Primary Care for Mental Health Patients – at a Lower Cost

Intermountain Healthcare, a non-profit integrated healthcare system with 22 hospitals in Utah and Idaho, has had a long-established clinical integration structure, which enables physicians, nurses, and medical assistants to collaboratively treat most patients with chronic illnesses. However, doctors in primary care often struggle with the burden of demand. In particular, these physicians felt ill-equipped to meet the needs of patients with co-occurring mental health conditions.

To address this issue, over the past decade, Intermountain has introduced a new model of mental health integration (MHI), radically changing the way in which primary care is delivered by improving coordination of services between the various parties involved. As of early 2010, the program has been implemented in over half (69) of Intermountain’s 130 primary care clinics. A leadership team has been established at each regional site to design, implement, and evaluate the program across all clinic sites.


Enhancing Primary Care for Mental Health Patients – at a Lower Cost The introduction of an integrated model of care has brought considerable benefits to patients, their families, healthcare providers and community partners in the US states of Utah and Idaho. By focusing on routine primary care for patients with mental health conditions, Intermountain Healthcare has achieved demonstrable improvements in quality with financial savings.

Patients treated in mental health integration (MHI) clinics have a lower rate of growth in charges for all services, with savings of 30% to 80%. In addition, the number of emergency visits for depressed patients fell by over half. The program places mental health at the heart of primary health care and is being replicated by local community health clinics in several other states.

The challenge

Intermountain Healthcare is a non-profit integrated healthcare system with 22 hospitals in Utah and Idaho. It has more than 2900 affiliated physicians, 700 of whom are employed with the medical group. Intermountain also has over 130 ambulatory care practices and its own health plan.

The group’s long-established clinical integration structure enables physicians, nurses and medical assistants to collaboratively treat most patients with chronic illnesses. However by the late 1990s it became clear that doctors in primary care were struggling with the burden of demand. In particular these physicians felt ill-equipped to meet the needs of patients with co-occurring mental health conditions. Dealing with such patients is inevitably more complex and often involves their wider families.

The approach

Over the past decade, Intermountain has introduced a new model of mental health integration (MHI), radically changing the way in which primary care is delivered by improving coordination of services between the various parties involved. As of early 2010 the program has been implemented in over half (69) of Intermountain’s 130 primary care clinics. A leadership team has been established at each regional site to design, implement, and evaluate the program across all clinic sites.

How the program works

When a patient arrives at the primary care clinic he or she automatically receives both a physical and mental health assessment via a questionnaire. This helps the primary care physician, the patient, and their family to identify and determine the nature and extent of any mental health problem, classified as:

  • Mild: requiring routine care with care management or peer advocacy
  • Moderate: requiring care management with additional mental health support from a mental health specialist or peer advocates within the team
  • Severe: requiring direct consultation with a mental health specialist and support from all team members.

The assessment also notes how much support is available to a patient and family to help them manage their chronic condition. Keeping everyone informed is vital, so information is exchanged routinely between all members of the team including patient, families, and specialized mental health providers. The team has a number of common tools available and results are reported centrally, which encourages consistency of practice based upon evidence. As Brenda Reiss-Brennan, the Director of MHI observes: “Standardized assessment tools and meaningful data really drive the clinical decision making that is matched to the appropriate level of team resource.”

Such a team-based approach considers the needs and satisfaction of all parties involved: patient, family, physician and staff, ensuring:

  • True integration: mental health becomes a fundamental feature of primary health care and is accessible to all patients, regardless of complexity of condition or financing. A mutually agreed treatment plan reflects the assessments and any observed problems
  • Real support to physicians: although patients and their families are the focus, the program also recognizes the challenges facing doctors, both in terms of work load and complexity
  • All contributions are acknowledged: reflecting the involvement of all members of the team in improving the quality of care, including the patients, carers and community members

The importance of training
A vital feature of Mental Health Integration is a standardized ongoing training program. This is offered to all team members, with dedicated implementation specialists and analysts working alongside to achieve continuous quality improvement. There are five key components of mental health integration:

