Jarjous-Strategic Analysis Paper Two
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Strategic Analysis-Part Two
Shadi Jarjous
2/14/2022
CR-510-CV02-Capstone: Policy & Strategy
Professor: Dr. Karen Kent
1
Introduction
As the COVID-19 pandemic evolv
es
ing
, Lehigh Valley Health Network (LVHN) like many others across the globe continues to face many more obstacles including staffing shortage, hospitals overcrowding, higher length of stay, higher readmission rate, poor patients’ satisfaction, and staff exhaustion. With my proposed integration of a multifaceted telemedicine program into our Hospital Medicine (HM) Division’s business portfolio, I hope to address many of these issues. The two arms of the program, Hospital Medicine Virtual Command Center (VCC) and Transition of Care Program (TOCP), will offer us opportunities to expand our HM reach outside the hospital walls with potential for accomplishing better outcomes and generating more profit. Situational Analysis The uncertainties that accompanied the COVID-19 pandemic, especially initially, forced health institutions to transition most of the non-urgent care into digital platforms to mitigate the potential risk of further spreading of this mysterious disease and to preserve acute care resources.
This rapid and transformational shift into virtual platform for health care delivery was a revelation for many in the industry. The successful virtual medicine experience in the past two years led numerous organizations to reassess their current tools and think how to incorporate it into their standard care delivery. The combination of electronic medical records, video call technology, remote patient monitoring, and home health allowed for an effective and safe virtual
delivery of routine medical care for many patients at LVHN. Observing how many of our network’s resources were devoted to virtual medicine and the capabilities of the available technology, we jumped on the opportunity to incorporate the new virtual tools in our hospital medicine (HM) operations. Our first experience with telemedicine was through the utilization of a video app on iPads to remotely communicate with our COVID-19 positive admitted patients. This process enabled our providers to complete their patients’ visits virtually and spend less time
in the patients’ rooms just enough to perform a physical exam. By doing so, we decreased the providers’ risk of prolonged exposure and contraction of this disease, especially at the beginning when we didn’t know much about it. In December of 2020, LVHN open one of the largest and most sophisticated emergency department in the state of Pennsylvania at the Cedar Crest Hospital (LVH-CC) to deliver the best care for our community. While the opening of the new 2
ED was very timely as the demand for emergency care and hospital beds was surging very rapidly, it created a little dilemma for our HM team. The physical distance between the ED and inpatient wards caused efficiency challenges to our providers as they tried to balance the timely completion of new admissions and discharges while attending to the needs of already admitted patients. We turned again to technology and used the same video app mentioned earlier to perform the history piece of the admission quickly, deferring the physical exam piece until the patients were transported to the medical floors. This allowed us to start patients’ treatment earlier
and improve their satisfaction. It also complemented TigerConnect, a secure messaging app that we have been using already in the admission process for communications among providers and other care team members. The bottleneck effect of the expanded ED at LVH-CC, however, was at full display during evening and night shifts where our HM staffing decreases to only few providers. Those colleagues have multiple responsibilities including admitting new patients, cross covering all our admitted patients, usually 300-400 range, and attending to all emergencies outside the ICUs across the entire hospital. Our staffing goes from about around 26 providers from 7AM to 7PM, to 7 providers from 7PM to 2 PM, and down to 3 providers after 2 AM until 7AM. This precipitous drop in staffing didn’t leave any buffer to deal with the increase in volume and acuity that accompanied the COVID-19 surges. To counter this new challenge, we created a new remote provider role using the available technologies such as remote access to Epic, our EMR, TigerConnect, and video app already present at nursing stations and patients’ bedside. We recruited some of our colleagues who were interested in performing extra work to help the nocturnists by covering non-urgent patient care issues remotely from home. The virtual provider in this role was fielding 50-100 calls a night from a less experienced and stretched nursing workforce. This intervention helped decrease the workload on our nocturnists and ensure
safe and effective patient care during the multiple pandemic peaks. One of the challenges that
the
team faced was the inconsistent availability of this support
,
as it was on voluntary basis and competing with all other available moonlighting opportunities during the more desirable day shifts. Therefore, and given how effective the program was, we are proposing to make it a permanently staffed position for our team, combining it with our triage operation into one complete HM Virtual Command Center (VCC) that will spread to cover all our multiple hospitals.
