High-cost patient populations: 3 areas to address

The solution to succeeding in value-based reimbursement models is to start inside the hospital with high acuity patients and build the systems that support them.

We all know the saying that 20% of patients drive 80% of costs.  Historically, hospitals have struggled to find ways to care for this high-cost population. They have also struggled with how to implement programs as the nation rapidly evolves from fee for service (FFS) to value-based care (VBC) methodologies.  By 2020, several of the nation’s largest health care systems aim to have 75% of programs reimbursed under VBC.

The solution is to start inside the hospital with those challenging high acuity patients and build the systems that support them in returning to and staying in their homes.  It’s a new “inside out” approach to population health to ensure seamless and integrated coordination along the continuum of care.  To secure the benefits of this approach, there are three key areas to address.  These include:

  • Emphasis on care for high acuity patients

  • Palliative care

  • Post-discharge care

Post-discharge care

BirdsallThe time after patients are discharged to when they are seen by a provider is often referred to as the black hole of healthcare.  Skilled nursing facilities (SNFs) are one way to ensure patients, especially those who are frail, better transition from the hospital back to home.  However, historically, about 25% of patients admitted to a SNF end up back in the hospital.  With Medicare penalizing hospitals (and SNFs as of 2018) for readmissions, there is greater emphasis on how to get more value from these facilities.

One especially promising trend is when inpatient physicians or hospitalists follow their patients to the SNF facility.  The physician already knows the patient’s status, medications, history, etc., and can ensure better transition from hospital to SNF and ultimately to the home setting.  

Another promising emerging model is the post-discharge clinic to ensure patients have a source of information and support in the critical few days after they leave the hospital.  Upon discharge, patients and their families are often overwhelmed with information and the recovery process. Few are able to schedule a visit with their busy primary care physician, if they have one, within a few days.  Post-discharge clinics ensure patients have access to a physician, ideally the same one that provided hospital care, within 48 to 72 hours of discharge.  This gives the patient a chance to get settled, recover more fully and think about the questions and concerns they may still have.

Post-discharge clinics can work in tandem with urgent care centers (UCCs). However, their primary role is to care for patients immediately after discharge and to help with scheduling routine tests and medical visits.  It is not necessary for the discharge clinic to be a separate brick and mortar facility, making it a cost-effective solution.  It can be a unit within the UCC, the emergency department (ED) or elsewhere in the hospital.

While a newer strategy in healthcare, early programs are showing considerable promise.  At one mid-size community hospital on the West Coast, over a four-month period in 2015, none of the patients admitted to the hospital, who were subsequently seen at the post-discharge clinic, were readmitted to the hospital. 

Next: Focus on high acuity patients



Focus on high acuity patients

Patients who are high utilizers of healthcare services run the gamut from those with complex illnesses such as COPD and cancer, to those with substance abuse and psychiatric needs.  Because these are the patients driving greater cost and utilization, this is also the population that warrants the highest emphasis on programs and services.

These patients need access to optimal levels of care at every step of the continuum from the UCC and the ED to inpatient care and other settings.  Achieving this objective may mean thinking beyond traditional healthcare services. Does the patient need transportation to appointments, help getting prescriptions, or even support with social issues? 

For example, at one community hospital an elderly woman was going to the ED multiple times over a one month period, and twice one day complaining of heart problems.  The woman actually had a normal cardiac catheterization on one admission, yet would continue to come in. Finally, a new approach was considered.  When the patient's social situation was explored it was discovered she lived alone and suffered from anxiety.  Therapies for her condition were provided, better addressing her needs while also helping the hospital better manage her care.

The key to caring for high acuity patients is to ensure there are appropriate care options at every step of the continuum.  Options such as telehealth, online advice, group visits, etc., can all provide important access points for care.

UCCs can play an important role in managing care for this population by providing an option other than the ED to seek care between visits to the primary care physician (PCP).  UCCs can also provide an alternative to costly ED or inpatient care when a patient’s health status may be “on the fence” of needing admission or being sent home.   

Typically ED physicians err on the side of caution and admit these high acuity patients. However, when an ED physician is connected to other providers on his or her team and knows that patient can get next day follow up care at a UCC or post-discharge clinic, there is a higher level of comfort in discharging that patient.


