Omaha, NE-based Alegent Health, with nine hospitals and 1,832 licensed beds, decided to blow up and reassemble its entire care team because it couldn't imagine getting to its quality goals any other way, says President and CEO Wayne Sensor.
"Our traditional care models that are endemic in this industry will not serve the needs, in our view, of really high-quality, low-cost healthcare," Sensor says. "From our vantage point, there is a self-induced mandate that if we are really going to improve quality, you have to rethink the care model."
The largest shift was understanding that to change the continuum required a new leadership structure or "triad" that begins at the system level but is replicated downward in the organization, says Fred Hosler, MD, Alegent's system executive vice president. The triad (based on the concepts of the accountable care organization) is made up of leaders from the physician, nursing, and administrative sides, with all three working together to decide systems of care based on evidence-based protocols.
"It is a significant cultural change to view ourselves not as a hospital-centric system but as an ambulatory-centric full continuum of care—which by the way includes hospitals," Hosler says.
The system leadership triad reports to Hosler and includes a system chief medical officer whose role includes the hospital, the voluntary medical staff organization, as well as the employed Alegent Health Clinic. A system chief operating officer and chief nursing officer complete the triad.
So how does the structure result in a more coordinated care team?
Hosler cites the typical example of congestive heart failure. "Why is the readmission rate so high for CHF? It really is not a mystery. The fact is that in most traditional settings, patients are discharged from the hospital because that is where their episode ends. And they may go home and are left to their own devices. They may follow up with their primary care physician or they may not."
In Alegent's case, the system chief medical officer—who has an eye on the inpatient and ambulatory physician staff as well as the care management structure—can link the care functions to ensure follow-up through an advanced medical home model.
Thinking about the care team structure from a patient's needs forced Alegent to reexamine key service lines, like cardiovascular, Sensor says.
"Patients need great diagnostic cardiology dispersed so it is convenient and quick. They need emergency rooms that are chest pain certified. There is a demonstrated correlation between your volume of cardiovascular surgery and your outcomes, so instead of operating two cardiovascular programs under the umbrella of Alegent we consolidated into one."
Neither the patient nor the care team now view a hospitalization as an end, but merely as a place along a continuum of care.
"There is a continuation of an ambulatory episode that might lead to a hospitalization," Hosler says. "And if there is a hospitalization, there is a continuation that occurs in the ambulatory environment. That requires connecting of caregivers which heretofore don't typically work together."