Let's review what's being asked of acute-care hospitals in a climate of fixed-fee, per-enrollee healthcare.
First, handle more complex cases but get patients discharged faster. Yet, keep staffing levels under control so payroll doesn't overwhelm the health network's operating margin.
But with those staffing levels, make full use of the latest equipment and technology; demonstrate to patients how to continue their care after discharge; and give them enough attention that they come away measurably satisfied.
And, finally, produce good outcomes of care: prove that former patients functionally improve over time and that they don't need to be readmitted for preventable relapses.
That's a tall order for the traditional hospital structure, which relies on legions of nurses and other staffers to supervise, soothe and educate patients. Further liability for progress after discharge means stretching resources even thinner.
But a two-hospital joint venture in Providence, R.I., has eliminated traditional hospital structure from its plan to provide acute care at 30% lower cost while providing intensive education on coping with life after discharge.
The Cooperative Care Center, a 74-bed facility that opened in July on the shared campus of Rhode Island Hospital and Women & Infants Hospital, is using family members or friends of patients to administer much of the routine care and then take that experience home with the patient.
The venture is predicting that its brand of acute care will lead to lower readmission rates, improved patient outcomes, shorter lengths of stay, fewer medication errors and enhanced satisfaction scores.
Those expectations are based on a 15-year track record at a similar unit operated by New York University Medical Center in Manhattan. The 104-bed unit's example hadn't caught fire during all that time, but now its cost savings and patient-education emphasis are playing into the hands of healthcare reform.
The hotel-style lobby and post-treatment observation units on the first floor of the Rhode Island Cooperative Care Center bring to mind the breed of medical hotels or "recovery-care centers" that sprang up in the late 1980s.
Those alternatives to inpatient care were a way of moving patients into a lower-cost setting and containing costs under Medicare's prospective payment system (Jan. 8, 1988, p. 35).
For inpatients only.But the Cooperative Care Center is a full-fledged inpatient facility, not an outpatient treatment or recovery center. Transfers from the main hospitals account for only one of every five admissions, said Bruce Komiske, the center's executive director. The rest are admitted directly from surgery or through the front door for a range of treatments normally done in a traditional hospital setting.
Prospective patients include those undergoing cardiac, stroke, AIDS or cancer treatment, or recovering from a hysterectomy, mastectomy or gallbladder removal, according to the center.
Checking in along with the patient is a "care partner," someone who's willing to learn about the nature of the illness, the treatment plan and what to do after discharge. These care partners are taught throughout the stay to give medication, take vital signs, chart the results, take the patient to and from treatments, and take the lead in home care afterward.
Just as important, the partners are a familiar face and sympathetic ear to ease stress and prevent depression following a traumatic episode-an outlet that patients otherwise could find only by summoning a nurse to talk to and reassure them, Mr. Komiske said.
The functions the care partners perform allow the center to operate with just three registered nurses on the night shift instead of the usual nurse station on every floor, Mr. Komiske said.
Patient rooms are located on the second through fourth floors, which have emergency medical equipment and call alarms. But medical treatment is concentrated on the first floor, with its observation unit, exam and treatment rooms, and therapy room.
The first floor is also where patients go for buffet meals, in a common dining room that offers additional companionship along with dietary instruction from a nutritionist; education sessions, in which nurses counsel patient and care partner on medication and continuing treatment; and the resource center, which has a medical library plus a range of books, pamphlets and computer-search services to foster understanding of conditions and illnesses.
The main criterion of eligibility for admission is mobility, because the ability to get around is central to the center's approach.
"There's not much sitting around," Mr. Komiske said. The routine is designed to literally get patients back on their feet-a contrast with traditional acute care in which patients are prone and confined to a room much of the time. It's also a contrast at night, when patients and their care partners can shut the door of their two-bed room and sleep without intrusion or nurse-station noise, he said.
Outcomes.Research on the New
York University Medical Center's Cooperative Care Center showed no reduction in patient safety by entrusting care and supervision to the partner. In fact, total falls in the unit during 1991, the most recent year for complete data, were 41% below the predicted rate for acute-care settings. Medication errors were 79% below the expected rate based on comparisons with adjacent traditional hospital units at the medical center.
The statistics are in a recently published book, Family Partnership in Hospital Care, written by the New York center's medical director, Anthony Grieco, M.D., and other administrators from the two facilities, including Mr. Komiske.
According to a study in the February 1990 issue of the journal Patient Education and Counseling, care at the New York center resulted in an average inpatient stay just over half the predicted length for traditional acute care.
And a study of functional status and rehospitalization in the same issue reported "no evidence that cooperative-care patients were hospitalized more often or needed more emergency, home care or other types of services" a year after discharge.
"There was, on the other hand, evidence as to the positive effect on patient understanding and self-management," the study said.
Costs.A comparison of the 104-bed cooperative-care center with a three-unit, 102-bed operation in the main hospital of NYU Medical Center showed that the care center required 43% less personnel and cost 38% less to operate.
That's about the same cost savings predicted for the Rhode Island center, Mr. Komiske said, and that's without adding in the lower cost of building the care unit compared with a traditional hospital.
The Rhode Island care center, built for $13.3 million, cost a third less than a comparable facility built to traditional acute-care standards, he said.
Mechanical systems were much simpler, no nursing stations were required, and oxygen supply was provided for only 14 of the rooms. Overhead paging systems were replaced by patient/partner beepers.
That put the cost per square foot at $125, compared with the $180 to $200 per square foot it cost to build a traditional hospital in New England in 1993, Mr. Komiske said.
The savings paid for amenities such as wallpaper and carpeting, "things people notice but in the scheme of things are the least expensive elements," he said.
Rooms are equipped with standard $300 hotel beds instead of $6,000 hospital beds, a major savings but also a practical element of post-hospitalization preparations. Patients are counseled on how to elevate their sleeping position and make other adjustments the way they'll have to do it at home, Mr. Komiske said.
Justifying the facility.In the late 1980s, 719-bed Rhode Island Hospital was facing replacement of inpatient facilities, which averaged 40 years old. About 70% of the beds were in four-bed rooms lacking basic hospital amenities, and they were expensive to operate, Mr. Komiske said.
Meanwhile, Women & Infants Hospital had just opened a new 137-bed facility. But with nearly 10,000 births a year, it was operating at more than 90% average occupancy and in need of further expansion.
Leaders of the two hospitals decided to jointly develop a new facility based on the best industry thinking at the time. They studied medical hotels as well as a model developed by Planetree, a not-for-profit consumer health organization advocating care based on a philosophy of openness and honesty among patients, family members and clinicians (Aug. 5, 1991, p. 27).
While the Planetree model incorporated much of the same architecture and education elements, the Rhode Island venture's research determined it didn't have much of an impact on cost reduction.
The cooperative-care approach "adds the dimension of the care partner to fortify the education component, and it costs less to operate," Mr. Komiske said. That conclusion led to a six-year planning dialogue with the NYU Cooperative Care Center, Mr. Komiske said.
The dialogue with state regulators lasted about as long. It took two certificate-of-need attempts and 28 formal approval steps to guide the proposal through health planning bodies, hospital boards and other scrutinizers, he said.
The state health department issued a license to operate the center as a hospital, but one of the conditions was a requirement that the center make good on its claim to provide care at lower cost to the public. Specifically, the daily charges had to be $140 less than for traditional care at Rhode Island Hospital and $70 less than Women & Infants.
Mr. Komiske said the daily charge at the Rhode Island Cooperative Care Center is $420, compared with $620 at the main hospital.