Published in the May 2018 issue of Today’s Hospitalist
AS SYSTEM CHAIR of the hospitalist division of what was then Mountain States Health Alliance in 2016, Amit Vashist, MD, MBA, had to grapple with some very familiar problems: how to rein in readmission penalties and how to transition to value-based care.
But Dr. Vashist also faced some unique challenges. For one, patients in Appalachia, which his health system serves, have a tough time accessing timely follow-up care. And at one hospital within the system—Indian Path Medical Center in Kingsport, Tenn.— inpatient volumes had dropped off 10% in 2016 alone.
“We needed to come up with some innovative, out-of-the-box solutions,” he says. “Decreasing volumes are part of the health care landscape for many of us, so we need to create different care models.”
“Decreasing volumes are part of the health care landscape for many of us.”
~ Amit Vashist, MD,
MBA Ballad Health
Fortunately, Dr. Vashist adds, the hospital’s very forward-thinking CEO—Monty McLaurin, along with chief medical officer Mark Wilkinson, MD, hospitalist site director Sudhir Patel, MD, and ED nurse manager Hope VanHuss—had a ready suggestion: launching a hospitalist-run transitional care clinic to provide immediate post-discharge care to the center’s highest-risk patients.
More than a year after the clinic opened, it has driven down readmission rates for the patients it serves and significantly lowered their costs of care.
But Dr. Vashist says he still has to contend with one big barrier: incomplete buy-in from many of the hospitalists who are reluctant to leave the wards.
Overcoming outpatient suspicions
Located in a section of the hospital’s ED, the six-bed transitional care clinic is open 9-5 on weekdays and staffed by hospitalists who supervise advanced practice providers and ED nurses.
The transitional care clinic was always designed to provide post-discharge care to complex patients with chronic conditions including those with sepsis, heart failure or COPD. Further, it was launched with a very specific mission: to treat only those complex patients with chronic conditions who were not attached to any primary care or specialty practice.
“At first, local doctors were very concerned that we planned to poach their patients and take away their ability to bill transitional care management codes,” Dr. Vashist explains. Within a few months, however, the clinic started accepting referrals from both primary care and specialty offices that either couldn’t schedule an appointment within seven days post-discharge for a complex patient or couldn’t provide a particular service that patients needed.
“Say a primary care doctor can see a heart failure patient within seven days of discharge, but that patient has gained 10 pounds over the last three days,” he says. “The patient needs Lasix infusions that are beyond the bandwidth of an outpatient practice, so the primary care office will now refer that patient to the clinic instead.”
The clinic offers a variety of infusions as well as transfusions. And as of a few months ago, an infectious diseases specialist began providing care there on an as-needed basis. “A significant subset of the clinic population has infections, including respiratory, skin and subcutaneous, and multi-drug resistant infections as well as UTIs,” Dr. Vashist points out. “We added that layer of specialty health.”
A new mindset
Patients typically will be seen two or three times in the clinic, usually within the first month post-discharge. As for “unattached” patients (who have no outpatient medical home), clinic staff can often place them with a primary care practice within two or three months.
For Dr. Vashist, the clinic continues to be a “win-win.” While the overall readmission rate for the hospital this fiscal year is running between 11% and 12%, it’s averaging less than 5% for clinic patients. And if the clinic wasn’t available, “those patients would probably come back to the ED and be placed in observation and possibly charged larger deductibles and copays there,” he points out. “Having the clinic helps patients avoid those.”
The once suspicious primary care community now embraces the clinic wholeheartedly, as do patients and their families. Even local oncologists are asking for access to the clinic for their infusion patients.
But full buy-in from the hospitalist group has so far proved elusive. In fact, while Dr. Vashist wants to expand the clinic’s capacity, that is currently limited because only two of the hospital’s 10 hospitalists have chosen to get involved.
So what’s the problem? For one, he points out, it’s a model of care that is far afield from what the physicians are used to. “Hospitalists haven’t been trained to provide abbreviated episodes of care for complex chronic conditions,” he says. “Having to take all the things you’d do in two days and condense them into two-to-four hour episodes goes against the conventional mindset and may lead doctors to question their own skills.”
Doctors also balk at having their inpatient workflow disrupted, which Dr. Vashist admits is a legitimate concern. “When doctors start their day with a standard census of 16, then get a call from the transitional care clinic at 9:30 while they’re in the middle of doing discharges, are they supposed to leave? We have to figure out how they can survive complex and competing priorities.”
Clinic reimbursement is another ongoing challenge. While the clinic can charge high-level office visits, outpatient services that can last hours go far beyond typical visit parameters.
“If we don’t have robust agreements with payers, we’re shooting ourselves in the foot in terms of decreasing admissions,” Dr. Vashist points out. “We’re in the process of negotiating so we’ll be rewarded, not dinged, for preventing hospitalizations.”
In 2017, Mountain States merged with Wellmont, another big health care system, to form Ballad Health, based out of Johnson City, Tenn. Because patient transportation in Appalachia remains a perennial problem, Ballad is exploring ride-share possibilities for patients, including system-owned vans.
And with 21 hospitals now part of Ballad Health, Dr. Vashist is trying to figure out how to launch more transitional care clinics throughout the system. “We’re going to start by opening clinics in two or three other markets,” he says. “We want to expand this to many more of our hospitals, particularly as we move more into population health.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.