Published in the February 2015 issue of Today’s Hospitalist
FOR YEARS, Santa Rosa Memorial Hospital in Santa Rosa, Calif., did an OK job accepting transfers from smaller community hospitals. But the hospital “a level II trauma center and the flagship facility of the five community hospitals in Northern California run by St. Joseph Health “knew there was an unmet regional need for local care of complex cases. Plus, the hospital had unused capacity in terms of resources and subspecialists.
“We had some bandwidth to take care of more transfer patients, particularly in trauma and cardiology,” explains Tuck Bierbaum, MD, an emergency physician at the hospital who became the medical director of its regional referral program. “What we didn’t have was a system that made it easy for sending physicians to call us and get an acceptance.”
Until such a system was in place, ambulances and helicopters from throughout the region would continue to go right past Santa Rosa Memorial and head south to San Francisco’s academic centers. That trend was borne out when the hospital examined statewide transfer data for patients in Sonoma and Mendocino counties and more distant outlying areas.
To gauge the interest of local hospitals in transferring patients to Santa Rosa Memorial, the hospital launched an outreach initiative. “We talked to about 100 emergency physicians,” says Dr. Bierbaum. “There was definitely a desire among referring physicians and patients to stay local. What we heard is, ‘If you can make it easier, we will always go to you.’ ”
In 2011, the hospital decided to invest in the internal infrastructure and external resources needed. Since then, transfer volumes have tripled from 850 to more than 2,400 a year.
The program delivers an impressive return on investment, says Dr. Bierbaum, with revenue from regional transfers helping fund the physician resources the program needs in terms of both hospitalists and subspecialists.
But now, the hospital system has another challenge: too much success. “We need bed capacity,” notes Dr. Bierbaum, adding that the regional program has expanded to place transferred patients not only in Santa Rosa Memorial, but throughout its four sister hospitals.
“We may need to buy a SNF or buy SNF beds to make room for new referrals,” he says. “We’ll definitely need to be creative.”
To get the regional transfer program off the ground, the hospital board approved a budget to cover several staff members. One is a medical director, which Dr. Bierbaum says is an absolute necessity. “These programs need a physician champion,” he explains. There’s also an administrative director and a person who does full-time outreach to the referring physicians at nearly 20 hospitals throughout Northern California that send patients.
The budget also covers the cost of hiring an outside transfer center, which Dr. Bierbaum says is “the best thing we could have ever done.” The hospital decided to contract with VeriHealth Inc. www.verihealth.com/, a Petaluma, Calif., company that provides ambulance and transfer-center services to hospitals throughout the state. (Dr. Bierbaum also serves as the clinical medical director of VeriHealth’s ambulance service arm.)
Too often, he explains, hospitals try to manage transfers in-house, relying on the physician networks their doctors have created with outside facilities.
But to build a successful transfer program, he says, “you need not only rapid physician-to-physician communication but the ability to coordinate hospital resources. Is an operating room or cath lab available, or does the receiving hospital even have an open bed?”
Outsourced transfer-center services can also arrange another key component: transportation. “Nobody in one hospital can do that,” he says. “Our transfer center understands regional resources in terms of different transport service lines including air, critical care, advanced life support or neonatal.”
Plus, having an outside center made it easy to start placing transfer patients among the five St. Joseph hospitals. “You need a center with the ability to assess capacity at five different hospitals with contact information for five medical staffs,” he says. Using an outside center also has allowed the program to differentiate itself from its competition, Dr. Bierbaum says.
“We guarantee that hospitals have to make only one call, and we’ll accept a transfer within 30 minutes,” he points out. But for those rare transfers that the St. Joseph network can’t accept, the transfer center will stay on the line with the sending hospital “until its patient is placed, even with a competing health system.”
Getting medical staff on board
All referring hospitals call the transfer center first. For calls about a trauma or STEMI transfer, the transfer center immediately contacts the emergency physician at Santa Rosa Memorial.
“We’ve made a commitment to always take those patients regardless of inpatient bed status,” says Dr. Bierbaum. “They are processed through the ED, and we figure out a bed later.”
For other patients, the first call the transfer center makes is to the hospital house supervisor to make sure a bed is available. (Throughout the day, house supervisors at all five hospitals upload current bed information to the transfer center to help the center make decisions about beds quickly.)
If a bed is available, the transfer center then pages the receiving on-call physician of the appropriate specialty, putting him or her on the line with the sending doctor. Those conversations are recorded, which Dr. Bierbaum says has helped with quality assurance, EMTALA protection and liability. Clearly, the system can’t function without the rapid response of medical staff. And getting all doctors on board, says Dr. Bierbaum, can be a challenge.
He first needed to convince subspecialists who receive on-call stipends that being on call meant responding to transfer patients, not just to patients admitted through Santa Rosa Memorial’s own ED.
“Transfer patients now make up one-quarter of our admissions through the ED,” Dr. Bierbaum notes. “So one-quarter of those on-call stipends is being paid for with transfer revenue.” He also argued that providing a service that smaller hospitals cannot supply is part of the hospital’s EMTALA responsibility.
And he structured an incentive that puts some subspecialist call pay at risk. “We created a quality metric related to providing access to needed care,” he explains. “We incentivize the doctors to improve that access by improving their acceptance rate of appropriate cases.” Admission to the hospital is not required, “only an affirmation to care for the patient in any appropriate venue.”
Another development that helped bring on-call subspecialists around: ensuring that the admissions work for nearly all transfers would be handled by the hospital’s intensivists or hospitalists.
At first, Dr. Bierbaum admits, the hospitalists pushed back. “We pointed out that the subspecialists had already been contacted and had agreed to take care of the patient, either emergently or by 9 a.m. the next morning,” he says. “So the hospitalists knew the subspecialists were on board.”
Regional referral revenue also funded a hospitalist swing shift. That allows day-time hospitalists to leave on time.
“You have to cultivate and reward regional behavior,” Dr. Bierbaum says. Along with the ED physicians, the hospitalists need to be the linchpin of a regional transfer program. “They’ve got to figure out a way to say ‘yes.’ ”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.