#55 - Deaconess Health System Expands Access to Care

Jeff Terry:

Hello and welcome. I'm Jeff Terry. Delighted to be joined today by Amy Kruger and Dr. Phillip Adams from Deaconess Health System. Welcome to the podcast. Hi.

Amy Kruger:

Hello. Good morning.

Dr. Phillip Adams:

Hello.

Jeff Terry:

So to start, Deaconess's Journey the last decade, I guess, has been pretty exciting growing from, I think, something like five to now 13 and, within a couple of months, 14 hospitals. Obviously with the goal, which we all broadly understand and read about, which is growing as a hospital network to connect resources and get patients the care they need across a wide geography, but you guys have been at the forefront of really doing that. So if you wouldn't mind, bring our audience into that, Amy, maybe starting with you. What are the factors of that? How have you approached that, realizing the potential of that network expansion?

Amy Kruger:

Absolutely. So I think the strategic goal of Deaconess obviously is to provide some stability with the growth as we see some of our smaller hospitals and the state and the region that are unfortunately failing somewhat economically with healthcare and everything that's going on. And so Deaconess really wanted to approach with a strategy of really stabilizing our community hospitals, keeping patients closer to home, and then also giving that quality care to patients closer to home so they don't have to travel for those services.

So that's the strategy that's been implemented. It's been wildly successful, as you've said. We've grown tremendously, and it's so exciting to bring these new facilities on board, provide some of that stabilization and watch them grow, shine, and again, knowing that we're giving back to that community by keeping those jobs and that quality care close to home.

Jeff Terry:

And I should have mentioned at the open, Deaconess is centered in Evansville, Indiana, so southern Indiana, but now spans, I think, four states in the catchment areas.

Amy Kruger:

That is correct. So we serve Indiana, Kentucky, Illinois, and then somewhat into a portion of Missouri and then even looking to expand down to Tennessee. With that being said, a lot of those areas are very rural in nature, and especially in Kentucky and southern Illinois. And so they don't have a lot of resources or big systems close by, so we're geographically just right in that great spot where we can help provide those services, that quality of care and keep those patients in their community.

Jeff Terry:

Absolutely. It's tough to staff an ICU at a 50-bed hospital. It's hard and harder to do. So expand on that a little bit. Or maybe Dr. Adams, what does that look like? So we want to get patients the care they need close to home. Unpack that a bit for us.

Dr. Phillip Adams:

Sure. So as Amy mentioned, southern Illinois and western Kentucky is pretty rural. Most other health systems are shedding services. They're getting rid of health systems, smaller hospitals. This area is really covered primarily by critical access hospitals. Illinois is sometimes a difficult state to practice in in terms of some of the physician friendliness, litigation, and lots of other factors play a role in Illinois, in general, but southern Illinois, with the vast majority of the population being in or around Chicago, you have a lot of really rural areas, and that can be very difficult to get patients care.

And so as they start to shed services, the challenge is how do we get care to them? So they would either go to St. Louis, which is about equal distance for a lot of the patients. Sometimes it's a little closer. Or they're going to go further north, or they're going to have to go more east towards us in Evansville. And as the growth has gone over the last really decade or so, those patients really preferred going to Evansville. It's a little smaller. It's a little bit easier to get their healthcare, easier access. And so we capitalized on that by saying, "Why don't we create a hub-and-spoke model where we have a larger facility in different areas that can accommodate the needs of those patients?"

And in doing that, what we were able to do is really center our focus and look at the types of resources we have and take a little bit larger facility to handle the normal volume of the critical access hospitals that would be transferred to a larger facility. And so as we've grown, we used to be able to take all the transfers we wanted, and then, of course, COVID changed all of that for everyone. We were still taking lots and lots of transfers, but at that point we realized we just couldn't take transfers from everyone. And in the way we built our process, we were the easy button. And so the rest of the health systems in the region realized that, and so we became their preferred partner. And so we capitalized on that growth by creating these hubs, these little bit larger facilities that can accommodate care.

