Investing in Outcomes, Creating Value: Group Health Cooperative

Making care more patient-centered and friendly can both improve care and reduce health care costs. But changing the status quo and making investments to create better value is easier said than done, unless you are Group Health Cooperative, determined and able to make changes rapidly to improve outcomes.    

The Problem: Transitioning patients to different care settings, especially from the hospital, is health care’s Achilles heel. In today’s fragmented health care system one in five Medicare patients ends up back in the hospital within 30 days of discharge and about one-third of emergency room visits are unnecessary, resulting in higher costs and lower quality care.     

The Solution: To improve patient care and reduce preventable hospital admissions, readmissions and emergency department (ED) visits, Group Health created the Emergency Department and Hospital Inpatient Improvement Program (EDHI) to transition members more smoothly and safely out of the hospital and admit those who truly need hospital care.

EDHI Results to Date:  

• Decreased hospital days by 29 days per 1,000 patients following EDHI implementation;
• Decreased 30-day Medicare readmission rate from 16 percent to a low of 12 percent;
• Contributed to $51 million in savings in unnecessary hospital costs in 2010; and
• Increased patient satisfaction rates among members hospitalized at the pilot site, Seattle’s Virginia Mason Hospital & Medical Center, from the 70^th percentile to the 90^th percentile within one quarter of implementing EDHI. 

Group Health: Investing in Outcomes and Creating Value

Modern medicine is wonderful in its ability to help people live longer, healthier lives. But the health care system delivering that care can be frustrating for patients and even dangerous. One of the most potentially harmful times for patients is when they are discharged from the hospital to a skilled nursing facility (SNF), home or other setting.

Studies have shown that many hospital patients don’t understand how to take the medicines they are discharged with or even remember their primary diagnosis. A big reason for these and other problems is the lack of communication and care coordination that occurs during the transition. As a result, one in five Medicare patients is back in the hospital within a month of being discharged. Many of those readmissions are preventable.

“We’ve seen an increase in technology and in our medical knowledge, but [medical providers have] become experts in our own silos,” says Brenda Bruns, M.D., executive medical director of Group Health. Unless hospital discharge is carefully managed, “we forget the patient is passing through and wants someone to organize their care.”

In early 2009, Group Health made a commitment to fix the confusing and unwieldy hospital discharge process. Even though its Medicare members were less likely to be readmitted to the hospital within one month—16 percent versus 20 percent nationally—the plan felt those numbers were still too high, especially when better coordination and teamwork could prevent even more patients from being readmitted. Hospital and emergency department care accounted for about one-third of Group Health’s care costs. Moving the needle makes sense from a quality standpoint and could save millions of dollars, helping all Group Health members and purchasers.

Using Lean Methods to Improve Hospital Transitions

When Group Health decides to make changes it is able to quickly and adeptly, thanks to the Lean method, a customer-guided management philosophy the plan has adopted. Lean focuses on providing exactly what the customer wants or needs by eliminating waste in associated processes to better meet customers’ needs. Part of the Lean approach is to make changes quickly and involve frontline workers in the change process. Group Health leaders have adapted the approach to patient care, including revamping how pharmacy and complex care departments deliver care.

In 2009, Group Health targeted a traditionally weak link in health care: the process of hospital transitions. Staff scoured the medical literature to identify best practices around successful care transitions. Group Health clinical leaders convened four, one-week rapid process improvement workshops around different aspects of hospital care, involving frontline clinical staff, administrative and clinical managers, and medical directors. In reviewing the evidence, the group mapped out new standardized work processes around key components of a hospital stay—hospital admission and discharge, emergency department process, skilled nursing facility admissions and end-of-life care procedures. 

“There have been an extraordinary amount of changes in a very short period of time,” says Janelle Bagley, a Group Health consultant for network services and care management. The four different processes were launched within two months at Virginia Mason Hospital & Medical Center, and rolled out to six other high-volume hospitals the health plan contracts with by late 2009. Modified approaches to transition management were implemented in two additional hospitals where only care managers are on site. Finally, patients in hospitals with an average daily census of less than 10 received transition coaching by telephone upon their return home. In those first seven hospitals, the health plan already had Group Health hospitalists and care managers working at the facilities to care for its members. “Our patients are pretty much only managed by us while they are in the hospital,” says Bruns. This was helpful in implementing the changes, particularly two pivotal changes—the “huddle” and standardizing transitions.

The huddle is a significant behind-the-scenes change that has Group Health hospitalists and case managers meeting each morning to discuss every patient and their symptoms, review their electronic medical record and evaluate the optimal level of care needed. A decision is made whether a patient can be treated safely and more effectively in the hospital, at home with home health services or in an SNF or other facility.

“We’re trying to plan for each patient transition as early as possible,” says Bagley. Each patient is designated into one of four categories, determining the next steps that will be taken:

• Blue: patients with uncomplicated conditions, such as new mothers with uncomplicated births and patients undergoing an appendectomy, who will need minimal post-discharge care.
• Yellow: patients with complex medical needs who will need help with their condition, drugs and doctor’s orders.
• Green: patients who can be discharged to an SNF.
• Red: patients who likely will need end-of-life care. 

Patients with complex medical needs (one-third of patients are triaged as yellow) receive high-touch care coordination that includes three chair-side visits by the Group Health care manager, who teaches patients about their diagnoses, medicines and care they will need following discharge. Patients are taught how to recognize symptoms that require them to call their doctor immediately and are coached to make follow-up appointments with their primary care doctor within 14 days of discharge.

Group Health nurses contact “yellow” patients within 48 hours of discharge to check on them, answer questions, reiterate proper medication use and red-flag warning signs, and help to arrange for any follow-up care or needed services. Within seven days of discharge, Group Health pharmacists contact patients to review and explain their medicines and check for any existing or potential problems.   

Patients with uncomplicated conditions receive a less intense version of the standard work plan. A separate protocol is triggered for the far fewer patients who may require palliative care. A slightly different choreographed routine is put in place for “green” patients, or those whose conditions are better handled in an SNF or other setting. At this point, Group Health staff coordinate the SNF placement process based on available facilities, member’s benefits, and member and family preference.

Creating Value 

Group Health and other members of the Alliance of Community Health Plans constantly innovate to deliver better health outcomes for patients, striving to do so at lower-than-average costs. To improve outcomes, plans like Group Health invest in their patients by implementing information technology and on-the-ground care solutions.

With EDHI, Group Health has reduced its Medicare readmission rate to as low as 12 percent, and has set a target of keeping the readmit rate consistently below 10 percent.

While Group Health has been working to lower readmissions, the EDHI program also has reduced admission rates by 5 and 10 percent for Medicare and commercial members, respectively. “Admission rates continue to decline,” says Brenda Bruns. “While we haven’t yet met our readmission target, we’re preventing significant admissions.” Avoided hospital days saves between $2 million and $4 million each month. 

Under EDHI, onsite Group Health physicians and case managers work more closely with the ED staff at each contracted hospital. As a result, the teams examine each patient’s case more closely, with Group Health investing in resources so that alternatives are available. For example, the elderly patient who presents at the ED with a foot infection that would require IV antibiotics and cannot safely go home can be transitioned to a less intensive and less expensive skilled nursing facility rather than being placed inpatient. Group Health has arranged for SNFs to accept Group Health members coming from EDs as late as 10 pm. By reworking processes, dedicating and adding needed resources, and investing in outcomes, Group Health is creating better value for members and others. Patients are better and more safely transitioned from hospital care, and unnecessary cost is squeezed out of the system. “It’s impacting the community,” concludes Bruns.

A PDF of the study can also be found in the Attachments box on the right side of this page.