In our decentralized care landscape, health system command centers (HSCC) are coordinating high-quality care through complex and integrated delivery networks (IDN). Recently, command centers were recognized by KLAS and Gartner as a new model of care delivery with the potential to impact clinical, financial, and operational outcomes. That means in addition to improving routine health system operations—and increasing access and throughput at individual health systems—the collective national and international impact of HSCCs on care delivery has potential implications for health policy and finance.
High-consequence, complex organizations with decentralized operations such as aviation, emergency management, the military, and national power grid operations have used centralized command center models for decades to foster communication and coordination of time-sensitive activities in order to achieve target outcomes.
Healthcare organizations adopted a similar model in the 1980s for use during emergencies called the Hospital Emergency Incident Command System (HEICS), which has since become the Hospital Incident Command System (HICS). Combining the lessons from both healthcare and these other industries, the concept of a health system command center to support daily operations has emerged in concept and practice at several organizations globally.
Command Center Value
Health system command centers vary in cost, size, complexity, and scope based on the profile of the system they serve – read more about Broward Health; Carilion Clinic; Kettering Health Network. Healthcare is predominantly a team sport―yet through rich traditions and professional practice, silos are also prevalent. An HSCC mitigates these traditional barriers through co-location of essential expert personnel, the automation of data collection, defined communication pathways, and structured workflows for a distributed workforce.
A distributed workforce, whose primary role is providing patient care, is often faced with the challenge of looking beyond their direct department and taking a broad, macro view of what is happening across a hospital or health system to accomplish daily work. When patients are cared for in a system that is coordinated across the care continuum, access to care is expedited and a reduction is seen in the length of stay, costs of care (both direct and indirect) and the potential for preventable harm. HSCCs provide insight into resource utilization, give visibility to peak-demand and under-use of valuable care venues, supplies, staffing, and beds. An HSCC is able to assign scarce resources to emergent patient needs while choreographing a scheduled care plan for expected patient care reliably and at scale.
Health System Consolidation
As care models and reimbursement incentives transition from volume-based care to value-based care, the landscape is shifting. That shift was first seen over the past two decades when independent hospitals came together to form hub-and-spoke systems with a single regional specialty care center serving as the hub and community hospitals as the spokes. In more recent years, the hub-and-spoke systems came together to form integrated delivery networks, where care is distributed among various care venues such as specialty hospitals, community clinics, and virtual care. In 2018, there were approximately 550 integrated delivery networks, that combined include over 5,500 hospitals with nearly 900,000 in-patient beds. In 2016, across the United States, 91.6% of all hospitalized patients were discharged from an integrated delivery network. These networks are growing, independent hospitals are disappearing―and complexity across care networks is increasing.
Health Policy and Finance
As U.S. health systems contend with increasing patient demands for care, the costs associated with delivering care also continue to escalate. The average care cost for an in-patient stay has risen from just over $8,000 in 2006 to $10,500 in 2014. A recent Health Affairs article reports the Center for Medicare and Medicaid Services (CMS) estimate the national health expenditure will grow 5.5 percent annually through 2027.
How can health system command centers reduce cost growth?
1. Reduce the costs that result from waiting for care.
Anyone who has visited an emergency department knows what waiting feels like. The crisis of waiting is acutely felt along with all points of the care network. We have all waited in our doctor’s office for the appointment to begin, often later than expected. Scheduling a follow-up appointment is often outside the recommended time to access that care.
Those who experience time-sensitive conditions, such as trauma, stroke, sepsis, and heart attacks are impacted significantly. And when treatment for those time-sensitive conditions are delayed the results are increased costs, longer lengths of hospitalization, and lasting debilitating effects upon returning home. For example, 1.9 Million patients leave without being seen each year while 39% of hospital beds remain unoccupied.
Each hour a patient waits in an emergency department for a hospital bed costs an average of $100. Not only is this a direct cost of waiting, but often the in-patient care is not being delivered to the patient while they are waiting in the emergency department. Hospitalization is then extended, increasing costs and time required for healing. Patients in the hospital ready to be discharged often wait up to half a day before being released. Proactive planning, awareness, and coordination of resources to ensure a timely departure for patients is supported by HSCCs.
The timely departure of patients from the hospital provides the functional capacity to allow the next group of patients to progress from higher levels to lower levels of care as they heal. Without an effective prediction, coordination and communication process across care silos, patients wait longer and end up costing everyone more.
2. How can resources align to meet the demand for patient care?
– Everyday millions of patients are waiting for the care they need simply because resources are not scheduled in a way that they are available when they are needed most. This is not intentional; rather it is a result of a siloed approach to resource management. Within a silo of care, resources are scheduled and deployed to care for expected patient volumes and levels of care.
When health systems centralize visibility to the system level, misalignment across care silos becomes apparent. The HSCC is able to use historical demand data to enhance planning and adjust staffing and resources to meet patient needs, while also calibrating for any seasonal variability.
Patients need care according to scheduled procedures and treatments. While much of healthcare is planned and known ahead of time, silos cause issues with that planning and coordination. The HSCC model of care activates a macro view of needs―from scheduled care episodes to emergency patient accommodations.
Without a macro approach, individualized care becomes fragmented and uncoordinated. Fragmented care causes over-corrections that result in excessive, costly and disruptive “stat” requests. By incorporating data into the planning process, HSCC staff are able to manage resources ahead of needs, so the resources are available to the patient at the point of care where and when they need it.
