Focused approach cuts adverse outcomes by 40%
Holistic system identifies synergies, savings
Programs that integrate women’s health care issues have dramatically decreased adverse outcomes in areas such as preterm deliveries and cesareans. Managers who have tried this "big-picture" approach say it has had positive implications for several women’s health diagnoses and should be applied more broadly to other areas of care as well.
Deborah S. Briggs, BSN, MBA, director of health management at Greenstone Healthcare Solutions in Kalamazoo, MI, a disease management consulting company, says programs can provide "prevention and protection from birth to menopause." These are just some of the diagnoses or "platforms of care" that relate to women:
• the birth event;
• breast disease;
• menopause and hormone replacement therapy;
• conception/sexually transmitted diseases;
• domestic violence;
• weight management;
• cancer;
• osteoporosis;
• urinary incontinence/infections;
• arthritis;
• cardiovascular disease;
• hypertension;
• depression/stress management;
• Alzheimer’s disease.
"We’ve looked at the individual platforms of care and brought them all back to the bigger picture of women’s health," Briggs explains. "We’ve made sure they all interrelate and support one another all the way from the menopausal state to osteoporosis to the birth event to depression. We’ve considered the whole picture, because we’ll never change where we’re going with the health care system unless we take a broader focus."
Briggs says it is not unusual for women’s health centers at hospitals to have a separate health team for treating women, no matter what their problems or conditions.
"There is a lot of cross-consulting," she explains. "Basically, there is one record for a patient. So if she comes in with a headache, [providers] can go back and see that she is a hypertensive patient. It’s important to look at the whole [person] instead of a specific symptom."
But what about men? Is looking at women’s health separately discriminating against them? Briggs says the company is planning to create a men’s health program as well, because men have their own specific health issues, such as prostate cancer. They also may require different types of care for diseases such as cardiovascular disease than women do. For example, women who have myocardial infarction (MI) may require hormone replacement therapy.
"What we’re saying is one type of care is not more important than the other," she explains. "They’re both important. But there has been a lack of realization that how you treat a woman after she’s had an acute MI and how you treat a man with the same diagnosis might be slightly different. There is a gender issue there that has to be acknowledged."
Episode of care’ is focus
Such has been the case at Lovelace Health Systems in Albuquerque, NM, which is focusing on the birth event, or "episode of care," says Janet Vertrees, RNC, BSN, senior consultant. The health system includes a health plan, clinics, a hospital, physicians group, and several research organizations. She describes an episode of care as "all the care provided to the patient with a particular disease or condition within a specified period of time across the whole continuum of care." Vertrees explains, "That means preventive medicine to acute hospitalization and all the way to long-term care. It’s an integrated system with all the disciplines working together wherever the care is provided,"
For example, in the birth episode of care, a "prematurity prevention program" focuses on risk reduction, says John Byrnes, MD, president and CEO of Lovelace. "The goal of that program is to get all patients screened during the first trimester and that they get prenatal care early in the course of their pregnancy," he says. "They’re given a questionnaire at that point, and that helps the physicians or nurse midwives determine if the patient is at risk of an early pre-term delivery. If she is, the patient is plugged into an aggressive care management program." (See sample questionnaire, p. 6.)
A midwife or nurse then calls the patient once a week to see how she is doing.
"It’s a tight surveillance program, so that if it looks like they’re getting into any trouble at all, we, the health system, are being proactive in identifying that and getting them in for care as quick as they need it," Byrnes adds.
He says that program has resulted in a 40% decrease in pre-term deliveries and admissions to the neonatal intensive care unit by more than 50%.
Another initiative at the organization is breast cancer. Byrnes says the episode of care team is "re-engineering" the whole care process, from making sure women obtain routine mammograms to biopsy, surgery, or radiation. That initiative is still under way, he says.
In addition, administrators are discussing having a separate women’s health center for any type of diagnosis a woman may face in her lifetime that will include primary care physicians, obstetricians, and specialists.
"What we’re doing now is going after the larger [issues] first birth and prematurity prevention being one, and breast care being another and then we’ll follow on down the line with a lot of the other diseases women face to make sure they’re all re-engineered," says Byrnes. "We want to pay attention to the entire continuum of care for women and make sure it’s all coordinated.
In 1993, the organization identified nine episodes of care that comprised about 24% to 30% of its costs. Multidisciplinary teams including members from all disciplines who interact with patients were developed. The teams have co-leaders: a specialist and a primary care provider.
"They represent the collegiality that needs to exist between specialists and primary care," Vertrees explains.
Teams review the literature and develop a continuum of care. "What is the continuum of care for birth?" she asks. "It could be that you would start with preconception care, prenatal care, and antenatal care as well as the hospital labor and delivery part, then the postpartum care. The teams define what those big parts of the care continuum are and what defines "best practice" in the medical literature.
"We do a baseline measure of all of our current data before we implement anything, then the team decides what interventions will move outcomes in a favorable way," Vertrees adds. "We design all the tools we’ll need to carry out those interventions and then we measure to see if we’ve made a difference."
Apparently, their efforts have paid off. In the late 1980s, the cesarean rate at the hospital was between 20% and 23%, she notes. Now, the rate is about 13% a year. A large midwifery practice has been instituted, and obstetricians tend to work mostly with very high-risk patients.
"What we think has really helped move our C-section rate [down] is that the midwives care for the women prenatally," Vertrees says. "Their whole focus is identifying risks and using risk-prevention strategies."
Clinicians work in equal ratios
In the meantime, obstetricians and primary care providers work closely together in a 50-50 ratio.
"So a lot of this care [for women] is delivered on both sides of the system in primary care and in specialty care centers," says Byrnes. "And with all the episodes now, what those are designed to do is coordinate the care between those two groups of providers as appropriate. So it becomes a virtual integration rather than a physical integration."
The two keys to doing so are making sure information on patient records is up to date with electronic medical records and using care managers in the outpatient settings. The care managers are usually RNs who coordinate groups of patients between physicians and the different sites they encounter.
"So for prematurity prevention, the care managers are the ones who coordinate any of the services the [patients] would need during their prenatal period," Byrnes explains. "Likewise, we have care managers on each of the primary care sites. So the patients there who are at high risk or fit into some of these specialized programs have someone who is truly coordinating everything that patient needs."
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