Hospitals Are in the Business of Prevention | Healthcare of Tomorrow

Last year, Shelly Stroud of Charlotte, North Carolina, 61, was on her way to developing Type 2 diabetes, the disease that puts her father, brother and 29 million other Americans at higher risk of heart attack, stroke, blindness, amputation and kidney failure. « I was overweight – obese – and was considering weight-loss surgery, » she says. So when Carolinas HealthCare System offered a free diabetes risk assessment at her local YMCA and other places in the community, she was one of 53,000 area residents who jumped at the chance – and one of nearly 7,700 who got a big wake-up call.

Stroud found out that she was indeed prediabetic and immediately signed up for a 16-week course offered by Carolinas that included exercise at the Y, classes on healthy eating and lifestyle change, and coaching to help break entrenched habits. « This program helped save my life and changed my life, » says Stroud, who dropped 45 pounds by this past spring and lowered her blood sugar to normal levels.

Welcome to the future of hospital care, where the point, increasingly, is to prevent people from getting sick in the first place. « We’re moving quickly to a world where most care, and the ability to impact health, does not take place in the hospital, » says Roger Ray, chief physician executive at Carolinas HealthCare. Providers have long been paid based on the number of tests and procedures they perform, naturally driving an emphasis on critical rather than preventive care.

Now, as Medicare and other payers migrate to a « value » system in which providers get a set amount of money per person or per medical issue, for example, hospitals will lose money if they can’t keep the medical care to a minimum while still producing good outcomes. Earlier this year, federal health officials set the goal of making 30 percent of Medicare payments by the end of 2016 through alternatives to the fee-for-service model, rising to 50 percent by the end of 2018. Private insurers and state-based Medicaid programs also have embraced payment changes.

The result: Hospitals are rescripting their role in all sorts of ways to keep people out of their emergency rooms and beds. They are emphasizing primary care, putting mental health specialists out on the front lines to lessen the burden of unhealthful behaviors, and making house calls and using telemedicine to head off return visits. Some are even opening fitness centers. Hackensack University Medical Center in New Jersey, for example, teamed up with the New York Giants to open a fitness and wellness center that boasts state-of-the art exercise equipment, an indoor pool, 150 group classes, personal trainers, a track and turf field – and nurse-provided health assessments and weight management programs.

The Carolinas HealthCare diabetes program, which includes stationing nurses and dietitians at 15 Charlotte-area Y’s, is making real headway; the first year, for example, 40 percent of the folks wrestling with high blood sugar got it back into the normal range within 16 weeks. Similarly, Florida Hospital for Children in Orlando has seen engagement in its Healthy Kids 100 program pick up since it decided last year to team up with YMCA of Central Florida and move the program out of the hospital and into three Y’s.

« We wanted to improve outcomes, » says Angela Fals, medical director of the hospital’s pediatric weight management program, of the effort to educate families of children struggling with weight and help them make changed behaviors stick. « We needed a partner that was already child and family friendly. » The program languished when it was housed in the hospital; more than 2,000 families now take part.

Perhaps there is no better place to witness the impact of the changes taking place than the Morris H. Blum Senior Apartments in Annapolis, Maryland. « I used to look out my window, and constantly ambulances were coming, » says resident Brenda Williams, 60, who in recent years has been affected by arthritis, high blood pressure and « borderline diabetes. » That was before Anne Arundel Medical Center started a walking club at the 154-unit complex, opened a one-doctor clinic there and began offering six-week courses on managing diabetes, heart health and hypertension and other topics. Five mornings a week, Williams walks around the high-rise for 45 minutes in her red sneakers. « We’ve had some seniors with wheelers and canes, » says Williams, who has lost 28 pounds and no longer takes blood pressure medicine. If it were not for the interventions, she says, « I would probably be on insulin for diabetes, I’d still be on high blood pressure medicine, and I’d be obese and incapacitated. I believe prevention is the way to go. »

That philosophy is showing results for the medical center. Over a six-month period prior to the primary care-focused program’s launch, there were 175 ER visits from that single address. Less than two years after it was put in place, the number had fallen by half, says the center’s president and CEO Victoria Bayless.

For people who do need to spend time in the hospital, efforts are being stepped up to prevent a readmission – historically a big (and expensive) problem, particularly among older patients with chronic illnesses. Medicare now penalizes hospitals when too many patients are back inside within a month of discharge. The most recent statistics show three-quarters of hospitals nationwide getting dinged.

Like a growing number of institutions, OSF Healthcare System in Peoria, Illinois, is placing a big bet on better outreach and patient monitoring. The system, one of the country’s first accountable care organizations, sends medically complicated patients home with their own team of overseers – a doctor, home health care nurse, social worker and care manager – who make house calls as needed to ensure that any follow-up appointments are kept and that patients understand how to take their medications. In one instance, a team even worked with community organizations to get a leaky roof replaced, free of charge, so that a patient with chronic obstructive pulmonary disease could remain stable in her (mold-free) home. Medicare monitors accountable care organizations on more than 30 quality and performance measures; organizations meeting the marks can share any savings with Medicare. OSF has saved more than $500,000 in the first two years and seen high patient satisfaction.

Cleveland Clinic, too, boasts a Medical Care at Home program that sends doctors and nurse practitioners specializing in geriatrics and home-based care out to visit elderly patients who are frail and often have cognitive impairments. An earlier Heart Care at Home program, which relied on telemonitoring of heart failure patients’ vital signs after discharge, proved disappointing when it failed to reduce readmissions. But a couple of lessons were absorbed as that program was shut down.

