The single-staff model for bone marrow transplantation.

Traditional models of health care have tended to focus on billing processes and places of service rather than patients. "Managed care" strategies have focused on reducing the utilization of inpatient services, limiting patient care options to "referred providers," and purchasing each phase of care from the lowest competent bidder. Such attempts to contain costs and the compensatory strategy of "unbundling" by providers have resulted in an environment in which patients are forced to have contacts with multiple provider teams in numerous locations, face increased opportunities for miscommunication and medical mismanagement, experience difficulties in knowing who is responsible for their care at any given time, and may be responsible for interpretation of a variety of instructions and forms under threat of loss of benefits.

On the provider side, these disintegrated models of care make it difficult for health professionals to adequately manage patient care. Under these arrangements, information management requirements, such as medical records delivery, can delay decision making; confusion over who should provide which aspects of care are inherent; and it is difficult to maintain patient compliance. In many cases, a comprehensive care plan is never developed because each specialist is looking at the patient only in terms of his or her area of accountability.

While such disintegrated care models may be adequate for illnesses of low acuity or short duration, chronically ill patients and those requiring very high intensity of care and surveillance for multiple complications over an extended period risk not just dissatisfaction but significantly poorer outcomes. In complex cases, such as organ transplantation, disintegrated care models make continuity of care more challenging, increase administrative costs because of additional record keeping and the generation of multiple bills, increase the utilization of medical diagnostic and evaluation tests, require that patient histories are repeated, and increase costs by not identifying and resolving "minor" problems before they become serious and more costly to treat. Further, expensive modes of care, such as emergency departments, are utilized because physicians offices are closed nights and weekends. These strategies also add functions with no medical benefit, such as the case managers required to police and administer the segmented care model itself.

The Bone Marrow Transplant (BMT)

Experience

BMT patients receive medical treatment that could free them from their disease or bring about their deaths. BMT patients undergo extensive medical evaluations, receive marrow ablative chemotherapy or a combination of radiation and chemotherapy, remain in hospital ICU/special care units for four to six weeks, and must remain close to transplant centers for up to 60 days posttransplant. Patients must take many steps along a care path that begins with a referral for consultation, continues through evaluation and preparation for transplant, crosses over a lengthy inpatient stay, and ends with gradually less frequent outpatient care and a return to the care of the patient's primary physician.

Some of the special needs of BMT patients include protection from infection, close monitoring by experts, round-the-clock access to medical expertise, and medical management that pro-actively diagnoses and treats potential problems, thereby preventing serious complications and the high costs associated with treating them. Managing such special needs requires a continuity of specialized care that is not easily accomplished in a segmented system.

In developing a new model for the care of these patients, we were faced with the following patient care challenges:

* Long duration of care (10- to 20-day preadmission evaluation, 20-to 60-day ICU, and 30- to 100-day subsequent outpatient care).

* High acuity of inpatient care (Medicare relative weight of 15.2890 and a mean length of stay of 37.8 days).

* Complex pathophysiology, with unique signs and symptoms that require specialized treatment knowledge.

* Extremely fragile state of patient, requiring intensive surveillanice, high utilization of blood products and infusion pharmaceuticals, and proactive decision making and care, even when hospitalization is no longer required.

* Extreme financial and social pressures on patients and family.

* Time constraints on team members by separate management structures and allegiances.

* Limited exposure of some team members and consultants to the entire patient course.

* Outpatient clinic open only from 7 a.m. to 6 p.m., Monday through Friday.

While any model for care that was developed and implemented had to be cost effective, successful implementation also would depend on how well the model served the needs of both patients and staff (table 1, above). A set of goals for the model evolved from these challenges, needs, and constraints (table 2, page 36). Once challenges and needs were examined in this way, it seemed obvious that a single-staff, single-facility model would be optimum. In addition, it became obvious that the only facility capable of meeting all of our requirements was the hospital inpatient unit and that the most appropriate staff was the hospital inpatient nursing staff. Only this facility and staff are available 24 hours a day, seven days a week, and have the level of expertise required to maximize patient care outcomes.

