When Bristol (Conn.) Hospital wanted to improve its patient-satisfaction scores and market share while building a stronger relationship with the community, hospital administrators turned toward the growing field of clinical outsourcing to provide better-quality care, greater efficiencies and improved communication.
The not-for-profit provider, an affiliate of Hartford, Conn.-based teaching hospital St. Francis Hospital and Medical Center, envisioned an efficient, 24-hour medical call center staffed by clinicians to handle its growing volume of triage and information calls, but it also realized that providing round-the-clock service using in-house resources would be costly.
Viewing an after-hours call service as critical to maintaining its reputation in the rapidly growing hospital community of 90,000-plus residents, Bristol Hospital entered into a clinical outsourcing agreement with IntelliCare, a Portland, Maine-based provider of medical contact center application software and services. Through the partnership, the 128-bed hospital was able to increase customer loyalty and reduce its nurse hours and costs.
Just by being there 24 hours a day, the call center "makes a powerful statement that Bristol Hospital takes healthcare very seriously," says Thomas Kennedy, the hospital's president and chief executive officer.
The facility is one of 225 hospitals, healthcare systems, health plans, group practices and employers outsourcing their call center operations to IntelliCare and using the company's technology and services to handle calls more efficiently, manage demand, provide effective disease management services for patients and ultimately boost downstream revenue. Bristol's medical call center now fields upwards of 1,500 calls per month including triage cases with clinicians, physician and counseling referrals and class registration. The center also provides coverage for the hospital's women's health clinic, home-care agency and employee benefits line.
As changes in market conditions and patient populations lead hospitals and healthcare systems to continually re-evaluate how they can provide higher-quality and more cost-effective care, providers are looking to update traditional outsourcing models. While contracts for food service departments, laundry and housekeeping services still lead providers' outsourcing initiatives, more hospital administrators are signing off on opportunities to outsource clinical functions such as medical call centers, nurse triage services and new niches of specialty staffing support. Hospitals are looking to gain efficiencies at lower costs and greater returns on their investments while eliminating staffing burdens. Healthcare leaders increasingly contend that they want physicians and hospital administrators to focus on building their hospitals' core competencies, ensuring the facility's survival and prosperity by increasing market share and competing with other hospitals in their respective region relative to quality and price.
"Hospital administrators are under a lot of pressure," says Lynn Massingale, president and CEO of Knoxville, Tenn.-based Team Health, a clinical outsourcing company that contracts with hospitals and physician groups to provide physician services in emergency medicine, radiology, anesthesia, critical care, pediatrics and hospitalist programs. "When hospital leaders can outsource clinical areas and expect to receive quality care and patient satisfaction, they can go and focus on other things like how to compete with outpatient surgery and diagnostic centers and get their costs down so that they can be competitive," he says.
While organizing outsourcing deals with emergency room physicians, radiologists and anesthesiologists is nothing new for hospitals, the reliance on clinical outsourcing is expanding and becoming increasingly specialized as hospitals find new ways of partnering with clinical outsourcing groups and companies.
"We're seeing a real acceptance of clinical outsourcing," says Victor Otley, IntelliCare's founder, chairman and CEO. "In the early years of outsourcing, there was a lot of resistance from providers to give up control of what they perceived as their core services. But this is changing as processes become more standardized along with clinical guidelines."
Growing acceptance of evidence-based medicine and reliance on best practices in clinical care and disease management has led to less variation in care, allowing for providers to become more comfortable accepting assistance in follow-up work and relationship management with patients.
Encouraging patients to use ancillary services, which increases both patient loyalty and hospital revenue, also has contributed to medical call centers' growth in particular. However, most hospitals often lack the tools or skills required to achieve economies of scale to maximize the value of internally operated centers, Otley says. Continually reinvesting in call center technology or software upgrades can prove difficult along with the ongoing challenge of recruiting nurses for the center, particularly as the nation endures a nurse shortage.
"The real benefit of the medical call center is to provide a higher and more convenient level of service as well as timely access to information in order to keep that patient or customer within the healthcare system," Otley says.
