Core Competencies

4.10 Healthcare Systems: High Value Care

Introduction

Value in healthcare is defined as quality achieved relative to cost. Quality encompasses individual patient and population health outcomes, safety, and experience while cost includes resource utilization and opportunity costs. In order to operationalize high value care (HVC), the Centers for Medicare and Medicaid chose to apply the Institute of Healthcare Improvement’s Triple Aim framework – improving the patient experience, improving the health of populations, and reducing the cost of health care. Pediatric hospitalists are well positioned to promote high value care by decreasing costs, increasing safety, enhancing the patient experience, improving efficiency of care delivery, and improving clinical outcomes. Pediatric hospitalists should deliver healthcare in a manner that optimizes value to the patient, patient populations, and the healthcare system.

Knowledge

Pediatric hospitalists should be able to:

  • Discuss how providing “the right care at the right time in the right place” is necessary to optimize value to the patient and the system.
  • Summarize the basic structure of the patient-centered health care delivery system, including the macro system (national and regional systems), the mesosystem (integrated inpatient and outpatient settings), and the microsystem (front line care between physician and patient).
  • Summarize the National Academy of Medicine’s (formerly Institute of Medicine) six aims of healthcare: Safe, Timely, Efficient, Equitable, Effective, and Patient-centered care.
  • State the importance of defining healthcare value as the ratio of quality over cost and compare and contrast value for a single episode of care for one patient versus for a population over time.
  • Discuss how coordinated management of complex chronic diseases and development of integrated delivery systems can impact healthcare value for patients, the family/caregivers, and the healthcare system.
  • Cite examples of how failure to coordinate and align care in and across each of the above systems can fragment healthcare delivery.
  • Compare and contrast the definition of healthcare quality from the perspectives of different stakeholders, including the government, other payors, healthcare systems, hospital and medical staff, and patients and family/caregivers.
  • Define the terms “overuse,” “over-diagnosis,” “over-testing,” and “over-treatment” and review how these may impact patient safety, the patient experience, and costs of care.
  • Using evidence-based medicine principles, describe how best practices and streamlined clinical care result in increased healthcare value.
  • Explain why hospitalists should have a working knowledge of the risks, benefits, harms, pretest probability, and relative costs of commonly performed healthcare tests and treatments.
  • Review the goals of shared decision-making discussions and cite how healthcare value should reflect the patients’ and family/caregivers’ unique perspectives on goals of care .
  • Provide examples of hospital care costs under control of the hospitalist and review how controlling costs for a single patient or population of patients impacts the value equation.
  • Illustrate the importance of local considerations when prescribing a treatment plan, such as total cost, compliance, pediatric formulation, and insurance formulary lists.
  • Summarize the relationship between patient safety, quality improvement, and high value care.

Skills

Pediatric hospitalists should be able to:

  • Demonstrate skills in communicating indications for tests, procedures, and medications, with patients, the family/caregivers, consultants, and the healthcare team.
  • Provide education and information to patients and the family/caregivers that assists them in understanding and choosing care that is supported by evidence.
  • Identify costs to patients (including time, anxiety, expense, and clinical harm) and the healthcare system (including time, resources, and expense).
  • Educate trainees on the definition of healthcare value and importance of cost considerations of medical care.
  • Demonstrate proficiency in adhering to best practice protocols and guidelines.
  • Identify interventions that provide no benefit to overall clinical health outcome and/or may be harmful and participate in abating or eliminating these practices.
  • Participate in developing, utilizing, or reviewing performance reports to improve delivery of value-based care.
  • Apply the concept of “Right patient, right place, right time” in practice, to maximize value to the patient and the healthcare system.
  • Work effectively and collaboratively to integrate hospital discharge and post discharge care.

Attitudes

Pediatric hospitalists should be able to:

  • Recognize the importance of providing preventive healthcare as part of a high value care.
  • Role model resource utilization stewardship by allocating resources that result in high-value and evidence-based care.
  • Realize the value of working collaboratively with other stakeholders to continuously improve health care outcomes in a patient centered and cost-effective manner.
  • Demonstrate leadership and professionalism by proactively seeking feedback on clinical practice patterns to identify actions viewed as low-value or harmful to patients.

Systems Organization and Improvement

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

  • Collaborate with hospital administration, colleagues, and other hospital staff to identify and share information about costs of care, including drugs, medical imaging, devices, procedures, and consultations.
  • Support healthcare system efforts to gather and disseminate cost, quality, and safety data for use in monitoring quality and business improvement efforts.
  • Promote standardization of clinical care based on local pathways or protocols and national clinical practice guidelines as tangible ways to improve adherence to best practices and increase value.
  • Collaborate with hospital administrators to determine and direct policies that impact healthcare utilization.
  • Provide leadership to affect change on a systemic level by identifying opportunities to improve outcomes, minimize harm, and reduce health care waste.

References

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