Navigating the Care Continuum

According to a recent 2018 hospital and health system provider survey by Research and Markets, “68 percent of health systems have plans to build, remodel, or acquire facilities across the continuum of care.” The survey also found that as these non-acute and acute-care settings merge, supply chain executives, feeling the squeeze of cost-containment, are eager to find distributors and other partners with solutions for reducing costs and streamlining operations. So, what exactly does it take to support patients through the full continuum of care today — and tomorrow — and what are the factors driving supply chains’ sourcing decisions?

Continuum of care — what does it mean now?

Providers are also growing increasingly more incentivized to modify the care model. “Across the care continuum, the patient’s providers, specialists and caregivers operated in a loose federation — often with incomplete information, in different locations, and with a lack of monetary incentives to adopt a team-based approach coordinating and optimizing care for each individual patient,” said Terence Maytin, Vice President, Market Development and Commercialization, Medocity. “Providers, payers and pharma have all taken a keen interest in developing more holistic, comprehensive approaches to deliver care across the entire continuum in a more efficient, coordinated manner. While the continuum of care is still a car by definition, it’s definitely not your father’s Oldsmobile anymore.”

Others seem to agree, noting how healthcare systems are widening their focus to include a more patient-centered approach to providing care. “The patient typically views their care journey holistically, and providers are now beginning to do the same,” said Lyndsey Lord, MBA, BSN, RN, Vice President, Clinical Studies, CipherHealth. “Previously, providers were very focused on regulatory and revenue items that were specific to their care setting and location. With changes in healthcare delivery, specifically alternative payment models (APMs) from the Affordable Care Act, providers are financially incentivized to track and monitor patient progress and activities longitudinally.”

The end is just the beginning

“The most significant change in this area is a growing awareness that care provided in a single venue (e.g., an inpatient stay at an acute care hospital) has an incoming context and an ongoing goal,” suggested Brian C. DeBusk, PhD, MBA, President and CEO, DeRoyal Industries, Inc. “In other words, why did the patient admit in the first place? And once the acute-care phase is over, how will downstream providers deliver seamless post-acute care and ensure that a readmission does not occur? Clinical and financial excellence within a specific venue is no longer enough; all healthcare stakeholders need to recognize their role in a larger ecosystem.”

Plus, the majority of patients want their providers to consider their welfare after discharge. A consumer survey conducted this year by The Beryl Institute showed 92 percent of respondents think it is either extremely or very important to participate in a discharge check-out process in which their treatment plan and/or next steps in care are clearly explained. There was also overwhelming agreement that helpful, timely follow-up communication should take place after an appointment, hospital stay or procedure. “The reality revealed in the responses of the respondents show that even thoughtful, tactical efforts to address experience may be overlooked if the central narrative organizations wish to convey is not clear, strong, consistently delivered and reinforced at every touchpoint,” stated the authors of the survey report.

“Activating the last mile is critical,” said Maytin. “Enabling clinicians to efficiently monitor and interact with patients wherever they are [is necessary]; after all, 95 percent of avoidable costs — $200 billion a year — occur between visits.

Supply chain affect

As Downey noted, the continuum of care model may be as old as the mullet, shoulder pads, the Delorean, the boombox or (insert your own 80s culture icon) but that doesn’t mean it has remained static or hasn’t presented new challenges for supply chain.

“Managing the continuum of care has absolutely affected supply chains,” Downy said. “Supply chain leaders now need a strategy that encompasses both their acute and non-acute settings, and many IDN’s are still creating or adjusting to this new environment.”

To survive, Downey says meticulous data collection and actionable analytics are crucial for accurately and consistently tracking and managing variances in spend, consumption, stock levels, etc. Supply chain also needs to choose the right distribution and logistics partners and select the appropriate programs within each. They’ll also want to adopt support services that can help them navigate new territory, such as knowing what items and services patient experience programs require to succeed or what the delivery of remote healthcare entails — a component that is becoming more common in a patient’s continuum of care. “Supply chain leaders must consider how programs like home health will tie into the supply chain for data consistency and supplies,” said Downey. “They must also determine where the health system’s pharmacy programs fit and how they may serve all facilities in the care continuum. Consideration must also be given for traditionally centralized programs like nutrition, laundry, security, HR, etc.”