A 2002 study by Evanston, Ill.-based Solucient identifies the medical call center as one of the most effective methods of driving revenue and profitability, increasing customer loyalty and attracting customers from a hospital's target market. The four-year study, based on more than 807,000 callers and 1.9 million calls from 11 call centers servicing 25 hospitals, found that a patient referred through a call center generates 150% more revenue for the hospital than the average patient. According to the study, callers to each facility on average generated $13,848 in hospital charges within 12 months of their first call. By comparison, the average hospital patient represented $5,524 in charges.
IntelliCare employs more than 300 nurses nationwide and also allows them to work from home to handle medical triage, disease management and other calls including "patient concierge" or patient advocacy calls, which are increasing as more people seek assistance in navigating the complexities of the healthcare system. Patients don't know that they're not speaking to someone right in the hospital, which is what hospitals want?an efficient experience for their customers, says Bristol Hospital's Kennedy.
"The selling point for us was the connectivity to the community," he says. "The service has paid for itself unquestionably."
Who's on the line?
For hospital executives debating whether to outsource their facility's medical call center or a healthcare system's multiple centers, the most critical--and often overlooked--question is to find out who is calling the hospitals and for what reasons, Otley says.
While that step is seemingly intuitive, he says many hospitals only measure calls in the areas of nurse triage or registration for hospital-sponsored classes, and they don't always count the number of incoming calls from the emergency room or other specialty departments like radiology. For this reason, it's also important to assess the value of the call beyond the volume of callers to determine whether a clinical outsourcing organization handling call centers might be able to assist the hospital with relationship building and patient referrals.
For hospitals that are reluctant to relinquish complete control of their call centers, one option is to reach a co-outsourcing deal to share the responsibility of operational burdens while still expanding service offerings. Clinical outsourcing groups can be brought on to oversee overnight shifts and weekend coverage only, particularly for nurse triage services and after-hours support, leaving the hospital to field daytime calls. IntelliCare has created such an arrangement for Bristol Hospital. The company also worked with BJC HealthCare's St. Louis Children's Hospital to establish a Pediatric Answer Line, which has grown to handle an average of 9,000 calls per month. More than 160 physicians use the center to manage triage calls and upwards of 100 rely on the call center's after-hours answering service.
Hospitalists for hire
A good hospitalist program, like efficiently run medical call centers, can also bring in new business for hospitals along with a reduction in cost per case and losses associated with care of uninsured patients, medical errors, unnecessary readmissions and ER crowding, industry experts say.
As the business and employment status of physicians in all specialties continues to change and as hospitals with hospitalist programs find that physician turnover is hurting their ability to sustain the initial positive results, an increasing number of providers are outsourcing a second generation of hospitalist programs. Research has shown that hospitalists--physicians who spend their time working in the acute-care hospital setting caring for patients that are handed off to them for the duration of their inpatient stays--generate lower hospital costs compared with other internists. A 2003 study in the Journal of the American Medical Association found that hospitalist care lowered costs by an average of 13.4% and reduced length of stay by an average of 16.6% without harmful effects on quality or patient satisfaction.
"Obviously the other physicians on the medical staff aren't bad doctors, but there's a consistency of work that occurs for the hospitalists," Massingale says. Because their sole focus is on hospitalized patients and physicians typically spend most or all of their workday in the hospital, they can be more readily available to a patient than a physician who spends much the day outside the hospital in an office or clinic setting, he says. Team Health now works with some 450 hospital in 40 states.
Healthcare executives debating whether to outsource their hospitalist program should first examine the frequency with which the facility's hospitalists adhere to clinical pathways or clinical guidelines. Most hospitals have ways to monitor when and how much physicians are following hospital-defined protocols during treatment and, for example, using another drug that might be more costly to prescribe.
Secondly, healthcare leaders should look at the severity-adjusted length of stay for both the in-house hospitalist group as a whole as well as for individual physicians. Also worth examining is overall patient satisfaction with the program and in particular, the degree of satisfaction both the medical and nursing staffs have with the care already being provided.
"A good indicator is if the attending physicians in the community and the community-based physicians feel comfortable referring their patients to the hospitalists knowing that they'll get good care, that the private physician will also get good communication," Massingale says. "How satisfied is the medical staff that that's happening? Candidly, the nurses know, too--they know good care, good attitudes, and which physician are empathetic, good with the families and are available."
