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Dec. 13, 2010
KANSAS CITY When federal officials came to Kansas City recently to talk about their desire to promote innovations in health care, they found a hospital on each side of the state line already blazing trails.
Drs. Donald Berwick and Rick Gilfillan of the federal Centers for Medicare and Medicaid Services spoke to an audience of about 150 health care leaders from four states, urging them to bring forward ideas for improving patient care and cutting costs.
The new federal health reform law includes billions of dollars for grants over the next 10 years intended to spark medical innovation. Berwick and Gilfillan were here to talk about that.
But each man also took time to tour a Kansas City hospital.
Berwick, the top CMS administrator, went to the University of Kansas Hospital in Kansas City, Kan., where he learned about the rapid response teams that have significantly reduced the number of patient deaths since they were launched about five years ago.
Gilfillan, head of the new CMS Center for Innovation, went to Truman Medical Center, in Kansas City, Mo., where he learned about groundbreaking programs for managing chronic illness at the hospital that is KC's leading medical safety net.
Anyone interested in the sorts of innovations that would excite federal grant administrators need only look to Truman or the KU Hospital, the CMS officials said.
"Truman's been working on chronic care for more than 20 years," Dr. Shauna Roberts, Truman's medical director, told KHI News Service. "We pulled together a lot of different pieces and parts and reviewed over 300 articles to capture what others around the world had done and found successful in chronic-disease management."
The result is that Truman has a number of programs that pair well-rounded medical teams with patients most likely to be what Truman Chief Executive John Bluford refers to as "frequent flyers," people whose conditions would otherwise make them susceptible to regular emergency room visits or hospital readmissions.
Roberts said most the patients matched with the hospital's special care teams have multiple chronic conditions, but diabetes is generally the primary or secondary problem for them.
Teams, or "cadres" as Bluford has called them, typically include a doctor, nurse or nurse practitioner, perhaps also a pharmacist, respiratory or other type of therapist and a social worker, patient advocate, translator or "navigator," to help the patient schedule and keep appointments and otherwise deal with what can be a dauntingly, complex medical system and especially so for someone gravely ill with little or no money and perhaps no English.
"We personalize the service delivery," said Bluford, who is slated to become chairman of the trustees of the American Hospital Association in January.
Essentially, the teams are intended to provide or be a conduit to whatever services might be required to keep the patient an informed and active participant in their own health care. That can be a complex task. Sometimes the patient is homeless, has mental illness and a variety of other health and social problems.
"Our primary goal is to develop a trust relationship with the patient. That's number one," Roberts said. "
The multi-disciplinary team approach relies "very much on the human touch," she said. "But once we see the trust relationship built, we see a big drop in emergency department visits and readmissions and improvements in the markers we're looking for in the quality of care.
"It's not really fancy," Roberts said. "It's connecting one human to another. But that face-to-face part has been an absolutely critical part of building the trust relationship."
Humanizing hospital care so that the patient knows someone cares about them allows more focus on preventing medical crises and keeping the patient well. That may not be "fancy," but it is a lot of hard work, Roberts said.
Keeping a team and patient connected requires a type of focus that is generally missing in the U.S. health care system, which Roberts said, "is good at responding to episodic emergencies but not good at focusing on a continuum of care over time with real, good, clear communication. Health care is not built for that yet."
Patients always know someone from the team is available if they need help. A call to or from a team member means a patient is more likely to find it through normal or routine channels at the hospital instead of showing up unnecessarily at the emergency department, which at Truman is a very busy place regardless.
Truman is the hospital for the city's core and its patients are disproportionately black or Hispanic and low-income. Most patients are eligible either for Medicaid, Medicare or both, though Bluford said the hospital also has seen dramatic increase in the numbers of privately insured patients in tandem with the upscale redevelopment that is occurring in various inner Kansas City neighborhoods.
Coupled with the intensive chronic care management have been various other "culture" changes at Truman designed to emphasize the quality of the hospital experience for patients, their families and hospital staff.
Art on the walls
The hospital's decor isn't what you might expect of an inner-city hospital that serves the poor. The walls of many hallways are lined with original works of art. The lighting is indirect on many wards, which eliminates the harsh, institutional glare found in some facilities.