And there’s more. “Given that many suppliers set up different pricing for items based on class of trade use, differentiating the class may be important for appropriate discounting,” he added. “But with more integrated supply chains, that designation is getting harder to differentiate without added costs. Some of the larger IDN’s realized this challenge and have solved it or are in the process of solving it. Those that have been most successful have driven standard adoption of supplies and clinical protocols across the continuum.”

John Sganga, Senior Vice President, Alternate Site Programs, Premier, shares similar views. “Providers are faced with more external pressures than ever before; these include an evolving regulatory landscape and changing reimbursement models, which lead to much narrower profit margins and the need to scrutinize every dollar spent, while still providing the highest-quality patient care,” he said. “To respond to these external pressures, supply chain teams are increasingly looking for uniform price across their facilities and class of trades. Standardization of pricing and products across facilities help integrate the acquisitions. The need to scrutinize all expenditures and utilization of product is greater than ever before, given the narrowing profit margins for non-acute providers. As a result, supply chain teams seek suppliers whose products provide not only the lowest cost, but also the best patient outcome.”

“Supply chain and sourcing strategies have become more complex for providers, as they are often collaborating with up-and down-stream providers on patient care activities; the critical path to completion has changed, and expanded, which adds risk to all supply chain activities,” said Lord. “Providers strive to continue a patient’s plan of care after they have been discharged from the hospital, and this often includes supplies and treatment initiated during the acute-care stay. Providers are beginning to make decisions that impact a patient trajectory and plan of care far beyond the care setting or moment where the provider is treating the patient.”

Maytin shared his own bullet-list of challenges facing supply chain, which he says is by no means exhaustive. First, he said there is “no one-size-fits-all solution” but the “risk of not acting puts companies at a disadvantage in a rapidly evolving, competitive market place.” Maytin also explored some of the factors health systems will need to consider when deciding whether to build or buy the solutions needed to support care continuum initiatives. Building, he says, “requires large, dedicated investments/capital expenditures; longtime internal development timeframes; and risk in creating tech that will be quickly become outdated.” Conversely, Maytin says those who buy will be faced with “how to choose the right vendor [in a market with] so many choices and no industry leader; integrating solutions within existing workflows, processes — technology is costly; and will the solution live up to its claim? Is it market tested and clinically validated?”

Thinking ahead

As supply chain leaders begin to recognize the broader role they must take across multiple venues of care, DeRoyal’s DeBusk points to some additional considerations: “Not only does a device supplier need to provide a quality product at a competitive price, what is their strategy to participate within the provider’s gain-sharing strategy? How will they support their product even after the patient is discharged? Could this device’s performance trigger a readmission or an emergency department visit? And what if this device now spans multiple venues and is used on an inpatient and outpatient basis? What if it is now needed in a remote ambulatory surgery center? Clinical protocols must be taken into consideration as well. The sourcing team may have developed an optimal wound care case management strategy — but is it seamlessly integrated with the provider’s post-acute care (PAC) network? Will the PAC providers simply implement its old (perhaps inferior) protocols?”

Good questions. Michelle Clouse, Vice President, Customer Development, Concordance Healthcare Solutions, says suppliers are listening and responding to some of those issues. “As an industry, we have worked hard to acknowledge that providers at each point of care need different supply chain products and services based on factors such as type of care provided and point of delivery,” said Clouse. “As we continue to navigate change and form strategies for the future of supply chain, it will be important for those involved to determine the most efficient ways to service the entire continuum of care while recognizing the differences and also viewing the health system as a whole. It’s a shift in mindset for providers and suppliers that will require collaboration throughout the entire supply chain.”

Economies of scale

“The continuum of care has grown increasingly complex due to continuous reimbursement cuts and higher scrutiny of documents; companies that have survived Medicare competitive bidding rounds have done so by diversifying, increasing operational efficiencies, and by growing through a variety of strategies, including through mergers and acquisitions to achieve economies of scale,” added Andrew Amoth, Corporate Development Manager, Aeroflow. “Vertical integration and strategic partnerships are proving to be viable paths for many companies.”