Jeff Terry:

Absolutely. And Amy, I want to double click on something you mentioned. I love that word stabilize. And I obviously don't want to be controversial or anything at all, but I think it's well-known that there's stress around rural hospitals closing. And so the strategy here has been, how do we ... Say more about that.

Amy Kruger:

There has been quite a bit of stress, and we've seen health systems within our own state of Indiana, even one of our larger health systems, are closing hospitals. And that ultimately is stressful to those communities. So again, I think it's important to help these smaller communities receive that quality of care. As Dr. Adams mentioned, our hub in Evansville, our mothership, are the most advanced services and where patients can come for those more complicated needs, but really capitalizing on the services that we can offer in those smaller hospitals. For example, one of our hospitals in Illinois has a strong cardiac program, so think of all those patients now that we can direct that way in that area and not have to take up beds at our mothership facilities. And so that's incredibly helpful to everyone to help with that balance loading.

Jeff Terry:

That's awesome. Amy, I love that example of the cardiac program. What are some of the other, I guess, pathways that you've worked on together to move certain types of cohorts of patients or certain clinical programs that you've stood up as the network has grown?

Amy Kruger:

Sure. So we've recently added a couple of neurologists to our facility in Kentucky. And with those two neurologists coming on board, they've had the capacity to really help us in telestroke and teleneurology. And so we took a hospital, Leapfrog scores weren't so great. In fact, we went from an F to an A in that facility in a few short years that Deaconess took on that facility. So we've really capitalized on that and saying, "This is a great place. If you are experiencing a stroke or you've had a stroke or you need neurological care, this is the expert facility to go to." So telestroke and teleneurology is an initiative that's really up and coming for Deaconess.

Jeff Terry:

And not necessarily all centered in Evansville.

Amy Kruger:

Correct.

Jeff Terry:

That's great. Absolutely. Dr. Adams, anything to add there?

Dr. Phillip Adams:

I was going to say just that we're really focused on the needs of those communities. So the hub-and-spoke model makes sense when you don't necessarily need a cardiologist in every one of those facilities, but you don't want your cardiologist to be three hours away, the closest one. So we're really paying very close attention to the needs of those communities. And a lot of times we've purchased facilities that may not have the best reputation, but have a lot of potential. And we're really trying to build our culture there so that you get the quality of care that you expect at our mothership hospitals, at our local, smaller communities, which helps to encourage those patients to stay local and makes it easier for the patient, for their families, and obviously for our system as well. So it just makes sense all the way around to try to create a win-win for everyone.

Amy Kruger:

I will add, just for an example, last year at this point in time, one of our newer facilities in Illinois had a census of 12 patients in the month of October. And we're up to 40, so that's pretty significant for that smaller hospital. We hope by December to get them up to 60. But they've taken pride in that, with that growth and that progress, and they're excited about really hitting that mark of 60. They're already in the talks of adding more beds, more units. We're getting some great physician recruitment in that area. So it just goes to show if you put the effort into it, it's quite fruitful.

Jeff Terry:

Absolutely. It's such a virtuous cycle for the staff, for the community and for the patient. Well, that's great. And if you wouldn't mind double clicking on, you guys lead teams that do a lot of things that are related to the management and the orchestration of the network. Would you mind explaining your roles a bit more in the teams that you lead?

Amy Kruger:

Sure. I can start. So I am the manager of our what was called the access center, but now we're calling Command Center. And I have two areas of that, a clinical side and a nonclinical side. The clinical side is quickly turning into what our Command Center program is. So within the Command Center, and I know we'll get to the structure of DCARE here soon, but of course, it's bed placement, transfer RNs, our clinical expediters. We now have EMS dispatch. We have environmental services dispatch. So bringing all those teams together into one combined space has been incredibly helpful.

