Strategically integrating hospital/home care services for improved profitability.As the first step in bringing order to the provision of home care services at Bethesda Memorial Hospital, Boynton Beach Boynton Beach, city (1990 pop. 46,194), Palm Beach co., SE Fla., on the Atlantic coast; inc. 1920. A major suburban area, it is also a beach resort and vegetable-shipping point. , Fla., the hospital Director of Medical Affairs, who was also medical director for the home care agency run by the hospital, implemented multidisciplinary discharge planning rounds that included nursing, social services social services
welfare services provided by local authorities or a state agency for people with particular social needs
social services npl → servicios mpl sociales , utilization review u·til·i·za·tion review
A process for monitoring the use, delivery, and cost-effectiveness of services, especially those provided by medical professionals. , physical therapy, and home care. Home health involvement was recognized as being invaluable in providing information concerning scope of services and insurance coverage.
Identifying the Problem Area
Discharge planning rounds have as an initial focus the appropriateness of continued hospital stay for all patients. As a derivative, the focus then becomes coordination of services needed for discharge. Using these perspectives, it was identified that medically stable patients were remaining in the hospital because of their need for infusion therapy not available as a covered benefit under home care. Maintaining these patients in the hospital was not cost-effective utilization of resources. Six diagnoses were identified as primary contributors to these extended lengths of stay: pancreatitis, cancer, osteomyelitis osteomyelitis (ŏs'tēōmī'əlī`tĭs), infection of the bone and bone marrow. Direct infection of bone usually occurs through open fractures, penetrating wounds, or surgical operations. , short bowel syndrome Short bowel syndrome
A condition in which the bowel is not as long as normal, either because of surgery or because of a congenital defect. Because the bowel has less surface area to absorb nutrients, it can result in malabsorption syndrome. , subacute bacterial endocarditis subacute bacterial endocarditis
n. Abbr. SBE
A subacute bacterial infection of the endocardium or heart valves, most frequently seen in patients with congenital or acquired valvular or cardiac defects, characterized by a heart murmur and , and hyperemesis.
A multidisciplinary team was convened to help identify possible solutions to this problem. All people and departments associated with hospital and ambulatory home infusion therapy home infusion therapy The IV administration of therapeutics–analgesics, antibiotics, chemotherapy, parenteral nutrition–outside of a formal healthcare environment. See Hyperalimentation, Patient-controlled analgesics, TPN. services needed to be involved. The following functional areas were identified: nursing, social services, utilization review, pharmacy, ambulatory care ambulatory care
Medical care provided to outpatients.
n the health services provided on an outpatient basis to those who can visit a health care facility and return home the same day. , medical affairs, finance (reimbursement), management engineering (cost accounting), and home care. Collaboratively, the team possessed all the information needed to design more cost-effective alternatives.
Identifying Service Delivery
The project team approach was used to identify alternatives to extended hospital lengths of stay. Work flows and functions were analyzed. After analysis, home care proved to be the optimal alternative for patient satisfaction, physician satisfaction, and scheduling flexibility.
A subproject team consisting of the director of medical affairs and two home care nurses conducted a retrospective
A rigorous cost-benefit analysis cost-benefit analysis
In governmental planning and budgeting, the attempt to measure the social benefits of a proposed project in monetary terms and compare them with its costs. was conducted by the subproject team (reimbursement specialist and cost accounting specialist), contrasting the actual cost of care with the cost of care under the redesigned treatment plan.
Three areas of financial impact were defined:
* Cost savings, or an operating loss operating loss
The excess of operating expenses over revenue. As with operating income, operating losses exclude revenues and expenses from operations that are not considered a regular part of the business. Also called deficit. Compare operating income. reduction, occurred as a result of decreasing the patient's length of stay.
* A profit was generated through the provision of home health visits.
* The costs associated with home infusion product, equipment, and delivery were unchanged and continued to generate a financial loss equal to that experienced in the hospital.
Reduced length of stay produced the most significant impact on loss reduction.
The study sample indicated that the financial outcome associated with the alternative infusion pathway designed by the subproject team improved financial outcomes by $116,000. Based on further review, it was determined that the sample size was indicative of an average month. Accordingly, the potential annual financial benefit of the alternative pathways could exceed $1,000,000.
Identifying an Implementation Plan
The project teams' next responsibility was to develop an implementation plan: identify goals and barriers and find solutions to those barriers. Barriers tended to relate to the need for change within the organization. The alternative infusion pathways required a broader scope of systems thinking for every department that interfaced with the process. This included the medical staff and administration. The solution involved a series of meetings and presentations whose primary purpose was to educate and obtain support.
Bethesda Memorial Hospital has an established, formal, and organized approach to implementing total resource management. The alternative infusion pathway project is an example of this philosophy. The multidisciplinary team approach was used to establish policies and procedures Policies and Procedures are a set of documents that describe an organization's policies for operation and the procedures necessary to fulfill the policies. They are often initiated because of some external requirement, such as environmental compliance or other governmental addressing issues such as patient identification and tracking systems, nursing education, patient and family education, and cost analysis procedures.
The example above is just the beginning of what can be accomplished by integrating hospital and home care delivery systems. The typical compartmentalized com·part·men·tal·ize
tr.v. com·part·men·tal·ized, com·part·men·tal·iz·ing, com·part·men·tal·iz·es
To separate into distinct parts, categories, or compartments: "You learn . . . approach, which divides service delivery systems and creates blind spots and inherent inefficiencies, can no longer be afforded in today's cost-conscious health care market. Strategically integrating previously separate hospital and home care delivery systems is a key to enhanced service quality and economic efficiency The greatest challenge may be to develop a vision of a unified service delivery system. Today, this system is often referred to as "the total episode of illness" and "the seamless continuum of care." Coordinating hospital and home care in order to manage the total episode of illness through a seamless continuum of care is a sensible strategy for improving both quality and financial performance.
Joan M. Rumberg, MD, was Director, Medical Affairs Bethesda Memorial Hospital, and Michael Girard, MA, was Executive Director, Bethesda Home Care Network, Boynton, Fla., at the time this article was written. Mr. Girard is now President, Home Care Solutions, America, Delray Beach, Fla.