However, he also suggests additional sourcing pressures may be driving some supply chains to choose less expensive products and services without sacrificing quality. “Durable Medical Equipment (DME) providers have received relief from some manufacturers that design equipment according to reimbursement rates,” said Amoth, adding that “More suppliers are sourcing products from overseas as managing the manufacturing and distribution processes support stronger margins and opens the door for additional revenue channels. “ This is not new territory,” he continued. “Supply chains have long strived to secure low-cost products in order to strengthen their margins by evaluating the variety of emerging sources and providers of medical equipment. However, some of the more nuanced areas such as distributor manufacturing and vertical integration are becoming more common.”

Manage the flow with a GPO

For a growing number of healthcare systems, staying ahead of the game — or just staying in it — requires partnering with a group purchasing organization (GPO). According to a report sponsored by the Healthcare Supply Chain Association (HSCA), Group Purchasing Organizations (GPOs) will have saved the healthcare system $392.2 billion to $864.4 billion between 2013 and 2022. The researchers suggest hospitals and nursing homes that partner with a GPO are saving 10 percent to 18 percent on supply-related purchasing costs compared to providers that do not affiliate with a GPO. Aside from their volume-purchasing power, GPOs deliver marketplace intelligence, product expertise, and more.

“GPOs support supply chain leaders with analytics to identify variation in spend across the healthcare system,” said Sganga. “GPOs with expertise in continuum of care work directly with suppliers to provide more contracted products/services that are specific to these providers’ requirements and needs. This leads to a contract portfolio that addresses alternate site needs and allows systems to aggregate spend across their facilities with standard pricing. GPOs play a key role in helping establish this collaborative relationship between providers and suppliers, where all parties have skin in the game. Additionally, GPOs like Premier are increasingly involving alternate site experts into the early stages of the sourcing and contracting processes to ensure agreements are tailored for alternate site providers.”

Downey says Vizient can help health systems implement patient-centered practices with tailored solutions that address a variety of areas throughout the care continuum. “Our solutions encompass non-acute needs through our Provista team, with a comprehensive offering of sourcing and operational solutions,” he said. “Our Advisory teams help supply chains develop strategies to solve for a range of challenges. Our clinical tools help assess care delivery performance, normalize for best practices and can compare to benchmarks. Our supply chain management solutions can staff supply chain roles with experts, and we are currently managing a number of IDN’s and non-acute supply chains. Our procurement and e-commerce platforms can connect buyers to suppliers digitally, lowering cost and improving service. And lastly, our networks connect leaders across our membership together to discuss challenges and share solutions that can speed performance improvement.”

Driving data in the right direction

“A health system’s data flow gaps represent — or underlie — some pretty major challenges in a patient’s continuum of care. Understanding the cost to deliver care for both acute and chronic cases, establishing a full cycle supply chain loop, and linking this information to patient outcomes is only possible when your data flow is continuous and connected,” said Nancy Pakieser, Senior Director, Industry Relations, TECSYS. “Addressing the fragmentation of your supply chain lets you plug those data points into the bigger picture without having to contend with blind spots or assumptions along the way. Being able to determine ‘readiness’ across an IDN is a tall order, so TECSYS designed a tool to determine that readiness across six specific pillars that are critical to a transformation effort to help shine a light on how they intersect. These pillars are Executive, Financial, Infrastructure, Operations, Collaboration and Momentum. We have found that neglecting any of these areas of focus makes more work later in the program.

“TECSYS’ IDN Supply Chain Transformation Readiness Tool guides people through the current state discovery process,” Pakieser continued. “Engagement with clinicians, sustainable and standardized processes, metrics in use, the inclusion of technology in planning — these are the mechanics for a successful effort towards supply chain consolidation, and in` turn, a feeder for continuum of care analytics. In the context of the continuum of care, a supply chain consolidation project is a fairly logical case to make; synthesizing all that data centrally means finding patterns and improvements on a broader and continuous basis rather than ad hoc. More complete data equals more informed decisions and reduced variation.”

