Sealing cracks in the care continuum

After discharge, does supply chain hold the glue?

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Healthcare facilities must face the sobering reality that reimbursement now hinges on whether or not patients are readmitted within 30 days of discharge. Obviously the patient bears responsibility for following his or her post-discharge instructions, but facilities also play an important role in the care continuum by making sure patients fully understand and follow their discharge plans.

Some would say healthcare delivery doesn’t stop at the hospital exit anymore and that today’s continuum of care model continues to expand to where it’s no longer a matter of managing products and services for inpatient care only. After the hospital gowns and ID bracelets come off, some healthcare leaders are making — or thinking about making — stronger efforts to ensure that discharged patients also get the support and services they need to make a successful recovery at home and other non-acute care settings.

How does Supply Chain fit into the plan?

Deborah Roy

It doesn’t, according to Deborah Roy, Principle for Group Purchasing Organization, Vizient. Not entirely anyway, at least not when it comes to home-bound patients.

“While our members are monitoring and tracking post-acute care, including readmission rates, services provided by the supply chain department ends at the time of discharge,” said Roy. “Prior to discharge, in collaboration with the physician, the case manager will assist in providing appropriate referrals, as well as proper treatment plans inclusive of specific products and equipment. A local durable medical supply company provides necessary equipment, dressings and other medical supplies required post-discharge. Even for patients provided with home health care within the 30-day window, products deemed necessary for continued care are provided by the home health care agency.”

For patients that move out of acute care and into affiliated non-acute care settings, others are finding that an integrated supply chain approach is increasingly necessary to reinforce the continuum of care for all of their patients in cost-effective ways.

Joe Walsh

“Supply chains for discharged patients already exist in many forms; therefore, it is not necessary to fully invest in building out net new supply chains for discharged patients,” said Joe Walsh, Executive Vice President of Operations at Pensiamo, an organization that helps facilities optimize existing supply chain assets and design solutions for all expense areas throughout the continuum of care. “Most home care companies already have existing supply chain operations, which get products to patients in a highly reliable manner. Specialty pharmacy companies and retail pharmacies have robust supply chain operations too. The challenge is that these supply chain operations are disconnected from the acute care supply chain. The opportunity is to connect the non-acute and acute operations into one segmented supply chain, centered on the entire patient experience.

“Even within some of the most progressive IDNs, its common to find a Chief Supply Chain Officer with little to no influence over the non-acute supply chain,” continued Walsh. “There is tremendous opportunity to segment the supply chain according to the spectrum of services and by the continuum of care so care pathways can be appropriately supported. This is the next frontier for supply chain. For every organization (other than those continuing to hang on to the legacy fee-for-service environment), the business case for change and investment is compelling.”

Mike Maguire

Mike Maguire, Vice President of Strategic Sourcing at Premier Inc. says taking on that added responsibility can be difficult for supply chain departments already feeling stretched thin by having to satisfy internal demands related to inpatient care.

“As it is currently built, the supply chain department cannot take on the order fulfillment function of thousands of small ship-to sites,” said Maguire. “This is why they need to work with a DME or outsourced provider to provide necessary logistics. Premier has many avenues to assist the supply chain team and internal partners. We have contracts that cover services for patients being discharged as well as direct-to-patient shipments of products. Premier also has the ability to provide extension of the products on our contracts to numerous classes of trade, such as physician offices, ambulatory surgical centers and long-term care facilities.”

“Supply chain has historically organized itself around expense categories or service lines throughout the hospital environment,” added Walsh. “Imagine a near-future world where organizations establish cross-functional teams to manage the continuum of care for an entire population for specific disease states or conditions. Supply chain leaders will be integral members of these committees and become responsible for implementing specific supply chain solutions for every dimension of category management, across the spectrum of services and throughout the continuum of care (see figure 1).