3
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When it comes to transition of care, early follow-up with primary care is known to decrease patients’ readmission to the hospital. The quicker the patients are seen after discharge from an acute hospitalization, the less likely they will need to be re-hospitalized (Misky, 2010) and the less adverse outcomes they will experience (Forster, 2014). Multiple factors play a role in patients’ risks of readmission including discharge diagnoses, comorbidities, physical condition, and socioeconomic resources among many others. These together predispose patients to the “Post Hospital Syndrome”, an
acquired state of vulnerability not necessarily linked to the original illness (Krumholz, 2013). LVHN has built and automated a risk score calculator in Epic, our EMR, to identify patients with higher risk for readmission so they can be provided with appropriate resources early post discharge. In 2015, LVHN established a centralized transition of care call center and care navigation services to help increase the timeliness of follow-up visits post discharge and connection to appropriate resources. In 2020, LVHN@Home program was created as a first step toward a Hospital at Home care delivery model. Through this program, “pre-engagement” specialists helped facilitate the care plan set by the patient’s discharging team for high-risk patients identified by the readmission risk score. Some of the services offered for those patients included RPM, home safety evaluation, home care nursing, physical
therapy, occupational therapy, speech therapy, palliative care, infusion services, and virtual video visits. Despite these excellent efforts, LVHN ACO performance was lower than peers when it came to all cause 30-day readmission for 2018 through 2020 calendar years according to Lehigh Valley Health Network Chief Quality and Patient Safety Officer, Dr. Matthew McCambridge. Part of the problem is the lack of prompt access at the primary care offices. Outpatient clinics are struggling to balance access for new patients, acutely ill patients, patients with chronic medical conditions, and those who are recent discharged. Also, some of our hospitalized patients have PCPs outside our network, which makes it even more challenging to coordinate post hospitalization follow up. The discharge process itself is far from optimal. Many patients discover several unanswered questions once they arrive home, many time choosing to return to ED instead of reaching to their PCPs. By opening a TOCP staffed by hospitalists who took care of most of these patients during their hospitalization, I envision better care coordination and early interventions that can help solve the prompt access predicament. The visits at the TOCP will be treated as extension of the hospitalization to home, another step towards the Hospital at Home Model. Internal Analysis/SWOT Analysis
4
Strengths
Hospital Medicine at LVHN has a large team of over 110 innovative and flexible physicians and advanced practice clinicians (APCs) who adhere to established HM processes that are unified across the different LVHN hospitals. This standard work allows for easy integration and cross coverage when needed among the different LVHN sites. Our hospitalists are generalists who can handle any clinical emergencies that might arise during their shifts. Our daily documentation incorporates a hand off tool called “Hospital Course”, which gives a summary of patient’s history and current hospitalization allowing anyone on our team to quickly learn the patient condition and make decision regarding care. Our prior experience and comfort using the existing technologies such as TigerConnect and video app as mentioned earlier will help make the addition of the TOCP and VCC programs quicker and easier. Our HM team has a strong collaborative relationship with all inpatient and transition of care teams. There is already infrastructure in place related to the RPM, LVHN@Home, and Transition of Care Navigators that can be incorporated into the TOCP program to ensure its success. “MyLVHN” app, which was used as platform for video visits during the COVID-19 pandemic by LVHN, can be used for the transition of care visits in the TOCP with phone call as backup if there were any technical difficulties. Virtual TOCP is cheaper to operationalize than regular practice due to lower overhead cost. Hospitalist experience treating hospitalized patients give them unique perspective when it comes to deciding the need for readmission vs. closer monitoring at home. There is a clear need for the TOCP as readmission risk is high and costly with failed prior interventions and inability of primary care to keep up with demand, risking the future of LVHN ACO. Weaknesses
One of the potential weaknesses for hospital medicine virtual TOCP is that most of the Hospitalists lack outpatient experience. The inability to perform physical exam curing virtual visits might hinder provider’s capability to generate an optimal assessment of patient’s condition and can potentially result in suboptimal recommendations and/or treatments. The lack of face-to-
face interaction or prior relationship with the patient will negatively affect the hospitalists’ ability to establish rapport, putting them at a disadvantage compared to Primary Care Physician or Specialist who have prior established relationship with the patient. Another concern is 5
potential Hospitalists’ aversion to yet another new change given their experience with constant changes since the start of the pandemic. Opportunities
Taking advantage of the momentum of virtual care created by the COVID-19 pandemic and adding a HM-run TOCP and VCC programs will open many opportunities for our Hospitalists team. With the movement to shift patient care more toward outpatient and away from the hospitals, expanding HM footprint outside hospital work presents extra opportunity for new sources of revenue and job security. TOC visit generates 2.11-3.05 wRVUs, which is higher than