3. How can prediction models manage care congestion points?
Every health system has the challenge to meet a patient’s needs when they present for care. Whether in an ambulatory surgical center, a hospital emergency department, or an urgent care center there will be both times of unexpected delay or extended need for treatment. When these situations arise, a cascade effect begins and quickly compounds to impact other areas not previously involved in the care delivery to the patient. Using advanced analytics, experts within the HSCC identify areas where performance metrics are exceeding pre-defined goals. When this happens the HSCC experts take targeted and precise actions to mitigate, and in some cases avoid, significant congestion delays.
Predicting and taking action on areas of congestion may only save a few minutes for each patient. However, minutes add up quickly when one considers the wide-reaching effects across a hospital or health system. Ideally, congestion never happens, and patients progress through the health system as expected and on-time.
Reality is that clinical care is as much an art as it is a science. Reducing the level of complexity in extraneous areas for clinicians allows for continued focus on the clinical challenges and care progression for the patients. The HSCC staff can reduce variation by managing risks, resources, and timetables. Over time, the current demands for care shift to earlier in the day, when care demands are aligned with improved care delivery capability. When supply and demand are better aligned, costs are reduced, and patients experience timely care delivery.
4. How might patients be balances across all care venues?
Integrated delivery networks have various care venues from virtual care, to primary care, to emergency care and specialty clinics. Often times, the selection of an access point is a matter of habit or routine for patients and/or clinicians. As technology improves and more options are introduced along the care continuum, making the right selection becomes challenging.
For example, a patient who may have historically presented to an emergency department for a condition such as influenza and now can be safely cared for at an urgent care center, or even a virtual visit using telemedicine on a smartphone. These options can be apparent when considered as a point solution, but when considering all the care options, and all the clinicians, within an integrated delivery network it rapidly becomes a complex decision-making process.
The HSCC can quickly aggregate the needs of patients based on geography, clinical needs, and available resources based on proximity, availability, and timeliness. More than two million times a year, patients are transferred from community hospitals to specialty care medical centers for care not otherwise available. In many transfer cases, the options are limited to transferring or not transferring the patient.
The practice known as “just say yes” is a practice from the hub and spoke days, when health systems competed fiercely for patients. Now that integrated delivery networks are aligned, and patients are essentially cared for within these narrow networks, the practice of “just say yes” results in 20% of patients being transferred when they could have been cared for safely at the community level.
An example is a patient who requires a specialist assessment and treatment plan. Instead of accepting the patient for transfer, the HSCC arranges an immediate telemedicine consult, an in-patient plan of care is initiated, the patient is discharged and then seen in the community-based specialty care clinic the following day. This streamlined care results in the avoidance of using resources that may be available for other patients in need.
These resources include ambulance or helicopter transport, tertiary or quaternary medical center beds, and specialty services within the medical center. With the HSCC’s ability to see the need and know the available resources, providing patient access to the right venue, at the right time, for the right costs becomes reality.
5. How do HSCCs impact harm reduction and improve quality?
Hospital errors and adverse events have been reported to be the third leading cause of death in the United States. Hospitalizations are not without risk― the longer the duration of a hospital stays, the higher the risk exposure. Conditions such as medication errors falls, infections and pressure ulcers are all a result of environmental factors, communication failures and time elapsed. An HSCC using principles of high-reliability, equipped with advanced analytics, is able to intervene when conditions become favorable for adverse events to occur.
Staff within the HSCC are equipped to take action and send help in scenarios where a patient may be experiencing physiological compromise, becomes at-risk for delayed treatment, or dwells too long in a particular status. In a recent RAND study, one hospital system that implemented an HSCC model was able to sustainably reduce adverse events by 15 percent.
Health system quality and service levels have been a part of the reimbursement matrix for the past several years. Many systems continue to struggle to define or positively impact quality and service measures. Quality and service are significantly impacted by the passage of time, experienced as “waiting” by patients and families leading to a sense of powerlessness. Reducing wait time is a primary outcome of an HSCC, which is addressed by choreographing care and assuring that patients are met by the clinical staff who are appropriately skilled, and equipped with the tools required, within an appropriate level of care venue. Using a combination of historical data, real-time data, and forecasting, these needs can be anticipated and met.
When certain conditions exist the HSCC staff are able to activate protocols and take action to mitigate problems and improve the service that reduces wait times, improves the experience for patients, and off-loads system-level burdens from front-line clinicians and staff. Using technology solutions, principles of closed-loop communication, and data-driven practices the HSCC becomes a specialty practice to operate the integrated delivery network.
As the United States continues to explore innovative healthcare policies and financing programs, the adoption of health systems command centers is just starting to be adopted. The work yet to be defined in the command center model is a common set of leading indicators for health system performance that gives rise to high-quality, reliable outcomes.
The IDNs that have initiated the HSCC model of care is starting to identify these key leading indicators while measuring the expected outcomes. Contemporary reports are encouraging, and new opportunities are emerging to have meaningful conversations around previously non-quantified measures. We do know that the pace of health system command center adoption is accelerating and the body of science to inform health policy and financing will continue to be refined and integrated into the national narrative.
About the Author
Scott Newton, DNP, RN, MHA, EMT-P is the Vice President of Care Model Solutions at TeleTracking, a provider of patient flow automation/hospital capacity management solutions to hospitals and medical centers. Dr. Scott Newton has more than 30 years of experience in healthcare—working as an EMT, a nurse, an educator, and a patient flow command center leader—he is also a trusted adviser and thought leader.
Dr. Newton has deep knowledge of the healthcare system and understands that success is tied to high reliability, just-in-time responses, and responsible solutions—that it’s about getting it right the first time for patients and clinicians. A graduate of the Doctor of Nursing Practice program at Johns Hopkins School of Nursing, Dr. Newton built a Command Center as an output of his doctoral project and believes that as healthcare continues to evolve, the patient flow will play an even more prominent role across the care continuum.