First, intensive, hands-on care is needed for fragile patients transitioning home from the hospital. « Telemonitoring may not be the magic bullet, » in this situation, says Eiran Gorodeski, director of the clinic’s Center for Connected Care. And « plain vanilla home care » apparently is not sufficient either. Additionally, he says, cognitive impairment seems to be « a single, extraordinary, powerful predictor of readmission. »

In the new program, five doctors and three nurse practitioners travel around to provide both post-hospital care and primary care to frail elderly people. « This is not a moneymaker in the fee-for-service world, » says Gorodeski. But it has definitely reduced hospital and ER use.

Even before all the payment changes, the folks at Boston Children’s Hospital observed in 2005 that asthma was the top diagnosis landing kids in the 395-bed facility. That inspired the hospital’s Community Asthma Initiative, which sends health workers out three times, on average, to visit families of children who have recently been to the ER or hospitalized because of asthma; there’s also follow-up by phone six and 12 months after discharge. The health workers help parents manage asthma medications properly, provide home environmental assessments and suggest ways to alleviate triggers such as dust, mice or mold. Nearly 1,500 Boston-area kids have so far taken advantage.

« His asthma has been controlled, and we have not gone back to the hospital since, » says Frank Burgos of Roslindale, Massachusetts, whose son Esteban is one of those kids. Esteban was in the ER « twice a month for a year » before the family’s health worker provided allergen-reducing Hepa filters, special covers for beds and pillows and a medication box to keep all medicines in one place, and eventually helped the family make the move to a noncarpeted apartment.

« We’ve reduced asthma-related hospitalizations by 80 percent and have seen a 56 percent reduction in any [emergency department] visits » among kids in the program, notes Elizabeth Woods, director of the program, which is now being replicated by hospitals and communities nationally.

To identify people with brewing medical issues oso doctors can intervene early, some hospitals are harnessing big data in a big way. NorthShore University HealthSystem in Evanston, Illinois, for instance, is mining tens of billions of pieces of information on 2 million patients through its electronic medical records. One recent project: to scan for people at risk of undiagnosed hypertension, which can lead to heart disease, stroke, heart failure and kidney disease. When 1,600 at-risk patients from 23 primary care practices were identified, the team alerted doctors and worked with them to get the patients into the office and, when needed, on medicine. « This was about being proactive, » says Jonathan Silverstein, a system vice president and head of its Center for Biomedical Research Informatics.

Because untreated mental health problems play such a major role in causing and worsening physical ills, one growing trend is to integrate the two types of care, putting mental health services in primary care clinics, for example. Treating both mental and physical health ills together can save the nation up to $48 billion annually, according to Seattle-based consulting firm Milliman.

« In mental health, there is a lot of fragmented care, and it’s hard to access, » says Shella Dennery, director of Boston Children’s Hospital Neighborhood Partnerships. So 13 years ago the organization teamed up with Boston Public Schools to place hospital psychologists and social workers into underperforming schools in low-income neighborhoods to provide counseling, get ahead of developing behavioral issues, promote social and emotional learning, and train teachers to cope with and head off problem behavior.

It’s about « better care coordination and keeping kids out of the hospital, » says Dennery, as well as maximizing their shot at college and career readiness. « There are huge implications, » she notes, of not addressing such problems as early as possible.

At-risk patients coming into Carolinas Healthcare’s Charlotte-area emergency rooms get a telepsychiatry consult; some 500 patients a month are identified who need services, and Carolinas helps them access the right care. « We believe one of the critical areas to focus on, if you’re going to be successful in population health, is behavioral health, » notes Ray.

To that end, the system is also integrating remote mental health services into its 135 primary care practices, where some 600 to 700 people are screened a month. Most of the time, says Ray, those in need of help can be treated effectively right in their primary care doctor’s office; so far, 77 percent of people treated have seen their depression symptoms improve within 14 weeks.

Some health systems are going so far as to take on poverty, unemployment, and lack of education, food and housing – all of which clearly are central to health status. Toledo, Ohio-based ProMedica and its community partners, for example, have since 2011 helped to provide 28 million pounds of food to residents who are at risk of going hungry. In Delaware County, Pennsylvania, Crozer-Keystone Health System is attacking health threats by aiming resources at high poverty rates and substance abuse among teens, which a few years ago contributed to the state’s lowest graduation rates (44 percent). « Health is totally tied to education levels, » says Gwen Smith, Springfield Hospital president and the system’s vice president for community health services.

Crozer-Keystone sponsors an adolescent-focused primary care center, school-based health centers, middle and high school mentoring efforts, scholarship programs and community-based leadership programs, teaming up with Swarthmore College and other partners. The health system hires some 40 students each summer for positions in the pharmacy, the operating room, in marketing and in other areas. These efforts have been credited with helping reduce youth violence and risky sexual behavior and with helping improve school attendance and on-time graduation rates, which now run in the high 70 percent range, says Smith.

Cleveland’s University Hospitals System has committed to « lifting the health of our community » by concentrating on ways to elevate its wealth and economic stability, says Heidi Gartland, the system’s vice president of government and community relations. Now Northeast Ohio’s second largest employer, with an annual economic output of nearly $5 billion, the system undertook a $1 billion-plus, five-year expansion a decade ago with a « buy local, hire local, live local » mantra; 90 percent of procurement dollars and 20 percent of jobs went to local vendors and workers.

« It has become the way we do business, » says Gartland. UH invests in workforce development programs that train unemployed local workers for careers as medical assistants and pharmacy technicians and include soft skills training. The system also provides new hires from the neighborhood with job coaches for their first six months, offers low-cost housing loans, invests in local after-school programs, sponsors healthy eating initiatives and is building a community center for women and children. As time has passed, more of the population has obtained health insurance, and the infant mortality rate in the area is dropping.

Excerpted from U.S. News’ « Best Hospitals 2016, » the definitive consumer guidebook to U.S. hospitals. Order your copy now.