Table 1. Patient and Staff Needs
Patient Needs
* Continuity of care
* Access to expert, familiar, acute care on nights, weekends,
  and holidays
* Flexible family access and education
* Simplified billing and up front knowledge of costs
* Personalized attention
* Effective education
* Patient and family housing and security

Staff Needs
* Good patient outcomes (low mortality, high disease-free
  survival)
* Involvement and awareness of the total process from consult
  to longterm
  follow-up
* Reduced staff turnover
* Simplified yet specialized patient care locations
* Access to necessary services at all times
* Positive multi-disciplinary interactions
* Role reinforcement

Table 2. Goals and Objective of the Single-Staff Model
* Design a model of care that conforms to the patient rather
  than forcing
  the patient to conform to the model.
* Implement a model flexible enough to change with new
  developments in
  medical technology.
* Develop a care team and delivery system that promotes staff
  satisfaction
  and reduces turnover.
* Develop esprit de corps among the care team so that patient
  outcomes
  can be improved through greater team work and better
  communication.
* Develop a care model where every one buys into the outcome as
  the bottom
  line rather than just accepting responsibility for their
  sectors of care.
* Ensure that all needed patient support services are provided
  in a high-quality
  manner regardless of their individual return on investment.
* Establish the highest possible levels of patient satisfaction.
* Ensure that reimbursement is sufficient to support the care
  model.
* Reduce the true costs of patient care by implementing a
  proactive medical
  management system that focuses on preventing rather than
  managing
  complications.
* Optimally utilize all human and clinical resources,

Implementation

There were a number of potentially serious obstacles to the implementation of this model. First were the political risks. The ambulatory clinic could potentially resent "its" revenue being transferred to the hospital, and nursing would be required to adjust traditional thinking related to patient care. The roles of consultants and housestaff, though potentially enhanced, would be affected. Third-party resistance to any change in billing, especially "bundled" billing with loss of administrative revenue and control and the appearance of contracting for higher cost care, (i.e., a global all-inclusive fee, when insurers were accustomed to monitoring only inpatient costs) was expected.

Second were the financial risks. The cost per square foot of inpatient space is significantly higher than the cost of outpatient space. No outpatient revenue system existed for managing outpatient charge structures on an inpatient unit. No reimbursement experience existed for this type of unit, and reimbursement could not be ensured. Last, internal budgeting and accounting systems did not provide a mechanism for allocating indirect program costs to the outpatient cost center, nor was there a method in place for reimbursing the inpatient nursing budget for nursing's efforts in the management of ambulatory patients.

Third were the physical and administrative challenges, such as how to develop an outpatient facility within an inpatient unit, who would report to whom, how would lost revenue or uncompensated services in one cost center be compensated from another, etc.

Ultimately, all of the major obstacles were overcome because of an entrepreneurial service line management structure, institutional commitment to excellence in patient care, a small close-knit team of managers and caregivers, and an open dialogue strategy for implementation. As the concept grew, patient and staff feedback was continuously sought and monitored. Policy and other modifications were made as needed. Entirely new billing systems were developed, and new budgetary structures were created. Because we were in a growth stage initially, the model was able to take advantage of some initial staff overcapacity. Physicians, nurses, and other team members had the opportunity to learn to perform simultaneous intensive inpatient and less intensive outpatient care without the stress of overutilization.

Because of rapid acceptance of this model by patients, referring physicians, and third parties during the first year of implementation, a number of improvements have been made, most in the direction of expanding the concept. The nursing staff and facility are now involved with patients from the time of decision to transplant until patients are transferred back to the care of their primary care physicians.

Results

The primary reason for the establishment of the single-staff model was the expectation that higher patient and staff satisfaction and improved patient outcomes would result. However, it was also calculated that lost revenue and possible underutilization of expensive space would be at least partially offset by efficiencies in the system.