Next: Palliative care



Palliative care

One subset of high acuity patients are those with end stage diseases. Palliative care programs were created to assist these patients and families, who often receive significant medical interventions (particularly when they present in an ED, as they often do). Palliative care programs are gaining traction as a strategy that is not only best for critically ill patients and their families, but also for hospitals. 

Palliative medicine providers work with the entire care team to clarify patients' wishes and goals. For example, a patient with incurable cancer may not wish to spend his last days grappling with the side effects of chemotherapy. In this case, the palliative care team needs to loop the oncologist into the conversation. What are the risks and benefits of continuing curative treatment? Where do we go from here? What does the patient want?

Important steps must be taken to initiate a palliative care program:

  • Identify patients who meet clinical criteria for life-limiting illness.

  • Initiate respectful, appropriate conversations with these patients and their families about prognosis and available options, including palliative care.

  • Create standardized palliative care order sets that can be used even in hospitals with no existing palliative care program.

  • Transition admitted palliative care patients to the hospitalist program for ongoing care that meets their goals and wishes.

Palliative care programs are still not fully reimbursed under the Affordable Care Act (ACA), but they soon will be.  The time to adopt such programs is now as the underlying principles-care coordination, transition to lower acuity settings and patient satisfaction-are important elements for reimbursement.

Partnerships, committed leaders and data

Two of the most crucial factors needed to support an inside out approach to population health management are:  

1. Strong physician leaders committed to the goals of their organization. 

2. Data to assess program performance and to facilitate collaboration and ongoing communication.

Neither of these contributors requires a costly investment. For example, an increasing number of successful hospitals are partnering with outside organizations to build collaborative physician teams across all care settings that are aligned with organizational goals and missions to ensure a cost effective and seamless approach to care.  External partners can also bring their own technology and systems to the hospital helping to avoid costly capital outlays for analytics.

Affiliations and partnerships help to create new points of care that are less resource-intensive and therefore cost less, which helps to offset future shrinking margins and/or limited infrastructure.  This creates greater flexibility and enables hospitals to better leverage new payment structures such as bundled payments.

Next: Questions to ask



To move forward with an inside out approach to population health, there are some important questions to explore:


1. Where are our biggest deficiencies and gaps in care? What areas present the most risk to the organization?  For example, many hospitals are concerned about CMS measures to reduce readmissions and length of stay (LOS).  Programs that reduce LOS ensure greater reimbursement.

2. What happens if we do nothing?  To help highlight the importance of programs addressing areas of need, develop a projection that shows what will happen if the organization continues with business as usual.  If you keep doing the same thing, what will be the financial result in, say, three years?

3. How are we improving the patient experience?  Remember that all patients are asked to participate in patient satisfaction surveys.  Patients are now paying more for care and as such are demanding better service. All programs, services and personnel must understand the importance of the patient experience and receive education and tools to improve patient satisfaction. 

4. What is the organization’s relationship with physicians, whether employed by the hospital or in the community?  Alignment of physician goals with the organizations will be critical to success in healthcare today. Put physicians on key committees, encourage them to hold leadership positions, encourage and recognize what they do in the community.   

5. Do we have the right partners? Finding ways to build not only the infrastructure but also the services to provide care from the inside out may seem daunting to hospitals.  By developing strong partnerships with trusted and experienced leaders in the industry, even smaller hospitals can take steps toward a population health focus.  For example, consider staffing UCCs and EDs with experienced physicians, physician assistants and nurse practitioners who share the philosophy and the technology to enable greater care coordination.  Or explore the benefits of forming collaboratives with local post-acute care providers.

Promise ahead

The past few years have been filled with considerable change and uncertainty. But as the marketplace settles, there are changes that bode well for patients, physicians and hospitals.  We are moving away from the disjointed approach to patient care we have had in the past. We are beginning to emphasize seamless, coordinated care throughout the continuum. For many of us in healthcare, the change is exciting and promising. 

There are of course challenges ahead, but if hospitals focus on acute care access points, care coordination, communication between care providers, and the development of engaged and aligned physician leaders, they will be able to create an inside out approach to healthcare that allows for a successful transition from FFS to the new focus on value-based care.

David Birdsall, MD, is vice president for CEP America.  He is a practicing physician and has received board certification for both emergency and internal medicine. For additional information, visit www.cepamerica.com.



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