My other area is practice transformation, which is taking a lot of the phone calls out of our clinic offices and centralizing them in one location, and then also providing that scheduling piece with that as well. And so they also provide scheduling for hospital follow-up, ED follow-up. And so we've been able to connect a lot of dots there by reducing admissions. For example, in our emergency department, if we can assure our physician that we can schedule an echocardiogram or a stress test the very next day for a patient, maybe he'll have comfort in sending that patient home, knowing that they'll have that follow-up care the next morning. So a lot of pieces intertwine within my areas, and then I'll let Dr. Adams explain what he does as well.

Jeff Terry:

Awesome.

Dr. Phillip Adams:

Sure. So I'm a hospitalist. I spend about half of my time working as a hospitalist still primarily at the midtown campus. That's the closest in proximity to the Command Center. It helps me to get to and from meetings and things as well. And then the other half of my time I spend, initially it was the medical director for the access center, so I helped to build our physician the access center program. So we have a hospitalist there from 11:00 to 7:00, taking transfer calls, the medical transfer calls, fielding some of the other calls as well, helping to get to the right specialist, make sure we get the right patient, right place, right time. So that's really important from that perspective.

We're actually working to grow that. That's been an integral part of our growth in terms of the regional growth. Having a physician that can access the transfer request within 15 minutes is our goal. A lot of times we're doing that in near realtime. They're calling, we get the information, we say, "Hold on just a second, let me get my doctor." And then the doctor talks and accepts that patient or whatever needs to happen. And so that process is very, very streamlined. It's been an incredible process for these smaller EDs that are trying to get their patients out of their facility when they can't handle that and get them into a facility that can help that.

So as we grow, that focus is really on making sure that we pick the right location. So that certainly is a little bit of a challenge with obviously the growth that we've had, but we really have to be on top of understanding where our services are at, what our capabilities are at each facility. And then of course, having DCARE with the GE software really helps us to understand where we have capacity and where we don't have capacity, because that really drives a lot of our decision-making to make sure that we get the right patient in the right place.

Jeff Terry:

That's brilliant. And I sometimes think this phrase is limiting, but I think it certainly applies to a part of what you do, which is together the access physicians, Dr. Adams and Amy, you and your teams, you are the air traffic control of that network that we spoke about. Not in theory, but in daily practice. Where should patients go? How do we get them there? And making the decisions throughout the day.

Amy Kruger:

Yep, that is correct.

Jeff Terry:

Awesome. And so Dr. Adams mentioned that you guys invested in something called DCARE, which we've obviously just been delighted to work with you on. And that is a Command Center to co-locate these functions that you mentioned and bring in some new information tools to make it easier to see who's where and waiting for what and all that sort of stuff. On the one hand, I think to the audience probably sounds great, but obviously Deaconess has a lot of things they could spend money and a lot of ideas, so evaluating something like that is serious business. So help us understand, how did you think about the decision to make this investment? What was important about it? How did you evaluate it?

Dr. Phillip Adams:

So honestly, when we first started the physician access center program, we started realizing we've got a lot of challenges. And historically we've been part of lots of committees. Amy and I have been on a lot of the same committees with throughput, working through some of the challenges that the system has. And what we've come to realize is that we really were having a hard time getting the patients to the right place, right time, and all of those pieces. And so we recognized that to be able to be successful, we really had to think about things differently. And especially in the height of COVID, when we were really struggling with beds, we had a waiting list, sometimes 20, 30 patients trying to get in. How are we going to really efficiently manage a system that's this complex?

And when I first started 10 years ago, we had two hospitals, and then over the last four or five years, we've added the other three. And then we were under the impression that we would have five hospitals when we started saying, "We can't manage all of this volume from all these around locations with the five hospitals we have." So we said, "We really need to think about this differently, and how do we do that?" So we started looking at the different options, and really our predecessor said, "I've got the permission to start looking into a Command Center concept." Well what's that? And she said, "Well, I'm not quite sure yet what that means, but I've got some ideas." And so I said, "Let's start looking."

