Making More Room at the Inn
Our hospitals in both Gainesville and Jacksonville are full. This is a good problem to have, but it is a problem. And as we figure out a way to accommodate continued growth within a fixed hospital chassis, we must do so in a way that further enhances the quality of care we provide. Needless to say, caring for more and more patients in an already crowded hospital and achieving high and improving patient satisfaction at the same time will be a challenge.
We must be up to the challenge. In this edition of On the Same Page, I will describe several innovative programs that are making an impact. Our two campuses are quite different; thus, tailored solutions have been developed.
In Gainesville, as a tribute to the efforts of faculty and staff in partnership with UF Health Shands, visits to faculty practices have grown substantially, as can be shown in Figure 1. The inflection point in 2012 occurred after the opening of UF Health Springhill, our multispecialty faculty practice outpatient facility, but an underlying upward secular trend is clear. In parallel, hospital admissions have also shown consistent growth, as shown in Figure 2 — a compounded annual growth rate of 6 percent. In a balanced, proportionate manner, patients came to see us in increasing numbers from in and around Alachua County, but also from around the state.
At the hospital, all this growth is stretching our capacity to its limits. Shown in Figure 3 is a bar graph of the range of occupied beds on a weekly basis over the past two years, where the top and bottom of each bar represents the high and low bed census reached during the week; the midpoint for the week is shown by a closed circle. The horizontal corridor shown in orange, which ranges from 535 beds to 555 adult beds, is the census level for our hospital where the system becomes constrained.
A major reason our hospital board made the decision to build two new hospital towers is to ensure that all of our patients — those in the new hospitals and those in the existing hospitals — will receive the best possible care in spaces that are tailored for their needs and right-sized for the volume of clinical activity. When we move into these new hospitals in three years, not only will these goals be achieved in the new facilities, but space in the North tower also will be vacated, semiprivate rooms will be converted to private rooms and clinical services will be consolidated in a geocentric manner. But what do we do between now and then? Increasing numbers of patients will continue to seek our services. We can’t turn them away and say “come back in three years.” Rather, we need to re-engineer some of our clinical processes and make the most of our existing facilities to accommodate continued growth.
A major focus in the clinical part of The Power of Together strategic plan is the development of methods to reduce length of stay and reduce readmissions. If we are successful, we will indeed be able to serve more patients with the same number of beds and improving care at the same time. While there is a long list of ideas, three initiatives are now being implemented — and with considerable success: Care One Clinic, Discharge Before Noon, and Reducing COPD Readmissions. Here is a snapshot of each of these programs:
Care One Clinic
A recent analysis by the Agency for Healthcare Research and Quality showed that the sickest 5 percent of U.S. patients account for over half of the nation’s health care utilization. In 2012, about 6 percent of patients at UF Health Shands Hospital accounted for 23 percent of emergency room visits and 20 percent of hospitalizations.
To do a better job in serving these “high utilizers,” Bob Leverence, M.D., a professor of medicine, and his colleagues assembled a multidisciplinary team in the fall of 2012 and opened the Care One Clinic. Composed of a social worker (Jacqui Pinkney), nurses (Robin Rocks/Pilar Doyle), a pharmacist (Joy Wright), a clinical psychologist (Lori Waxenberg Ph.D.), an addiction medicine specialist (Robert Rout, M.D.) and primary care doctors (Deepa Borde, M.D.; Susan Nayfield, M.D.; Sharon Gavin, M.D.), this clinic provides in one setting all the resources our sickest patients needed. The Care One Clinic strives to address, as effectively as we can, the triangle of chronic disease, poverty and mental illness/addiction that most commonly drives high hospital utilization.
As a result of the Care One Clinic, these patients have reduced their E.R. usage by 27 percent and hospital admissions by 37 percent. We consider this a win-win, for not only do these patients receive better care and avoid repeat visits to the E.R., but now more bed capacity in our hospital is available for other patients. The Care One concept has worked so well that services are being expanded within the clinic and the model is also being exported to surrounding UF Health clinics.
Discharge Before Noon
Orchestrating the hospital’s 120 combined admissions and discharges each day is a delicate balancing act. Successful orchestration, which means prompt discharges for patients ready to go home, frees up beds and reduces the amount of time an admitted patient waits in the E.R. Poor orchestration results in unhappy patients who become backed up in the E.R.
Recently, we created a system aimed at increasing the number of patients discharged before noon. Given the multifaceted nature of this task, nearly every hospital department has become involved. We started by standardizing an old concept — “discharge planning starts at admission.” Specifically, under the leadership of Bob Leverence, M.D., and the Internal Medicine residency program, the literature on early discharges was reviewed and the best available evidence was used to benchmark a needs assessment on the Medicine units and services. Afternoon multidisciplinary afternoon rounds were then implemented, which identified patients who should be discharged the next day. Incorporating a checklist of duties, along with sending weekly reports to all nursing unit managers and service chiefs, has resulted in a substantial improvement: discharges before noon have risen from 11 percent to 25 percent. An additional important benefit of this initiative is that discharge education and preparation now occurs on the day before discharge. Dr. Leverence and his team are in the process of refining the method and then plan to disseminate the initiative to the rest of the hospital.
