Service Lines: Getting It Straight Under Reform

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 - Service Lines
From left, Congestive Heart Active Management Program nurses Sharon Alfaro, RN, BSN, and Laura Uro, RN, BSN, consult about the program, which is offered through the Mercy Heart & Vascular Institute in Sacramento, Calif.

Designed correctly, cardiovascular service lines help hospitals and physicians maximize efficiencies, lower costs, improve outcomes and grow market share. But with the shadow of healthcare reform growing larger by the minute, some champions also are calling these structures into service to help them maximize their potential as they transition to more patient-centered models of care.

Meeting the challenge

Peter L. Duffy, MD, director of quality at the Reid Heart Center at FirstHealth of the Carolinas, likens hospitals to repair shops. Patients arrive sick, they are treated and then sent home better. When his own repair shop received a multimillion dollar gift to seed a state-of-the art heart center in Pinehurst, N.C., he and his colleagues knew they had an opportunity to build a spectacular facility and simultaneously improve the quality of care and hospital dynamics. “We recognized that if we built the facility for $85 million and the patient walking out the door of that facility was no better off than the patient walking out the door of a facility that we hadn’t built, we would have failed,” he says. 

To ensure better patient satisfaction and outcomes, he and his colleagues formed a team of nursing, administrative, management and physician personnel to knock down silos and begin sharing insights on ways to fulfill the mission of improving care. The process evolved into a cardiovascular service line with three goals: to increase quality, maximize market share and lower costs. The latter is key, he emphasizes, because under healthcare reform, reimbursement will only be going down.

At the same time, their new repair shop—a five-story facility with six operating rooms, five cath labs, two electrophysiology suites and two hybrid operating rooms—opened in early 2012, bringing with it not only the excitement of a beautiful building but also its overhead. “That was the catalyst,” he says. “We needed to create the service line to increase volume by increasing market presence, as well as the type and array of services we provide. We can’t increase reimbursement—no one will pay us more because we have a nice building—so we had to cut costs.” 

They devoted a year and a half to developing the service line structure, which includes seven physician directors, administrators, a chief medical officer and a cardiothoracic surgeon, and now focus on meeting their key goals to ensure the best care possible for their patients.

Prudence & patience

It is prudent for any hospital that provides cardiac care to develop a service line, says Jerome L. Hines, MD, PhD, chair of the American College of Cardiology’s (ACC) Council on Clinical Practice and co-author of an ACC white paper on cardiovascular service lines. Hospitals may tap into their own resources, as Reid Heart Center did, to develop new service lines, or look externally at partnerships to boost the effectiveness of existing service lines. The increasing number of private cardiovascular practices integrating with hospitals provides one option by allowing these physicians to co-manage the hospital’s service line.

Hines knows first-hand the benefits and challenges of that opportunity. As president of Illinois Heart and Vascular in suburban Chicago, he and his colleagues at the cardiology practice joined Adventist Hinsdale and Adventist La Grange Memorial Hospitals and Adventist Health Partners in 2010 to form the Adventist Heart and Vascular Institute. A private practice with 27 physicians and 80 to 90 employees, Illinois Heart and Vascular had an efficient service line with an EHR that ensured high-quality data. In the 18 months prior to integration, they glimpsed some of the challenges before them, including a less efficient service line and data that were lacking or sometime even erroneous.

 

MedAxoim
Who is in charge? Who manages the cardiovascular service line? MedAxoim asked that question at a 2012 conference attended by more than 200 cardiologists and cardiovascular executives.
 - Who is in charge?

 

“All of a sudden their data become your data,” Hines says about integration. The physicians realized that they needed to apply their skills and standards to the hospital service line to ensure that the quality level they had achieved wasn’t compromised.

Now, nearly three years past integration, Illinois Heart and Vascular physicians have succeeded in instilling their principles in the hospital system’s service line. They transferred some personnel with data expertise to the hospital, realigned staff and, with the hospital, shared in investments to improve efficiencies. With the growing emphasis on EHRs and the use of data to measure and report quality and patient outcomes, these steps have helped to raise the hospital’s public profile.

The service line has “improved remarkably,” Hines says. “I am not sure we have gotten efficiencies up to where we were as a private practice, but we are getting there.”

Being reformed

Service lines also may be due for a review when circumstances change. That was the case for Mercy Heart & Vascular Institute of Greater Sacramento, which collaborated with a six-hospital service area in California until 2011, when an expansion broadened the group. Mercy, a virtual service line structure, used a hub-and-spoke approach to coordinate care and facilitate a smooth transition of care to ensure patients and physicians easy access to services. With the addition of two more hospitals to the service area, one of which is a full-service cardiac hospital, service line leaders are re-evaluating the structure to meet the challenges of healthcare reform and maximize opportunities.

“Historically, many service lines have been focused on inpatient care: How do we get patients into the hospital, build our market share and volumes, and do that cost effectively,” says Doris G. Frazier, RN, MS, vice president of cardiovascular services at Mercy and a board member of the American College of Cardiovascular Administrators. “As we look forward with healthcare reform, especially with ACOs [Accountable Care Organizations] and readmissions penalties, it makes us look at our business in a different way.”

Duffy, Hines and Frazier agree that bringing administrators and physicians together in a meaningful partnership is the first step to building, rebuilding or tweaking a successful service line. In some circumstances, reform may provide an impetus, Duffy says, but for it to achieve the highest level of quality, all stakeholders must be aligned in a structure that is clear in its goals and committed in its efforts.

Hospitals already wrestle with aspects of reform, including Medicare’s penalties for preventable heart failure and MI readmissions. Mercy’s service line is expected to play a role in reducing readmissions through programs such as its Congestive Heart Active Management Program (CHAMP). The system-wide outpatient telemanagement program uses algorithms with standardized order sets and a defined protocol that allows nurses to titrate medications. CHAMP nurses are located in a centralized office and travel to the hospitals to participate in readmissions task forces.

Using heart failure patients as their own control, the program’s analysts calculated a post-CHAMP reduction of 80 percent in readmissions compared with pre-CHAMP enrollment. In 18 months, CHAMP enrollment climbed 300 percent.

“When you look at service lines, you have the clinical, marketing, finance and resource utilization pieces,” Frazier says. “But if you start with quality patient care, you will start to drive the best practices in the others as well. CHAMP is an example of that.”

Patients are the main beneficiaries of a well-run service line, Duffy claims, followed by the system and then employees. “We come to work every morning to do a good job for the patients,” he says. “The service line will give us a better vehicle for doing that.”