e g iona liza tion Re inve nting r R ic a rdo Ma rtine z, MD Bre - - PowerPoint PPT Presentation

Re inve nting r e g iona liza tion

Bre nda n G. Ca rr, MD MS

University of Pennsylvania

R ic a rdo Ma rtine z, MD

E mor y Unive r sity

• Carr

– Federal research funding

• AHRQ, NICHD, CDC, NINDS

– Foundation research funding

• NRCPR/GWTG

– ASPR Policy Research Fellow

• IPA in process
• Martinez

– Former President, Schumacher Group Division East – Chairman, Medical Sports Group

Disc lo sure s

• the organization of a system for the

delivery of health care within a region to avoid costly duplication of services and to ensure availability of essential services.

– Mosby’s medical dictionary

What is regionalization?

What is regionalization?

• The purpose of regionalization is to

concentrate limited or expensive health care services locally within an area while dispersing primary and secondary care more broadly.

• The Parkland plan

What is regionalization?

• A method of providing high-quality, cost-

efficient health care to the largest number

• f patients, by sharing information,

avoiding duplication of services, improving resource allocation, and capitalizing on economies of scale.

Overview

• The Trauma System
• Volume & Outcome
• Time & Outcome
• The Emergency Care “System”
• Taking it to scale
• Reinventing regionalization
• Where are we now?

Accidental Death & Disability

• “The patient must be transported to the

emergency department best prepared for his particular problem…Hospital emergency departments should be surveyed…to determine the numbers and types of emergency facilities necessary to provide

• ptimal emergency treatment for the
• ccupants of each region….”

I OM – 1966

System - A complex unit formed of many often diverse parts subject to a common plan or serving a common purpose

T ra uma Ca re – A Syste m

The Rule Book(s)

The Trauma Model – Inventory

Access to trauma care

The Trauma Model - Outcomes

Overview

• The Trauma System
• Volume & Outcome
• Time & Outcome
• The Emergency Care “System”
• Taking it to scale
• Reinventing regionalization
• Where are we now?

Regionalization of Surgical Care

• 12 surg ic a l pro c e dure s

CABG, AAA, T

URP, e tc .

• 1500 ho spita ls

Proc e dure s Mortality =

The Volume-Outcome Relationship

Regionalized Elective Care

• CABG (public reporting)
• Neonatal ICU (high risk pregnancy)
• Cardiac Care Center
• Cancer Centers
• Vascular Surgery (Leapfrog Group)
• ICU care (Leapfrog Group)

Overview

• The Trauma System
• Volume & Outcome
• Time & Outcome
• The Emergency Care “System”
• Taking it to scale
• Reinventing regionalization
• Where are we now?

STEMI

Sepsis

Volume T ime

Overview

• The Trauma System
• Volume & Outcome
• Time & Outcome
• The Emergency Care “System”
• Taking it to scale
• Reinventing regionalization
• Where are we now?

ACEP Report Card

Future of Emergency Care

• …e sta blish a (ne w) le a d a g e nc y fo r

e me rg e nc y a nd tra uma c a re

• …prima ry pro g ra mmatic re spo nsibility fo r

the full c o ntinuum o f e me rg e nc y me dic al se rvic e s a nd e me rg e nc y a nd tra uma c a re fo r a dults a nd c hildre n

• …inc luding me dic al 9-1-1 a nd e me rg e nc y

me dic al dispa tc h, pre ho spita l E MS, a nd ho spital b a se d e me rg e nc y a nd tra uma

• …de ve lo p e vide nc e -b ase d c a te g o rizatio n

syste ms fo r E MS, e me rg e nc y de pa rtme nts, a nd tra uma c e nte rs b a se d o n … c a pa b ilitie s

• …e sta blish a de mo nstratio n pro g ra m … to

pro mo te c o o rdinate d, re g io na lize d, a nd a c c o untab le e me rg e nc y c a re syste ms…

Future of Emergency Care

IOM Recommendation: Regionalize emergency care

Institute of Medicine

Regionalizing Emergency Care Systems Sept.10-11, 2009

What is an Emergency Department?

