A full audience in the ballroom at the Waldorf Astoria Hotel in Chicago listened to an impressive roster of speakers share their insights on improving information exchange, advancing teamwork in patient care, patient engagement, analytics and more.

Co-chaired by David W. Bates, MD, MSc, and Patricia Flatley Brennan, RN, PhD, the meeting focused on evidence across the care continuum. Speakers included nursing leaders, informatics experts and other professionals who shared expertise and research on improving care both within and outside of office and hospital encounters.

“It has become clear that if we are to deliver really good care, we have to do it as teams. We can do better,” said Bates, chief quality officer, senior vice president and chief of the division of General Internal Medicine at Brigham and Women’s Hospital and medical director of clinical and quality analysis at Partners HealthCare in Boston. He was one of several participants who focused on improving care for those with chronic illnesses. “If we interact with them more effectively, we can improve the care they get and, at the same time, reduce healthcare costs.”

“As we try to move from the point of care to the process of care, we need lots of different perspectives,” said Brennan, who is Lillian L. Moehlman Bascom Professor at the School of Nursing and College of Engineering, University of Wisconsin-Madison and national program director of Project HealthDesign.

The tools for translation

Delivering the keynote address, Mary D. Naylor, PhD, RN, the Marian S. Ware Professor in gerontology and director of the NewCourtland Center for Transitions and Health at the University of Pennsylvania School of Nursing and the national program director for the Robert Wood Johnson Foundation program—Interdisciplinary Nursing Quality Research Initiative, said effective transitions have several factors in common, such as consistent, standardized assessments and care planning.

Naylor spent years conducting research on how to improve care transitions but eventually noticed that nobody was using the information. “No systems were changing. We could have just continued to publish our findings but we were in it to influence care and outcomes in the real world.”

She admitted they were quite naïve, not realizing how important were the tools of translation. “We had to develop those tools for patient screening and recruitment. We built webinars. We had to build a clinical documentation system, quality monitoring and improvement systems so we could engage everyone in the culture of learning.”

A comparative effectiveness research study with a payer offered the chance to get their foot in the door. “Despite many barriers, we were able to demonstrate improvements and cost savings that lasted a year. That enabled us to get in the doors of health systems.”

Naylor created a service line for this as well as setting rigorous performance expectations. “We review everything we’re learning and make adjustments in the model of care as we go.”

Healthcare needs to think about better follow-up, she said, especially for those with chronic conditions. “This is a population whose transitions in healthcare are so frequent that we’ve got to be able to be nimble in responding by engaging caregivers, improving symptom status and preventing acute resource use.”

Teamwork for better care

Coordinated care depends on teamwork, said Ann O’Malley, MD, MPH, senior fellow at Mathematica Policy Research, Washington D.C.

One of the biggest challenges to successful teamwork is physician buy-in, she says. They are not trained to be good team members because they are trained to trust no one and to verify everything for themselves.

Practices can achieve staff buy-in by engaging staff to identify and refine optimal workflow. “Make one small change without rattling everyone’s world but improves care and then they will be much more open to more changes.”

Staff meetings in which everyone discusses their role can help build empathy as well as identify duplication in roles and identify possible opportunities to streamline work processes. “Clarifying upfront who does what is critical to teamwork.”

Through her research, O’Malley said she learned that daily huddles—quick debriefings—to assign responsibilities and discuss patient-specific issues that arise are very valuable once practices learn how to properly conduct the meetings. “It sounds like a simple concept but it’s not that simple and you have to be patient. You can’t try it once. It took most practices months to refine this process. You really have to keep working on it.”

Another challenge is the fact that EHRs predated the care manager role so care management software does not integrate with EHRs. To manage that, some practices have created templates and macros. Patient registries also are not integrated with EHRs. “There are lots of ways this is being handled as health IT evolves but users want this to be more seamless and they want it to be actionable.”

Advancing the care model

Bates delivered a talk that included his findings in a recent paper on the future of medical homes. “One key foundational thing is having the right problem list in the patient record,” he said. Partners built a tool that goes through records to find clues indicating that a patient might have a problem not on the problem list. The tool has been “enormously popular,” and has resulted in a 48 percent increase in items added to problem lists, he said.

Population management tools need a variety of functions, he said, and should offer different front-end views for different providers. They also need the ability to generate lists. “So far, highly functional multidisease tools are not widely available. We need these badly.”

Team care is going to be absolutely critical for getting to the next level. It involves getting to relationship-centered care.” Most EHRs don’t support this very well, he said.