Reducing COPD Readmissions
Chronic Obstructive Pulmonary Disease, or COPD, is a progressive and debilitating lung disease that causes shortness of breath. Most COPD patients have between one and four exacerbations a year. If not identified and managed early, an exacerbation often leads to E.R. visits and hospitalization. Moreover, post-hospitalization, in the absence of coordinated follow-up after discharge from the hospital, readmission often occurs. In fact, about 20 percent of patients hospitalized with COPD were re-admitted within 30 days.
In early 2014, a multidisciplinary team was assembled to review the COPD readmission rates at UF Health Shands Hospital, including UF Master of Health Administration students. At the recommendation of the team, designated respiratory therapists received training and certification as COPD educators through the American Association of Respiratory Care. In October 2014, a pilot for COPD patient education was initiated. Components of the program include:
- Upon admission, COPD educators conduct an initial visit to assess patient condition, medication requirements, frequency of therapy required and social needs that may impact a patient’s ability to manage COPD.
- During subsequent visits, education is provided to patients regarding the status of their medical condition, their medication use and proper administration techniques, the importance of smoking cessation if applicable, how to identify the early signs of an exacerbation, and appropriate outpatient interventions.
- Medication recommendations are developed using the Global Initiative for Obstructive Lung Disease guidelines to ensure the appropriate maintenance and rescue medications are prescribed prior to discharge.
- COPD educators conduct a pre-discharge evaluation with the patient’s care team to develop a care plan addressing therapeutic interventions, social needs and home care requirements.
- Following hospitalization, the COPD educators contact the patients at three, seven and 30 days post-discharge. This communication allows for reinforcing education, compliance with the care plan and early detection of declining respiratory status, allowing the care team to intervene before hospitalization is required.
Initial results have shown great promise. During November 2014, the very first month after the program was initiated, patients in the program pilot had a 6.7 percent readmission rate within 30 days, compared with 19.3 percent for all COPD patients. We will continue to evaluate the results as they accumulate, while incrementally expanding the program.
Currently, UF Health Jacksonville, our downtown hospital, remains very busy, but for different reasons than UF Health Shands Hospital in Gainesville. UF Health Jacksonville serves as the principal safety net hospital in the community, with large numbers of uninsured and underinsured patients gaining access to health care through our emergency room. Such individuals, with limited access to primary care, have more acute illness by the time they present at the E.R. and often require admissions. Thus, it is not unusual for 10 to 20 patients to be admitted to the hospital, but to be waiting in the E.R. for admission because of a lack of open beds.
UF Health Jacksonville has had only a modest growth in volume, but this growth atop temporary closures of some hospital units for remodeling as modern private rooms too often pushes past a “tipping point” of available beds. This bed shortage will only become more critical as the new UF Health North campus opens, with perhaps six to 10 new admissions per day.
To improve our ability to address the needs of our patients in Jacksonville who require inpatient admission, the following programs are underway:
Expansion of Beds:
- Opened 28 additional beds in the adjacent “Pavilion” hospital facility for lower-acuity patients
- 17 newly renovated ICU beds will open in March
Expedited Discharge and Change of Rounding Protocols:
- Twice-daily bed control meeting (includes Nursing, Hospitalists, Environmental Services, PT and Radiology)
- Early identification of possible discharges and barriers to their discharge
- Potential discharges are seen first, with the goal of discharging before noon, as in Gainesville
Reengineering of Case Management
- A Case Management team dedicated to discharge from the hospitalist service
- An RN/Case Management Daily Huddle will begin shortly
Total Care Clinic
- This patient-centered medical home has ambulatory services tailored to patients who qualify under a capitated city contract. Successful outpatient management of these patients reduces their use of the emergency room and inpatient care.
- The TCC provides transitional care appointments after hospital discharge and better access to primary care for city contract patients, including drop-in appointments.
A Strategic Imperative
Last week, at a group meeting of senior hospital and Health Science Center leadership, I asked each individual to identify the single most important strategic imperative facing them in 2015. Totally independent of my writing this newsletter, when it came time for Ed Jimenez, interim CEO of UF Health Shands Hospital, to speak, he unhesitatingly stated that “accommodating growth” was his most important objective. Similarly, Russ Armistead, CEO of UF Health Jacksonville, believes that accommodating growth on 8th Street while successfully launching UF Health North is his key strategic imperative.
As stated in the introduction, the fact that there is “no more room at the inn” is a good problem to have, but it is a problem. Caring for more and more patients in already crowded hospitals, while achieving high and improving patient satisfaction at the same time, is our challenge. We must be up to this challenge to achieve our clinical and academic missions.
David S. Guzick, M.D., Ph.D.
Senior Vice President, Health Affairs
President, UF Health