Emergency Care - Inventory

E me rg e nc y me dic ine o rg a niza tio ns sho uld “ re vise the c la ssific a tio n o f e me rg e nc y de pa rtme nts . . . to re fle c t the le ve l o f c a re a va ila b le …a nd indic a te whe the r o r no t fa c ilitie s a re a de q ua te …24 ho urs a da y.’ ’ June 1999

Emergency Care - Categorization

C amar g o e t al, A c ad EM 2007

Pennsylvania & Wisconsin Emergency Departments

249/ 301 EDs (82.7% r e spo nse r ate )

Disease based regionalization?

Disease based regionalization?

Disease based regionalization?

The Emergency care “system”?

Overview

• EM in perspective
• Volume & Outcome
• Time & Outcome
• The Emergency Care “System”
• Taking it to scale?
• Reinventing regionalization
• Where are we now?

STEMI

STEMI

30+% of ST E MI pa tie nts g e t no re pe rfusion the ra py

3% of isc he mic stroke s tre ate d at T JC c e rtifie d c e nte rs 3-8.5% re c e ive rt-PA

Sepsis

Sepsis

5-7% of E Ds pe r for m E GDT

26% of physic ia ns ha ve use d hypothe r mia

The New Jersey STEMI “system”

Survival after out of hospital Vfib arrest

5 10 15 20 25 30 35 40 45 Alabama Dallas Iowa Milwaukee Ottawa Pittsburgh Portland Seattle Toronto Vancouver City % survival to discharge

Va ria b ility in OHCA o utc o me s

Ho spita l c ha ra c te ristic s & o utc o me s

Regionalizing Emergency Care Workshop

Sept 10, 2009

• Broad-based stakeholders –private, fed/state/local government,

Public health, academic.

• Little progress since 2006 Report.
• Looking for consensus and strategies to move

regionalization forward

• Multiple views – modern and traditional
• Workshop report published in December, 2009

Where are we now? Where do we want to go? How will we get there?

When focus has its drawbacks….

When focus kills…

Model Drives Adoption

• Driving force of regionalization

since 1970’s: –Get the right patient to the right place at the right time

Where are we now?

• Current model:

–Designed for low frequency, high impact events –Changed the world! –Led to many improvements in patient care! –Frustratingly low uptake in market –Current format may not meet emerging and future needs

TERTIARY/URBAN SUBURBAN SMALLER RURAL

• EM trained physicians
• Specialist consultants
• Interventions/equipment
• Non- EM physicians
• Scarcity of specialist
• Less resources

SMALL SUBURBAN/LARGER RURAL

Acuity at Arrival (TRIAGE)

• Resuscitative

5.1%

• Emergent

10.8%

• Urgent

36.6%

• Semi-Urgent

22.0%

• Non-Urgent

12.1%

Most Frequent Chief Complaints

• Abdominal Pain
• Chest Pain
• Fever
• Headache
• Injury

High frequency, moderate impact

Financial “Health”

• Economics of Transfers

–On patient –On local facility –On local providers –On community Is this even measured??

TERTIARY/URBAN SUBURBAN SMALLER RURAL

• EM trained physicians
• Specialist consultants
• Interventions/equipment
• Non- EM physicians
• Scarcity of specialist
• Less resources

SMALL SUBURBAN/LARGER RURAL

Attributes of Quality Health Care

• Patient-centered
• Safe
• Effective
• Efficient
• Timely
• Equitable

Can be measured at patient, provider, facility and systems level

“Crossing the Quality Chasm”

• Institute of Medicine, 2001

Six Redesign Imperatives

• Reengineered care processes
• Effective Use of Information

Technologies

• Knowledge and skills management
• Development of effective teams
• Coordination of care across patient

conditions, services, and sites of care

• ver time

What is the “market” saying?

Maybe the model is wrong. Change the model!

Challenges

• Time, distance, geography
• Restricted access to information
• Workforce shortages –

provider/caregivers

• Maldistribution of provides and

resources

• Aging population
• Growth in patients with chronic disease
• Access to primary care limited

Stibilit f dl

Opportunities

• Lots of redundancies and resources

– Helicopters, beds, ICUs, specialties..