And so we started looking, and we started realizing as we started looking at the different products, we first found GE, of course, and said, "Oh my gosh, this is really everything that we have been asking for forever. How do we tackle not only capacity in a broad sense, but how do we tackle capacity in an individual patient sense? How do we figure out what that one thing that's holding that patient up really is?"

So interestingly enough, during COVID, the CEO called me and said, "We've got 175 COVID patients in the hospital. Tell me who can go home." I said, "That's a really good question. Let me look." So I spent about three hours, I got through about 20, 25 patients, and I said, "I have no idea. I don't know how to take a chart and chart review all these different patients and figure out what does this patient really need to be able to progress on their care line, their care progression?" And so that really struck a nerve with us in terms of we didn't understand what we were really waiting on and what needed to happen to make this care progression happen.

And so that's where all of this started. And so of course, just like with any health system, you've got to figure out a way to pay for it. So we went with the simplistic way. We didn't want to find any quote, soft dollars or anything like that. We wanted direct income. And the easiest way to do that is looking at your transfers, and that had always been a growth area for us. We've always focused on transfers. And so we wanted to look at that and say, "If we're going to do that, what can we realistically add day by day to help impact those patients?"

And so we came up with a budget of two patients per day as our benchmark, and that way we could look over a course of a couple years, two-and-a-half years would essentially pay for the cost of the program. Well, we ended the first fiscal year at 5.6 transfers more than what we had from the previous year, so almost three times what we said we would do. So that made it a much easier process in terms of explaining and linking that to our administrative team. They could buy into bringing in more patients equals increased revenue, and so that was an easy sell for us from that perspective. Everything else is just bonus is the way they looked at that decreasing length of stay. Exactly. Quality metrics, all of those things that we think we can really improve on as we move forward, that's how we're bringing in other people, recruiting physician and more physician engagement, more nursing engagement. It's the successes that we accomplish after that, but we just had to come up with one way to be able to pay for the program to start with,

Jeff Terry:

And one that's tangible, it's not hard to track, which is important.

Dr. Phillip Adams:

Exactly.

Amy Kruger:

Right.

Jeff Terry:

So that all makes perfect sense, and you guys are both very close to it, so it's very clear. I'm curious, if you recall, as you're going through the committees and different people are getting involved, many of whom are not as close to this problem, was there any reaction or challenge or question of theirs that comes to mind that you had to address or explain?

Amy Kruger:

Oh, yeah, absolutely. We're a very frugal organization, and so there's a lot of red tape to get through if you want something. So I won't say that the process wasn't challenging to move this forward, but there truly was administrative support. They recognized the need, especially post-COVID when we were triaging and trying to figure out how to get patients to the right level of care. But I will say one question that we were challenged with over and over is, well, how do we use what we already have? What tools do we have that we can use? And we really pushed. We really tried. We explored every single option, because that's just what we have to do in order to push something. We have to explore every avenue, and there was just no comparison to what we found in our GE product.

Dr. Phillip Adams:

We also had to set a realistic target. We expected to increase four or five transfers, realistically, between the two of us per year over our baseline. But we couldn't go out and say, "Hey, we're going to bring in 10 more transfers or five more transfers a day for the entire year," because they would look at us and go, "Well, how are you going to do that?" And so that's been the backdrop of actually having fewer beds. So that's what makes it even more interesting. I think we could have actually grown quite a bit more. So having said all of that, we really spent a lot of time working with our senior admin, explaining the concepts and catching them in the hallways as we're walking to and from meetings, just presenting those little pieces. Setting the groundwork is so important to be able to help get that change management to occur. It's little baby steps, and it felt like it took us forever to do that, but we were constantly laying the groundwork for the next thing.