While an increasing number of hospitals have or are adding hospitalists to their staffs, many are finding that to maximize the benefit of the model, more is required than simply stationing physicians in the hospital round the clock. Ron Greeno, chief medical officer for Cogent Healthcare, Irvine, Calif., another provider of inpatient management services, says every hospital in the country will have a hospitalist program in the next few years whether it's something they create on their own or outsource to an outside partner. Most will be looking for assistance in setting up the best model.
"Hospitals need to take control of the process," he says. "Otherwise, they are going to have a hospitalist program that just happens to them, one that they have no control over and that does not necessarily benefit the institution or the patients."
The Society of Hospital Medicine, a group that represents hospitalist physicians, is actively working with the medical community to change the term "hospitalist program" to "hospital medicine" to describe the actual service itself. The society still uses the term "hospitalist" to describe the physicians. In the mid-1990s, there were about 800 hospitalists in the U.S. By 2010, the group estimates that some 25,000 hospitalists will be working in acute-care facilities nationwide.
Cogent's model of inpatient physician management wraps a multifaceted support system around a core group of hospitalists the company employs, allowing them to focus on clinical care while another team of clinicians gathers and manages data and handles scheduling and coordination of care. Cogent employs hospitalists at 21 hospitals in 11 states. Most recently, the company partnered in October 2003 with four-hospital, 546-bed Cape Fear Valley Health System, in Fayetteville, N.C., to provide seven physicians for Cape Fear Valley Medical Center and Highsmith-Rainey Memorial Hospital.
Cape Fear's medical director of primary-care practices, Eugene Wright, says increasing patient loads, an attempt to reduce overall length of stay and pressures to improve the quality of care using evidence-based guidelines led to the system's decision to outsource.
"It's hard to address these challenges when you have a small, home-grown (hospitalist) operation," Wright says. "It became apparent there was a demand for us to grow this program, and in assessing where we could go with it, we found there was a need to affiliate ourselves with someone who had experience operating large programs."
Making sure there was good dialogue and communication with the referring physicians in the community was paramount for Cape Fear, Wright says, adding that the hospital also needed to ensure that discharged patients weren't falling through the cracks or getting readmitted. In the six months the program has been operating, Cape Fear Valley Medical Center's patient census is up 50%, Wright says.
Cogent's discharge plan emphasizes quality improvement whereby each patient system has a discharge summary faxed to their primary-care physicians within 24 to 48 hours of leaving the acute-care setting. The hospitalist calls into Cogent's service center to complete a dictation over the phone at the time of the patient's discharge, and the company's clinicians--physicians and nurses--follow up those calls with patients to address discharge questions and review medication instructions. Such steps can ward off serious medical repercussions and readmissions.
Baptist Hospital in Pensacola, Fla., winner of this year's Malcolm Baldrige National Quality Award, just announced that it has saved $2.6 million in two years with Cogent's hospitalist program through reductions in average length of stay and other efficiencies. The facility's length of stay decreased an average of two days and cost per case was reduced by 44% for patients managed by the hospitalists. Thirty-day readmission rates for patients treated by hospitalists were 40% less than for patients treated by nonhospitalists, and Baptist reported satisfaction ratings of 99% from both patients and primary-care physicians.
Baptist's success was noticed by hospital executives at neighboring Lee Memorial Health System in Fort Myers, Fla., which signed on with Cogent to provide hospitalist services for patients at Lee Memorial Hospital; HealthPark Medical Center, Fort Myers; and Cape Coral (Fla.) Hospital.
Craig Miller, senior vice president of medical affairs at 492-bed Baptist, says the hospital decided to outsource its hospitalist program originally because the investment of time and resources required to meet the hospital's standards was more than the hospital could commit.
"We have learned that having the best processes ... is the most important element in a successful program," he says. "The quality of the aircraft is more important than who is flying it. At the same time, our hospitalists must be committed to the hospital's philosophy of customer service and customer satisfaction, and be incentivized to meet the hospital's goals."