The Problem
A highly successful initial clinic redesign at the Duke Outpatient Clinic (DOC) has led to substantial reductions in ED visits resulting in hospitalization. However, we identified the following problems after this redesign:
- A large (but addressable) number of visits by DOC primary care patients to the DUH ED that occur during hours when the DOC would be available to care for these patients (n= 665 in FY15). Many of these visits (1 in 4) result in inpatient admission (n = 175), many of which are potentially avoidable with substitution of intensive primary care.
- There is a high cost of care for DOC patients admitted to the ED. At an average cost of $7,800, these admissions resulted in $1.4M indirect costs in FY15, not to mention any opportunity cost when the hospital is at capacity.
- DOC patients visiting the ED for higher-level complaints. A big part of the challenge is that the case mix for these visits has shifted from over half being lower-level visits for basically ambulatory complaints, to the vast majority (4 in 5) being higher-level visits requiring a significantly higher level of care –- which the clinic is less prepared to manage.
- Excess daytime ED visits to DUH by DOC patients during week, when clinic was open. A vast majority (85%) of these visits, however, required treatments and/or were at an acuity level not normally handled in a primary care clinic setting.
Our Solution
Development of new HIDOC (Highly Individualized Dedicated Onsite Care) program at DOC, a targeted program whereby patients seen by providers at the DOC are availed higher-level services than are typically offered in primary care.
The program includes the following key components:
- Analytic visualization platform: Use of an analytic platform to identify the top five complaints for which patients visit DUH ED and patients that would benefit from the HIDOC program.
- Care guidelines: A multidisciplinary team at the DOC worked together to develop care guidelines and menu of services for treatment of shortness of breath, chest and abdominal pain in the absence of trauma.
- Treatment nurse (RN): serves as the bedside “treatment nurse” for patients seen in the acute illness care model, while, at other times, is responsible for clinic-based care management of the high-need DOC patients enrolled in the model.
- MD supervision: Additional attending staffing will be required to supervise the APP and resident provider in the acute illness care model; and time protected to support the development of acute illness care guidelines for the clinic, as well as individualized care plans for patients selected for the pilot.
- Advanced Practice Provider (APP): The clinician “on point” for managing the acute episode, with same-day availability “built-in” to her schedule.
Impact
Successful establishment of working prototype of HIDOC team (bedside RN/care manager, APP, MD leader and in-clinic coverage, supported by addition of pharmacy assistant plus other clinic resources), and suitable acute treatment space.
Commitment from DUH for MD support needed to make walk-in HIDOC access and proactive MD involvement in care management possible on a daily basis. Parallel commitment secured from PDC to support APP attached to HIDOC team.
“Soft” launch began in March 2017; and was launched as a standing service in July 2017 to an ongoing caseload and referrals in queue, acute treatment space and support available to clinic at-large daily.