On one floor of the hospital, patients can order their meals a la carte from the hospital's Blossom Cafe and get it within minutes, whenever they feel like eating it.
During the warm months, the hospital co-sponsors a farmers' market on its campus, which helps bring nutritious food to inner-city residents who otherwise might not have easy access to quality, fresh produce.
The diabetes care center resembles a community center and among other things has a large classroom in which patients are taught how to cope with their illness.
Once a month, members of the hospital's various care teams meet and share ideas, which means things that work in one area of care can be adopted or adapted in other areas.
Truman is the teaching hospital for the University of Missouri-Kansas City School of Medicine. The school, since its creation about 40 years ago, has focused on the team medicine approach Roberts said.
Passport to Wellness
Truman uses its team approach to treat sickle cell anemia, heart disease, asthma, HIV, diabetes and other conditions.
The two most recent team programs are called Passport to Wellness and Guided Chronic Care, each of which builds on Truman's earlier efforts. The latter is being done jointly with the medical school, which is evaluating data from the team-care programs to precisely measure what works and what doesn't for potential replication throughout the hospital. It is funded primarily with a grant from the Health Care Foundation of Greater Kansas City.
Passport to Wellness and Guided Chronic Care extend patient care beyond direct health issues so that team members become more aware of the various factors in a patient's life that have bearing on well-being.
"I think everyone who studies these issues understands that health care delivery in the U.S. is very chaotic and that social factors often get in the way of desirable medical outcomes," said Dr. Bill Lafferty of the UMKC School of Medicine. "This program is designed to help patients deal with social factors that might be sabotaging their medical care. "I think its our goal to build something that could work in almost any setting."
Across town at the University of Kansas Hospital, CMS Administrator Berwick was interested in the the rapid response teams that have reduced patient deaths dramatically since they were first introduced six years ago.
The team or squads are on call and ready to go whenever they are alerted by anyone - staff worker or visiting family member - that a patient is displaying symptoms that indicate the person's life is imperiled or soon could be.
Code Blue in a hospital typically means a patient is in cardiac arrest or needs resuscitation. But at KU Hospital, the goal is to detect and respond to the problem before Code Blue is sounded.
The teams include a doctor, intensive care nurse and respiratory therapist. Crucial to making the teams effective has been empowering virtually anyone at the hospital with the ability to summon a team, said Chris Ruder, vice president of patient care services.
"We believe caregivers have pretty good gut feelings about things," Ruder said, "or if a family member says something isn't right or patient says something isn't right, that can be a trigger for a rapid-response team. Anyone can call. That results in a quick assessment at bedside and if necessary, the bringing of additional resources to the patient. Often, nothing is wrong. But that's OK, we've heightened awareness around this patient."
The process bypasses the bureaucracy that in other hospitals can mean additional resources don't show up until a nurse clears it with a doctor, etc. The teams respond anywhere on the hospital campus and sometimes have rescued hospital staff workers or visitors in health emergencies.
"It is 911 within the hospital," Ruder said. "Historically, 911 has always meant the Code Blue team. This is the same level of urgency," but without waiting for a Code Blue.
Ruder said the teams respond within 30 seconds of a call. There are back-up teams for instances when the first team or second teams are already in action and another call for help is raised.
The results have been dramatic and demonstrable.
"We have tracked the data from every patient in this since day one," Ruder said. "In studying data, our goal is to always improve. Over the six years, we've made a number of changes to the rapid response teams."
At first, family members weren't allowed to call for a team for fear they would summon help at the slightest concern. But that quickly changed.
"We've had no abuse of that," Ruder said. "people are very good about using it well. What it does is empower the family and patient to say we need help."
Hospitals employ what is called a mortality index, which assesses a patient's likelihood of dying. A high index score means more patients died than expected given their conditions and medical histories.
KU Hospital has seen dramatic improvement in its score since implementing the program.
Last year, that meant 296 fewer people died than expected at the hospital. Over the six year life of the program enough lives have been saved to populate a small Kansas town.
"When you start quantifying it and putting it in the context of lives," Ruder said, "that's 296 people who left our hospital who weren't expected to leave alive. Those were somebody's brothers, sisters, mothers, fathers, grandparents."
Along with the response teams, the hospital has focused on training staff to recognize conditions such as sepsis or blood poisoning that otherwise might go undetected until too late.