The Cleveland Clinic is making inroads in the quest to reach the Triple Aim of healthcare—better care, better health and lower costs—and the successes so far have inspired clinicians within the organization to want to do more.
The nonprofit multispecialty academic medical center, a leader in efforts to improve the patient experience, has several ongoing initiatives that aim to provide patients with better access to care, more affordable care and improve the quality of care, Chief of Staff Brian Donley, M.D., told FierceHealthcare in an exclusive interview. Among those initiatives: expansion of the organization’s telemedicine efforts, an e-ICU, a mobile stroke unit, standardization of care pathways and caregiver wellness programs.
The organization’s telehealth services have grown considerably since 2015 when it first partnered with American Well to deliver urgent care via telehealth. The service allowed patients to download a free app to connect with a physician or nurse to receive advice for minor health issues, such as a rash or the flu. The services are now available 24/7 and the Cleveland Clinic’s Express Care Online allows patients to use their computer or mobile device to meet with a doctor by video 365 days a year. “No matter where you are, you can connect to a Cleveland Clinic physician and they can answer any problem you have,” Donley said.
Intensive care patients have an extra layer of care via the organization’s homegrown tele-ICU program it has dubbed eHospital. The program allows board certified intensivists to monitor the sickest patients remotely in a command center between 7 p.m. and 7 a.m. and intervene immediately if there is a problem. The eHospital intensivists oversee 208 ICU beds within community hospitals in the Cleveland Clinic’s system in Ohio and Florida. The program, Donley said, has “dramatically increased quality of care and reduced length of stay in the ICUs.”
Another exciting initiative, Donley said, is the Clinic’s mobile stroke unit, which has been able to shorten the time between the patient’s onset of strokelike symptoms and the administration of clot-busting drugs from 94 minutes to 56 minutes. Timing is critical because the clot-busting drug must be administered within three hours of when the patient first experienced symptoms.
The unit, which is an ambulance equipped with a CT-scanner and video equipment, is staffed with a paramedic, a critical care nurse, a CT technologist and an emergency medical services driver. The mobile stroke unit team is sent to a patient’s home if the 911 dispatcher, after asking a series of questions, believes the patient may be experiencing strokelike symptoms.
Donley said that the team will conduct the CT-scan in the patient’s driveway and transmit the images to the neurology department at the main campus. If the neuroradiologist determines the patient is experiencing an ischemic stroke and needs a thrombolytic drug, the team will start the drug in the ambulance. “It’s dramatically decreased the time between figuring out what type of stroke a patient is having and administering the drug. We’ve had some patients who had a stroke under the previous treatment and had lifelong mental and physical disabilities,” he said. But patients who received treatment via the mobile stroke unit have gone home the next day with no disability, Donley noted.
Although the unit is expensive ($1 million), the Centers for Disease Control and Prevention estimates strokes cost the United States an estimated $33 billion a year for healthcare services, medicines to treat stroke and missed days of work. The Clinic believes it will end up saving money on the back end because the mobile unit allows clinicians to treat patients faster, with fewer side effects, and patients won’t need further treatment or rehab. Since July 2014, the mobile stroke unit has administered the clot-busting drug to 102 patients.
Standardization of care
Another effort to help reach the Triple Aim is the organization’s decision to reduce variation of care by developing care paths or guidelines for treatment of certain conditions. Donley said that when all doctors follow similar pathways to treat their patients, it reduces variation in care, lowers costs and increases quality.
Care paths have been developed for strokes and the total knee and total hip program. The stroke care pathway has led to a 43% decrease in stroke mortality and a 25% decline in the cost of care, he said. Stroke costs per day were $3,402 prior to the introduction of the care path and since implementation have dropped to $2,553.
The care paths for the total hip replacement and total knee replacement have also had impressive results. The Cleveland Clinic reports that since the pathways were implemented in October 2013, its average length of stay for a total hip replacement has decreased 29% and 34% for a total knee replacement. Furthermore, patient discharges to home have increased 39% for total hip replacements and 44% for total knee replacements. Costs area also going down. The Clinic says direct cost per encounter has decreased 8% for total hip replacements and 5% for total knee replacements.
Caregiver wellness initiatives
But the Cleveland Clinic isn’t just trying to achieve the Triple Aim. The physician-led organization is also taking steps to meet what has been described as the Quadruple Aim, which involves improving caregivers' experiences.
In order to take great care of its patients, Donley said the organization believes it’s important to take care of its caregivers too and reduce burnout. For the Clinic, that means truly listening to doctors to hear their concerns and helping all clinicians find a sense of meaning and purpose in their work.
So physicians can have more time with patients and less time entering data into the electronic health record, the organization has medical scribes input information in the system. It also has taken steps to reduce the number of clicks necessary to get to the next screen. In addition, it has hired a pharmacist to handle the majority of prescription refills to free up physician time. To help doctors have a sense of community, the organization also sponsors monthly social events so physicians can talk with one another. It also has a program to train physicians to be mentors and coaches to help other clinicians.
While the efforts have helped reduce burnout, Donley said it’s still an issue. “The national average for physician burnout is 54%. Our assessment shows our physicians at 35%. So while it is much lower than the national average, we are still concerned and actively working to address it,” he said.