If we do this, then we can do that. If we only had this piece, if we only had that piece. And to Amy's point, we looked at everything, and we realized that there was no other product or service that could provide the information that we wanted the way GE could. And so that was an easy decision. That was probably our easiest decision, honestly, was to make that one. The hard work is really creating those metrics that you have to show that you're being successful by. You've got to create that return on investment. You've got to look at what your real ask is. How many people are you really asking for? This was a completely new project for the both of us. We're asking for new FTEs. We're trying to grow a program, all while doing our normal work too. So that's one of, I think, our biggest challenges in starting a program like that is just, how do you get all the resources and all the knowledge in place to be able to be successful at that? It's very challenging

Jeff Terry:

Actually making it happen. Amen. And congratulations to you both, by the way. It opened in August. It's beautiful. The place, but also the teamwork and the practices that are within it. And Amy, you used the word founder. It's a great word. Dr. Adams, I think you guys as the co-founders. But it's one thing to say, "We're going to do this." All the pieces you've got to do to make it go is remarkable, so congratulations.

Dr. Phillip Adams:

The other thing that I would really highlight too is it's really important to have somebody that's got similar strengths, but also some strengths that you don't have. So to partner with Amy, she's fantastic at being able to do all the things that I don't have time to do. She manages all of the people and the logistics of so much of that. And then I spend so much of my time working with the physicians and working with some of the ideas. So together we make a great team, because we compliment what each other does so well. And I think that's what you really have to look for when you're setting up your program as well is really finding the right people. And we've got a great one in Kate as well, and having somebody that really compliments us and that by extension, anytime you have a meeting or you have something you need to work on, you can trust your team to be able to take it whenever you're not available and have other responsibilities. And we rely heavily on each other to be able to do that.

Jeff Terry:

Amen. Complimenting and function and in style as a team. Go ahead.

Amy Kruger:

Yep, for sure.

Jeff Terry:

Awesome. I wonder if we could double click on one other thing, just almost like double clicking into DCARE. Could you highlight a practice or two, an example of what that group is doing that might be interesting to the audience, what a clinical expediter is doing, or how the transfer team is working differently and a practice or two to bring it to life?

Amy Kruger:

I think probably one of the biggest pushes that we're working through right now is really redefining our MDRs, having those meaningful conversations, make sure that we're tasking in our Tiles for DCARE so our clinical expediter can see those tasks and start working those. So that's been a huge educational piece at this point in time for our staff. And I feel like we're finally getting to a point of understanding and hardwiring. Even so, we're having great conversations on our leadership huddle in the morning with the entire health system where we're bringing up the Tiles, we're talking through our summary review, seeing how many outlying tasks that we have and where are they.

So that's been a culture shift for us in the past maybe week or so that we're feeling. We're finally getting there. We've been at this, well, we've been in implementation for over a year, and I will say that it's been a little bit of a struggle culturally as many healthcare systems know that when there's a huge change or shift. So that's one of the pieces that we felt recently is just overall engagement is finally rising and really getting into the Tiles and digging into that meaningful, realtime data, realtime view. So again, talking through those things on the leadership huddle, working on that MDR process that, like I said, that's completely being overhauled. And then having the ability for not only our expediter, but other areas, ancillary areas, whatnot, to start prioritizing correctly. So I feel like it's finally all coming together. There's finally a breadth of understanding.

Jeff Terry:

Totally. Dr. Adams, any practices you would highlight that I guess that have changed in the last year?

Dr. Phillip Adams:

It seems like everything's changed in the last year.

Amy Kruger:

There's a lot.

Dr. Phillip Adams:

There's a lot. But I think Amy hit on that as well. The ancillary services, just prioritizing echos and tests that sometimes have to be delayed until the next day for the right patient. That's such a different concept to really think about what's the right patient, what's the right order, how do you sequence them correctly? I think the other thing that I'm really excited about in the partnership with you guys is building a swing bed module. So as we've talked about these critical access hospitals, the thing that's so important for their survival is to be able to have patients in beds.