“Analytics are a smart way to manage patients and populations,” added Maytin. “The utility of patient-reported information is gaining respect among previous skeptics. Artificial intelligence, big data and machine learning are unlocking the potential to identify, collect, analyze, and act upon new sources of information about patient status and well-being beyond the hospital walls,” he explained. “For population health management, advanced analytics are yielding greater insights (e.g., behaviors, compliance, outcomes, etc.) to inform treatment approaches in traditional categories (healthy, well, rising risk, chronic, complex, and acute) as well as previously unidentified sub-segments within each.”

Maytin also described how Medocity technology works: “Bridging the gap between the hospital, clinic and the home, the Medocity Virtual Care Platform enables optimized engagement and continuous care for patients with chronic and complex conditions. Medocity’s award-winning technology combines condition management, remote monitoring, artificial intelligence, cognitive computing, and telehealth interventions in a single cloud-based ecosystem. Accessible in real time on any device or operating system, the Medocity platform integrates with EMRs, digital assistants, and hundreds of connected sensors delivering meaningful patient-centered care away from the hospital or clinic.”

Lord explained how CipherHealth’s technology automates the filtering of data points to generate real-time alerts and notifications for providers and others involved in the care continuum. For example, “If a surgeon requires certain devices for some of their procedures and patient populations, but prefers a different device for other types of procedures of patient groups, it can be challenging to understand how to estimate supply needs and order appropriately,” said Lord. “Leveraging automation to filter through various data points can help determine which devices are needed for each procedure and patient, and ensure that necessary quantities are secured from the time of procedural scheduling. Oftentimes, these determinations are made from various data points across multiple IT systems and are not specific to a procedure alone, but rather include patient-specific clinical information, lab values, demographics, or payer type. Alerts can be automated to suppliers as well as providers to receive clarification or resolve potential issues related to size, quantity, and forecasted need.”

Connected & protected

“On the frontend of healthcare, patients seem to be moving frequently between providers for their urgent care and non-chronic needs. There is more loyalty to a single physician when it comes to treating chronic conditions in primary care and those requiring specialists,” noted Mark Richards, Senior Vice President, Sales and Marketing, Aprima Medical Software. “For minor aches and pains, patients aren’t inclined to wait until there is an opening to see their primary care provider, and are willing to go to any of the multitude of urgent care centers that have popped up. What this has done is splinter the primary care aspect and requires more communication to get a true view of the patient’s history.

“From our perspective working with healthcare systems, interoperability is evolving and, while each healthcare system has its own path, and some are further along than others, it is already underway and won’t reverse course,” observed Richards. “Aprima provides not only the PM/EHR technology necessary in today’s world of regulations, but it continues to be a leader in interoperability and data sharing capabilities. As the number of care givers for any individual patient expands, and the traditional medical record is diluted with fragments of care, it’s more important than ever to be able to ‘grab’ those disparate pieces to have a complete picture of the patient. “Whether it be connectivity to the hospital, an urgent-care facility, or other providers in the community and across the region and nation, Aprima has the tools available to send and receive patient information easily,” he added. “In many cases, fax is still the least common denominator so integrated inbound and outbound fax is available, and wherever possible interfaces, direct messaging and networks such as Surescripts Record Locator and Exchange and Commonwell/Carequality are gaining traction. Because there isn’t a single, universal way to share data, we offer it all so that providers can choose any or all methods that make sense in their local environment.”

Achieving success with RTLS

“The healthcare supply chain is overdue for an overhaul,” asserted DeBusk. “IoT, cloud computing, and RFID are just a few of the technological innovations that will upend the current supply chain operating model. Every year we are seeing new advances in UHF RFID with each generation of tags becoming less expensive, higher performing, and more feature-rich. These disruptive technologies will enable supply chain models that haven’t even been contemplated by today’s leaders.

“Our continuum solution enabled with GPS and RFID technologies give supply chain leaders the real-time information they need to manage resources across venues, as well as the tools they need to drive care coordination and financial alignment,” he continued. “Our patented Digital Chain of Custody technology provides ongoing information about the quantity of materials at any location, as well as the dispensing and utilization patterns associated with each item.”