Figure 1 – Model of supply chain organized across the spectrum of services

“The supply chain of the future will have a dozen or more distinctive supply chains, which will each have dedicated talent, processes, technology, vehicles and facilities uniquely configured to the end users, markets, and products they serve,” Walsh continued. “This is accomplished through supply chain segmentation. The days of ‘one size fits all’ and ‘building for scale’ are behind us.”

Frank Fernandez, a supply chain consultant at waypoint2580 and former IDN supply chain leader at Baptist Health South Florida, says organizations tied to non-acute settings that can pick up the baton when patients are discharged will often take a more coordinated approach to implementing product continuity and achieving best outcomes. For those who don’t, he says their patients may fall through certain cracks along the care continuum.

“If the discharge hospital is not focused on the continuum of care to include post discharge, then the patient is left to navigate this uncharted territory,” asserted Fernandez. “The patient may have been on a therapy device in the hospital, for example; however once the patient goes home, the patient’s insurance company may not cover the same device. The covered device might not perform in the same manner as the device used while the patient was in the hospital. As we move toward post discharge tracking by CMS, hospitals will be forced to coordinate this process in order to support good outcomes for the patient and appropriate levels of reimbursement for the healthcare provider.”

Roy from Vizient says their members don’t yet have a need to procure products for discharged patients, nor have they experienced any related reimbursement penalties. “Our focus is on providing our members with the processes and tools necessary to efficiently manage their supply needs and deliver quality care to their patients across the continuum,” she said. “Vizient addresses those needs in a variety of ways: robust supply and clinical analytics that inform supply decisions and value analysis processes, expertise on supply chain operations to gain efficiencies, and opportunities for clinical collaboration to speed the implementation of best practices that improve patient outcomes.”

But if those Supply Chain members were to be charged with such a task, the requirements needed to drive successful outcomes across such a vast continuum of care would be many, says Roy. “The hospital’s supply chain department would need a very robust data warehouse that populates all the identifiers for managing not only the total episode of care from the acute side, but inclusive of post-acute care as well,” she said.

Doug Golwas

“It can be done,” said Doug Golwas, Senior Vice President, Corporate Sales, Medline. “Recent industry trends are putting pressure on U.S. hospitals to hold themselves more accountable for patients’ quality of care regardless of where the patient is cared for. At Medline, we talk about systemness a lot. Systemness is the ability to provide a consistent experience for patients, clinicians and staff across the continuum — regardless of the care setting.

“IDN supply chain executives enter into prime vendor agreements with distribution partners such as Medline to service an IDN’s comprehensive medical and lab product needs,” Golwas continued. Through this vendor partnership, IDNs receive the logistical, technological, and clinical support to meet an IDN’s patient care objectives across an IDN’s continuum of care.”

Fernandez says ongoing dispensation of medical supplies and devices for post-discharge patients would require both minor and significant structural changes, depending on circumstances. “Collaboration agreements might be created between the hospital, and community-based DME and medical supply providers, to ensure post discharge supplies to the patients,” he said. “A structure where the acute care provider establishes a wholly-owned outpatient service that focuses on post-discharge follow-up to patients, might fulfill this requirement, although such a structure would have to be fully vetted, with consideration for legal reimbursement, and compliance requirements.”

As it stands now, Fernandez noted that supplies issued to patients for long-term post discharge for care at home could violate the Robinson-Patman Act. “Supply Chain might issue a reasonable or limited amount of supplies to the discharged patient, to facilitate the transition of the discharged patient, to the home. However, Supply Chain may not be engaged in the sale of continuous amounts of supplies to support post-discharge care. The only way this could be accomplished, is if the patient were enrolled as a patient, in an outpatient program that supports post discharge care from the discharge hospital.”

Walsh from Pensiamo says if managing supplies and services for the discharged patient does become common practice down the road then it’s probably something supply chain departments might want to explore now.

“Over time, hospitals are expected to shift more care towards the home. Supply chain leaders need to contemplate the lead time necessary to build the non-acute infrastructure and ultimately connect it to the broader integrated supply chain,” Walsh concluded. “It’s not too late to get started, but the clock is ticking.

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