We completely eliminated after-hours patient service gaps and opportunities for medical mismanagement. Ambulatory patients had a single telephone number to call and could come directly to the BMT Unit any time of day or night to receive care from nursing and physician staff who were expert and known to them. No readmissions were required because of the unavailability of appropriate facilities or expertise. In the third quarter of operation, we received a patient satisfaction score of 97 percent for this unit, the best in the UAB hospital system.

Because of the single staff for both inpatient and outpatient care, we were able to discharge patients earlier. During the first year, our average length of stay was 29.2 days, 12 days below the national average. At the same time, physician efficiency was increased by consolidating patient care in one location with a single dedicated nursing staff that already knew the patients and were able to provide a higher level of care. This shortened length of stay resulted in UAB's being able to increase the potential annual number of transplants per bed from 7.5 to 11. This meant that, even with the loss of space to outpatient care, we were able to transplant approximately 77 cases per year, compared to 52 cases per year under the traditional model.

The cost savings resulting from the efficiencies of this model were substantial. By developing an outpatient billing system that could be accessed by the inpatient unit secretary, we were able to eliminate the need for an additional outpatient billing clerk and the generation of a separate outpatient bill. By providing outpatient care in one facility, we were able to provide outpatient assessments and therapies without duplication of nursing staff. This also eliminated the need for' any outpatient nurse evening and weekend on-call pay. Because of consolidation of preadmission, inpatient, and acute outpatient care into one facility that is managed by one staff, we have been able to increase the efficiency of social work, chaplaincy, and other support services and eliminate the lost time and costs associated with transferring medical records. These cost savings and the ability to more efficiently utilize the existing facility more than compensated for the revenue lost by taking one bed out of inpatient service and converting the space into an ambulatory clinic.

Other longer term advantages are anticipated. Excellent staff morale may result in lower staff turnover and a higher level of commitment. High patient satisfaction and good outcomes provide an opportunity to negotiate from a standpoint of strength with third-party payers and help to protect valuable referrals.

Summary and Conclusions

The reasons for developing a single-staff model of care were to:

* Improve the continuity of care.

* Improve patient outcomes.

* Improve the quality of life for patients.

* Improve staff satisfaction.

* Reduce the costs of care.

* Provide greater access by lowering costs.

All of our initial goals, except for success in negotiating simplified reimbursement arrangements with our major third-party carriers, were met. The single-staff model has been well, accepted by staff and administration, patients, and referring physicians. The model represents the kind of common-sense thinking that can improve patient services. Effective, implementation of this model shows that it is possible to develop care models that provide high patient satisfaction, high-quality clinical outcomes, staff satisfaction, and cost reductions.

The true test of a care model should not be how cheaply one can-buy each phase of care, but rather what is the total cost for a given patient outcome. Outcomes should be measured in terms of improvements quality of life related to dollars spent; patient satisfaction; and, of course, cure rate. The total cost should be calculated for the entire care episode (diagnosis through recovery) rather than for the largest component of service, hospital admission. Implementation of the single-staff model for episodes of care such as bone marrow transplantation or even for whole periods of illness could result in high-quality care and substantial cost reductions.

Kent Giles, MPPW, was Cancer Services Administrator, Comprehensive Cancer Center, University of Alabama at Birmingham, when this article was written. He is now Executive Director, Cancer Center at West Paces, Atlanta, Ga. Mary Nell Winslow, MSN, who was a Clinical Nurse Specialist and Nurse Manager for Bone Marrow Transplantation Clinical Services, is a Certified Nurse Practitioner at the University of Alabama Hospital, and William P. Vaughan, MD is Professor, Internal Medicine and Pharmacology; Associate Director for Clinical Research, Comprehensive Cancer Center; and Director, Bone Marrow Transplantation, University of Alabama at Birmingham.