A greater call for house calls

Patients demand convenience and for many that means receiving at least some of their healthcare at home — and providers are delivering. Results from the 2018 U.S. Telemedicine Industry Benchmark Survey from REACH Health, a telemedicine software company, indicate that almost half of provider respondents are taking an enterprise approach to telemedicine, a 23 percent increase from 2017.

“Telemedicine and remote monitoring are becoming more and more significant to routine patient care; especially as reimbursement is changing, and many providers are participating in APMs, it is increasingly important to understand a patient’s clinical status while they are caring for themselves outside of the hospital walls,” said Lord. “The data received through remote devices is imperative for clinicians to detect minor changes in a patient’s condition. This information allows clinicians to intervene remotely prior to an adverse event or unplanned hospital admission.”

Maytin said, “Shared connectivity gives greater peace of mind; connecting patients and care professionals regardless of their physical locations. While face-to-face encounters are still the gold standard, patients gain greater peace of mind and remain more engaged knowing their support network is just a click away.”

Increasing adherence to treatment plans when patients are home is another challenge that suppliers are helping providers tackle. According to the Centers for Disease Control, hospital admission rates increase for non-adherent patients with chronic illness by up to 69 percent. Although not a surprising fact, it is a sobering detail and one that supply chain must consider.

“Adherence and supply chain are inextricably linked, in that supply chain management is entirely lined up toward the expectation of consumption through adherence to medical guidance,” said Vik Panda, Vice President of Marketing, Adherium, which sells personal digital medication monitoring systems for patients with chronic respiratory conditions. “Not only is adherence poor currently, but visibility into adherence is also highly limited. Supply chain managers have taken this relative blindness for granted. But what if you didn’t need to be blind to adherence, but instead had real-time data to support modeling, prediction, and new strategies? So long as at least half of patients in the U.S. are not following through with taking their medicine as directed once they leave the doctor’s office, we will continue to spend as much as $300 billion on preventable medical costs. So there’s enormous opportunity.

“In therapy adherence, the portion of the continuum where we focus, the state-of-the-art has been a written log; today we can use digital tools to supplement uneven habits and memories and do better, really to take the friction out of adherence and make it second nature,” Panda continued. “Smart, connected devices like Adherium’s Hailie offer a quantum shift from pen-and-paper. Beyond supporting a patient and their family after they leave the clinic by delivering nudges and recording usage data, this data is valuable to understand how the supply chain can react in real time.”

Offsite medical equipment

As post-surgery care at home and in other healthcare settings increases so does the demand for home medical equipment (HME) which can help patients recover faster and avoid readmissions. “Aeroflow sees this as an important time in the HME industry where many of the providers who have survived competitive bidding rounds are entering various types of strategic partnerships or launching M&A initiatives,” said Amoth. “It is also important to note that through M&A activity economies of scale can be achieved and give the growing company more negotiating power when working with vendors. “Aeroflow explores synergies with other companies to discover mutual, untapped revenue streams,” he continued. “Subcontracting, joint ventures, and acquisitions are a few ways Aeroflow has shared success with its network of partners built in recent years. Patient care and billing are also at the forefront of Aeroflow’s priorities. Being able to provide exceptional care and quickly collect reimbursement for medical items are crucial for remaining profitable in the current climate. As larger providers acquire more businesses, they will appreciate economies of scale while securing larger market share.”

“We are definitely experiencing a transformation in the way healthcare is consumed; telemedicine and other advanced services will continue to take shape as providers focus on healthcare delivery for the next generation,” added Clouse. “As a distributor of medical supply products and supply chain services, we are working closely with our customers and focusing on creating the best processes to deliver products to the point of use, including delivery to patient homes. [Concordance Healthcare Solutions] believes that having the right products to patients when they need them can save lives so we are dedicated to working with our supplier partners to create the most efficient supply chain possible. By streamlining product flow throughout the continuum of care, efficiencies can be created that enable providers to spend more time with patients.”