  • Leadership and cultural integration: to identify and integrate leadership ‘champions’ — people with mental health and medical backgrounds — to provide institutional commitment and accountability for the integration goals
  • Workflow integration: training all staff from different provider backgrounds to work together as a team in the primary care setting, utilizing standardized clinical tools and creating complementary team roles. This also helps change the culture, reducing the stigma associated with mental health conditions and helping people identify the physical symptoms linked to such conditions
  • Information systems integration: a secure, centralized data repository for data enables all team members to access and update clinical and financial records and communicate with each other. This creates coordination between clinic administrators, physicians, nurses, and medical assistants, bringing greater continuity in patient and family care. Patients also have the facility to email their primary physician.
  • Economic and financing integration: linking clinical and financial outcomes brings together payers and providers, giving a comprehensive overview of all financial costs in the context of improved quality
  • Integration with the community: one of the most challenging and critical aspects of integration, this training encourages members of the community to become active partners with the MHI team and leaders and offer enhanced community support to patients and families beyond the clinic.

Continuous improvement is a key objective, according to Dr. Charles Sorenson, CEO of Intermountain Healthcare: “… our organization sets goals around six dimensions of care — clinical care and service, physician and employee engagement, operational excellence and community stewardship. What is so promising about the Mental Health Integration initiative is the opportunity it gives us to demonstrate benefit and add value in virtually every one of these dimensions.

The model developed by Intermountain Healthcare is now being taken up by local community health clinics across the US in Mississippi, Maine, New Hampshire, Oregon and Utah.

The results

Intermountain Healthcare is now internationally recognized as a high performing system, with US President Barack Obama, speaking at a recent 2010 joint session of congress on healthcare, citing the organization as offering “high-quality care at costs below average”. Evidence of this can be found in improved physician, staff and patient satisfaction, lower costs and better quality outcomes.

A more robust evaluation carried out in 2009 aimed to understand the impact of the MHI on quality (as measured by reduced in-patient admissions and emergency room visits) and cost (measured by allowable charges to the health plan). These findings are published in a 2010 edition of the Journal of Healthcare Management:

  • Lower average growth in patient charges:
    Patients treated in an MHI clinic have a lower rate of growth in charges for all services (with the exception of outpatient psychiatry charges, and prescriptions for anti-depressants, indicating more timely treatment and referral) – In the 12-month period following diagnosis average patient charges increased by 73% for MHI patients compared with 100% for usual care clinics patients – Patients with one other diagnosis in addition to depression had only an 8% increase in average charges in the 12-month period following initial diagnosis, while similar patients treated in a traditional care clinic have a 90% increase – For all levels of complexity (mild, moderate and severe) and overall, patients with depression treated in a MHI clinic cost less in the year following their diagnosis than those treated in usual care clinics. The rate of growth of expenses was $405 US less than for patients in the traditional care group — a 10% reduction – In the 12 months following diagnosis of depression, the 429 patients in the traditional care group in the study would have saved almost US$300,000 in charges, had they been treated in an MHI clinic
  • Lower utilization of emergency room services:
    Depressed patients treated in MHI clinics are 54% less likely to have emergency room visits than depressed patients treated in non-MHI clinics

As Dr Linda Leckman, CEO, Intermountain Healthcare Medical Group, explains: “Physicians not only have a higher level of sensitivity to mental health issues, they are more confident in their own ability to provide care because they have these resources at hand. So it not only results in better care for the patient, but higher physician satisfaction as well.”

Sources

  1. Interview with Brenda Reiss-Brennan, Mental Health Integration Director, Intermountain Healthcare Medical Group, February 2010
  2. Conis, E [2009] A model for mental health integration. Health Policy Monitor, October.
  3. Reiss-Brennan B et al [forthcoming] Cost and quality of Intermountain’s Mental Health Integration Program Journal of Healthcare Management
  4. Health Policy Monitor [2009] USA/Utah: Mental health — from isolation to routine healthcare www.HealthPolicyMonitor.org

Keywords: behavioral health, care coordination, care teams, clinical integration, cost, EMR, electronic medical records, evidence-based medicine, health information technology, Intermountain Healthcare, mental health integration, prevention, Salt Lake City, Utah, safety, treatment, value

FOR MORE INFORMATION:

Dave Green
Communications Manager
Intermountain Healthcare
36 South State Street
Salt Lake City, UT 84111
tel. 801.442.2844
dave.green@ihc.com
www.ihc.com