By Ted Kloth, MD, FACEP

The time is coming when consolidation and transparency will reign supreme, and the effects are already being felt throughout the healthcare arena.

Looking at the healthcare landscape and how the major players are reacting to the effects of reform, it is obvious to me that the need to consolidate is becoming a reality for many physician groups and service providers. Health systems are merging with larger health systems and clinical outsourcing groups are entering into joint ventures with their long-time clients to provide care at a lower cost. The rationale behind this shift is the belief that integrated systems reduce costs and increase profits for all parties involved. And with fewer reimbursement dollars at play, it seems most are looking for ways to increase profit margins by doing more for less.

By Scott Lopata, MD

So, I’m sitting in a restaurant overlooking our local Arizona ice rink (yes, we do have an active hockey establishment in the desert) and watching my son skating round and round at a school event. As I’m watching him, it occurs to me that the circular nature of the ice rink is a good parallel to the Acute Care Continuum. Lately, I’ve wondered about the growing importance of inpatients understanding their discharge instructions and medication side effects; or how and why we need to be concerned and anticipatory in regards to the prevention of readmissions. 

The concept of the Acute Care Continuum can often be overwhelming. By dictionary definition, a continuum is “a continuous extent, series, or whole.” I read it as patient-centered care at every point in the healthcare process. As an individual healthcare provider, at times I have difficulty imagining how I can singularly make a difference in the entire continuum of care. As an emergency physician who manages just one instance of care, it seems even less likely that I can change a patient’s path – helping him or her avoid the rut in the ice and steering smoothly through the process.

By Josh Sheridan, MD, MS

The hospital system I work for has an ED and two Urgent Care Centers (UCCs) in the same city. Between the two UCCs, we serve all payer populations so that everyone in the community can access urgent care services when needed. In this way, we try to be highly available for everyone who needs immediate care. At the same time, we have also made the decision to have limited testing facilities in the urgent cares and to focus them on particular patient populations. While our UCC set up is not the standard, the results have been beneficial for both patients and the hospital.

Our first UCC is referred to as the Community Clinic. It is located in a very accessible area and provides care predominantly to underserved patients who have no insurance and who are at risk for slipping through the cracks. This center is staffed by mid-level providers and is subsidized by the hospital system so that it can treat all comers regardless of whether they can pay for services. At times, patients use the community clinic for primary care services, and while the UCC is not an ideal supplier of primary care medicine, it does provide important preventative services. Patients will also occasionally receive follow-up care after hospitalizations if needed. The goal here is that patients released from the hospital are hopefully less likely to return to the ED. Just as Steven Larsen, MD describes at his UCC, even in cases where the UCC receives no payment, the hospital system as a whole can experience a net financial gain. We see a financial gain here in two ways: the UCC services are significantly less expensive to the hospital than equivalent care provided in the ED, so treating patients in the UCC reduces financial losses to the hospital. Secondly, our hospital readmission rate is going down and thus our hospital system is avoiding penalties for readmission imposed by Medicare.

Back in the old days medicine was practiced through home visits.  In the early 20^th century, as healthcare became institutionalized and medical insurance replaced ‘pay-as-you-go’, home visits became a thing of the past. Today there are a multitude of factors that are giving the practice of home visits a second look, and I think this is a positive development.

Rapid advances in mobile technology open the door to health records and devices that previously could not have been accessed in a home such as blood tests, monitors, collaborating with digital photos, and even x-rays. For patients who are in-between needing the services of a SNF yet need care and have a difficult time getting to the provider, a home visit can be much more effective than a phone call.

The patient navigator shows how a small scale change and modest expenditure could quickly yield improvements in ED resource utilization while at the same time providing much needed support to patients. This could be a “win win” for patients, hospitals and ED staff.

Patient navigator programs, an example of which is currently in use at Sutter Health emergency departments in Sacramento, attempt to broaden the help given to ED patients. The program at Sutter General and Sutter Memorial Hospitals is still very new, with the pilot phase just completed in the fall of 2011.  It places patient navigators, usually trained social workers, in the ED.  Their job is to assist patients who do not have access to follow-up care.