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, 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, utilization review, 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, short bowel syndrome, subacute bacterial endocarditis, 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 services needed to be involved. The following functional areas were identified: nursing, social services, utilization review, pharmacy, ambulatory care, 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

Alternatives

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 chart review of a sample of the six diagnoses primarily contributing to the problem. The subproject team determined the point at which medical stability was reached and developed the frequency and service delivery requirements necessary to provide completion of care in patients' homes.

A rigorous cost-benefit analysis 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 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 addressing issues such as patient identification and tracking systems, nursing education, patient and family education, and cost analysis procedures.

Conclusion

The example above is just the beginning of what can be accomplished by integrating hospital and home care delivery systems. The typical compartmentalized 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.