Bates cited another recent paper he co-authored which covered six use cases around improving organizational efficiency. One use case is high-cost patients—that 5 percent that account for half of healthcare spending. The first step in managing those patients, he said, is identifying that group by increasing data about mental health, socioeconomic status, marital and living status and more such information. “That’s likely to help us figure out what to do. One of the most important things is to identify specific actionable needs and gaps to help keep that person from being so expensive.”

Improving communication

Ineffective communication is a leading cause of the 400,000 patients harmed within the healthcare system, said Patricia C. Dykes, PhD, RN, senior nurse scientist and program director of the Center for Patient Safety Research and Practice and the Center for Nursing Excellence at Brigham & Women’s Hospital in Boston.

Working to engage with patients, families and caregivers has been proven more effective than dictating treatment. Dykes presented research from several fall prevention studies where patients and families were engaged, and results from a randomized clinical trial in which in-hospital falls were reduced for patients, especially those identified at risk of falling and over 65 years old.

Dykes conducted a two-year mixed methods study funded by the Robert Wood Johnson Foundation with a qualitative phase that considered why hospitalized patients fall, as well as what interventions are effective and feasible in hospital settings. In the randomized control trial, her team designed a toolkit to address issues identified during the qualitative phase.

Her team determined that communication surrounding fall risk status and the plan of care in the hospital setting is highly variable. They also found inconsistent communication across team members a barrier to collaboration and teamwork, other team members do not view the plan as detailed in the medical record, and there was inadequate, incomplete or incorrect information at the patient’s bedside.

With the assistance of team communication, leveraging existing workflows, using health IT tools such as surveillance and customized communications, the team was able to reduce the number of in-hospital falls.

Safer care transitions

“Making transitions safer is a national patient safety goal,” said Vineet Arora, MD, MAPP, associate professor of medicine and director of the Graduate Medical Education Clinical Learning Environment Innovation at the University of Chicago Pritzker School of Medicine, citing the Joint Commission. “But really, it’s a requirement.”

“Service transfers occur when you are escalating or de-escalating care for a patient. This may mean they are going in or out of ICU, or going from surgery to post-surgical care, or being transferred to a specialty unit,” said Arora. “These handoffs are really a type of communication, whether written or verbal, and importantly, they are a transfer of professional responsibility.”

According to Arora, speakers systematically overestimate how well their messages are understood by listeners. Senders assume the receiver has all of the same knowledge the speaker has.

Arora reviewed tests she conducted to assess the success of handoff communications in inpatient pediatrics. Incoming and outgoing pediatric interns were interviewed one hour after handoff. They were asked to identify the single most important thing about the transfer. They were incorrect 60 percent of the time.

“The verbal handoff is best understood as a dialogue,” said Arora. A dialogue fosters common ground and the person that needs to be most invested is the receiver. There are cues the sender can see to verify the receiver is getting the message such as eye contact, nodding and body language.

Everyday care

In the future, healthcare and technology needs to reach into the everyday lives of patients to allow providers to deliver better care, said Brennan.

Brennan leads Project HealthDesign which aims to use technology to engage patients in self-care and disease management. “Professionals are experts in clinical care but people are experts in everyday living,” she says. “If we leverage the best skills of everyone on the care team, including the patient, we will get to better care and probably less stress, and maybe even less cost.”

Lots of conversations are needed to make sure everyone is on the same page, she said. For example, when talking about pain is everyone talking about the same thing? Self-reported experiences and patient-defined information could change the conversation. “As we bring tools into patients’ lives, the conversations with colleagues and vendors will be essential.”

Recognition of the importance of social and behavioral determinants of health (SBDH) is growing, she said, but the goal isn’t to collect more data but the right set. She said an Institute of Medicine (IOM) report is coming out soon that will recommend the most parsimonious set of SBDH determinants.

The IOM studied “a range of things we might want to know about a patient because they are indicators that have shown a relationship to patient outcomes, mostly morbidity.” Those determinants include racial identity, language and financial resources. For example, studies have shown that the fear of losing one’s house is as stressful as actually losing one’s house. Psychological conditions such as health literacy, stress and behavioral aspects need to be factored into patient care. Social engagement is useful as well, she said, because “we have learned that people are more likely to die from loneliness than from high cholesterol because of the secondary effects of that loneliness.”

Other factors such as exposure to violence, military history and past incarceration also impact health. “We believe a parsimonious set of data would improve immediate care of individuals but also allow us to forecast and plan care.” 

For more coverage of the meeting, go to clinical-innovation.com/conferences/hclf. The 2014 Healthcare Leadership Forum was sponsored by Elsevier/Clinical Key and hosted by Clinical Innovation + Technology.