And so they get some of their patients from acute care from their ED, but a lot of their patients are what they call swing beds or beds that are used more for an inpatient rehab versus a SNF situation where they have those excess beds, and that drives the revenue that keeps these hospitals open. And so it's such an important part of keeping access in some of these rural areas is to have patients. And so to be able to create a process that we're able to really highlight the best patients, that small group of best patients to be able to get to the swing beds is so important. It's so much different than looking through 300 charts and trying to figure out which are the best patients to move to swing bed. It's just we're very excited for that.

Jeff Terry:

And do I have that right? When you say swing bed, you mean a bed that can swing in level of care between a SNF and an inpatient med surg type bed?

Amy Kruger:

Yes.

Dr. Phillip Adams:

Correct, correct.

Jeff Terry:

And then you said something which I think is so right, and it really resonates with me, is it's trying to find the small cohort of the right patients that match up with that is vital, and it's also harder than it sometimes sounds. And I love your example earlier, I was going to ask that, of, hey, it took you three hours to get through 25 patients, much less 185. Is that different now with DCARE? Is that an easier question to answer, who's ready to discharge?

Dr. Phillip Adams:

Absolutely. Hugely different. And that's one of the things that, in the stories that I tell people, if we had that to do again, we could change the filters on that, and I can tell you in a few minutes, I can give you 20 patients to look at. And we've got the top 20 patients that we might be able to impact. We can just forget looking at anybody else. And maybe it's not even 20, maybe it's really 10 that we have the most impact. And I don't have to dig through the charts. I don't have to spend hours trying to review everything. We can pull all that information into DCARE and really be able to see at a quick glance. Within a few seconds to a minute, I can probably review 20 patients and give you the best options for being able to discharge. And so that's completely different than the situation we were in a couple of years ago.

Jeff Terry:

That's great. I'm glad to hear it. Wonderful. I guess then last question, which is the future. So we've come a long way. You've already described a couple of things that are ongoing. Maybe Amy, starting with you and then to Dr. Adams, how do you see both Deaconess and DCARE evolving over the next couple of years?

Amy Kruger:

So right now we're really focused on throughput, balance loading capacity. That's been our phase one for DCARE. Phase two, we really want to get into the quality realm, really start adding ... potentially an EICU structure for some of our critical access hospitals that we've talked about, telehealth. So the possibilities are endless, but where we really want to focus on next once we have a good handle on capacity and throughput is more of the quality piece that we can impact. So I think that's exciting as well. So like I said, the possibilities are endless, but that's where we plan on going next.

Dr. Phillip Adams:

I agree completely with Amy. The quality part's so important, and we're really excited to move into that. But I think the other part of that is that we're constantly reevaluating or looking at current processes and seeing if we can do something different to make the system work better. And I think we continue to grow in those areas. We continue to look at innovation. What are new concepts or new ideas that other ecosystem members have? What are they doing? Well, one of the things we learned from Tampa was how to do a departure lounge. And so we stood one up, and we're still refining that process, but that was something we learned by visiting Tampa to see the GE product. And so as we learn from our colleagues in other places, the Dukes, the Tampas, the other fantastic organizations, we really are excited about the different things that we can do that we're learning from our partners.

And at the same time, we're also excited to share what we're doing with our partners as well. And to see the growth and the change in this realm, because it's so new for everyone, and yet it's so important. Everyone's looking at this as the wave of the future or the key to success, so to speak, over the next few years. And so we fully agree with that. Without having this knowledge, looking at capacity and what your strategies are and all of these things, this innovation, hospitals are going to get left behind. And the only way right now to get to success is you can't keep building buildings, you can't find staffing. Your only option really is to find ways to be more efficient. And that's what Command Centers do for you, and that's what GE has done for us.

Jeff Terry:

Amazing. Thank you for the kind words, Dr. Adams and Amy, that's wonderful. We love working with you and for you, and thank you so much for all the insights today.

Amy Kruger:

We appreciate you having us.

Dr. Phillip Adams:

Thank you for having us.

Amy Kruger:

Thank you so much.

Jeff Terry:

Thank you again. And with that, we'll close the podcast.