• Technologies can leverage our ability to

scale cognitive resources and integrate

• thers
• Move to electronic data, images and

records

• Growth of high-speed data and voice

connections/Internet

• Move toward quality and value-based

payments

Resources

• Equipment/technology – fixed

– Move patient to

• Procedural skills – fixed

– Move patient to

• Cognitive skills – mobile

– Move to patient

Electronic Collaboration

Connecting… providers patients resources

“Integration and Collaboration”

Electronic Collaboration

• Patient care consultation

–Real time and retrospective

• Patient Monitoring
• Imaging/ECG review and

interpretation

–real time or asynchronous with care

• Education and training
• Transfer of care/treatment planning

Attributes of Quality Health Care

• Patient-centered
• Safe
• Effective
• Efficient
• Timely
• Equitable

Can be measured at patient, provider, facility and systems level

“Crossing the Quality Chasm”

• Institute of Medicine, 2001

Ch-ch-ch-changes…

• Driving system development, 1970s:

Get the right patient to the right place at the right time

• Driving system development for

Integrated Networks of Emergency Care:

Get the right resource to the right patient at the right place at the right time

Abundant Care Resources Provider and Patient needs

TERTIARY/URBAN SUBURBAN SMALLER RURAL SMALL SUBURBAN/LARGER RURAL

Extending the Reach

• Poison control
• Critical Care
• Radiology
• Neurology
• Cardiology
• Ob-Gyn
• Pediatrics
• Psychiatry
• Dermatology

Why not Emergency Medicine?

Just start in one spot…and grow…

The Winds of Change

It’s all coming together

• Wireless sensors
• Pervasive connectivity
• 3G/4G secure networks
• Emerging standards
• Regulatory changes
• Increased funding and payments
• Health information exchanges
• Smart phones
• Clinical decision support
• GPS everywhere

Steps

• Categorize the ED’s, patients, and

resources

• Change the driving goal of

regionalization

• Match resources and needs
• Develop simple, understood model
• Deliver well-understood, reportable

quality care measures

Measure monitor deliver improve

• Change the name

– Integrated Networks of Emergency Care

• Change the goals

– Get the right resource to the right patient at the right place at the right time

• Change the rules

– Do the greatest good for the greatest number. – Drive value thru measurable quality. – Play with others – something for everyone. – Do no harm to those in the network

The Road Ahead…

The best way to predict the future… is to create it!

Overview

• EM in perspective
• Volume & Outcome
• Time & Outcome
• The Emergency Care “System”
• Taking it to scale?
• Reinventing regionalization
• Where are we now?

• “Regionalization is a paradigm that applies to

the critically injured or highly technical complex patient who needs a level of technical expertise that is not available at an isolated local facility, but is available in a tertiary care setting. But a point of emphasis this morning was that regionalization needs to be a web, not a funnel…The idea of bi- directionality is very, very, important – regionalization must be a win-win proposition.”

– Kellermann, IOM Regionalization Workshop

What is regionalization?

• "a euphemism for rural hospital

closures.“

»

• Dr. Karl Stobbe, president of the

Society of Rural Physicians of Canada

December 2010 Issue

A Quality framework ?

• Ambulatory Care Sensitive Conditions
• Conditions for which good outpatient care can

potentially prevent the need for hospitalization,

• r for which early intervention can prevent

complications or more severe disease.

• Emergency Care Sensitive Conditions

 Conditions for which rapid diagnosis and early intervention in acute illness or acutely decompensated chronic illness improves patient outcomes.

Quality metrics for regional emergency care systems

• National Quality Forum & ECCC
• Environmental Scan
• Develop a framework for metrics to

evaluate regionalized emergency care

• Compliance with disease based time guidelines
• The ability to match needs with resources
• Efficiency of competing care delivery systems

Critical Access Hospitals According to Iowa Hospital Association

Stroke Death Rates

• Pre hospital vs. Interhospital transfer vs. ?

– Longer prehospital times, re-arrest concern

• Triage rules
• Multidisciplinary buy-in (EM, cards, icu, neuro)
• ED/ICU crowding & hospital capacity
• Credentialing/Certification body
• Structure of the Network
• Move the patient…or move the knowledge?
• Integration with other diseases/systems

F uture Cha lle ng e s