produced by all the three subsequent hospital care visit levels and the first two initial hospital care visit levels. i.e., only level three initial inpatient care visit produces a higher wRVU. Also, improving transition of care quality via TOCP has the potential to improve many of the metrics for which hospitalists are held accountable. Outcomes of metrics such as length of stay, patient satisfaction, and readmission rates are many times tied to HM providers’ compensation, especially when it comes to bonus pay. Feedback by providers working at the TOCP can also provide invaluable insight to help improve the quality of the discharge process for all patients. TOCP has the potential to serve as first step to link patients without PCP to LVHN clinics and to decrease ED overutilization. Therefore, improving care quality by prevention and early intervention. Similarly, patients’ throughput metrics, also compensated operational metrics, can all be positively affected by the work VCC. The VCC will improve the efficiency of patient throughput, decrease ED crowding, and decrease the time of response to emergencies. Most importantly, however, it has the potential to prevent turnover in our nocturnists group, which itself is a major satisfier for the entire HM team. Providers’ burn out and shortage is real and only exacerbated by the challenges of the COVID-19 pandemic. Rotating into remote work might give our nocturnists a much-needed change of pace and the convenience to work from home, which is likely to improve their morale. Threats
Hospital Medicine as a service line is crucial for efficient, high quality, and safe hospital operations and does generate significant downstream revenue. However, it doesn’t usually produce enough profit from professional billing to cover its cost, which is the main item that is listed traditionally on the P&L statement to reflect hospitalist income. Our Hospital Medicine program, like many across the nation, is subsidized by the network. Therefore, it is incredibly 6
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challenging to secure more providers’ FTEs without a proven potential for new growth and boosted revenue. Justifying the VCC program and convincing leaders of its value is especially difficult as it will directly generate zero wRVUs. As far as the TOCP, one threat is the competition from other teams within the network such as PCPs and Specialists who are usually paid based on RVUs production and would not want to lose TOC visits revenue. Another concern is that the reimbursement options for TOCP visits might be limited once the COVID-19 related temporary waivers by CMS expires. As COVID-19 pandemic moves closer to being an endemic, more face-to-face visits will be feasible and patients as well as providers might lose interest in virtual visits. Patients might opt to follow up with PCP even if that means delays in access. Technology might prove to be more difficult for the most vulnerable patients who could have the most benefit from the TOCP visits such as older patients and those with some cognitive decline, especially those lacking consistent family support. Technical challenges can cause dissatisfaction to both patients and providers alike. Also, if outcomes are slow to improve, the programs can be the target of reduction of scope strategies by the network. External Analysis
External Issue Map & PESTEL Analysis Categories of Issue
General Environment-
United States Healthcare System-
United States Service Area-Lehigh
Valley, PA
Political/Legislative
Polarized political system. Transition from Trump to Biden presidency with different and opposing views on many subjects. Multiple COVID-19 related relief funds legislations.
Potential impact of midterm election on 11/8/22.
Beneficiary of COVID-19 relief funds legislations including expanded coverage for Medicare
telehealth services. Fallout of COVID-19 pandemic and vaccine mandates. Continued preparation for more value-based payment while still operating in mostly FFS model. 21
st
Century Cures Act
required healthcare providers to give patients access to all health information in their electronic A mirror of the political map across the country. Beneficiary of COVID-19 relief funds legislations. Ensuring compliance with 21
st
Century Cures Act and No surprise Act.
7
medical records without delay. No surprise Act of no surprise billing for out of network providers.
Economic
Slower economic growth and worsening inflation. Economic fallout of COVID-19 pandemic. Discontinuation of economic stimuli related to COVID-19 pandemic. Decreased workforce. Shifting to increase domestic products, which will result in higher costs. Potential changes to taxation policies. Medicare is running out
of funds. The provider Relief funds to help compensate for financial loses and unanticipated costs during the pandemic. Waiver of Medicare payment reductions and increase in physician payment under the Medicare physician fee schedule. Increase in Medicare payments for inpatient COVID-
19 admissions by 20%. Payment for COVID-19 vaccine. Expanded coverage for Medicare telehealth services. Incentives to move care from inpatient to outpatient and decrease readmission by both CMS and private insurance companies. Healthcare costs will continue to rise. Healthcare reimbursement will continue to decrease overtime. LVHN maintained positive margin for the last couple of years mostly due to help from the federal
relief funds.
Staffing shortage consistent with national trend. Early success with ROI from RPM and Virtual Visits. LVHN is struggling to make shared saving programs and
other value-based programs profitable.
Lehigh valley has a balanced and multifaceted economy with strong
manufacturing and healthcare sectors. The formation of Neighborhood Improvement Zone in Allentown and the many projects by
the City Center Investment Corp. Many of LVHN administrative functions moved to One City Center as part of the PPL center completed in 2014. Social or Demographic
Aging population. Most growth is among minorities and mixed-
Older patients with multiple complicated chronic medical Lehigh Valley had significant growth in
population 8
race population. Immigration will be the
main driver of population growth. conditions. Increased demand on healthcare access and outcome. compared to other areas in PA, mostly in young adults. Hispanic population had the most growth.
Technological
Continuous and rapid technologic advancement in all fields. Digital communication tools continue to advance and gain widespread acceptance.
Social media revolution. The rise of big data and
artificial intelligence. Electronic medical record widespread adoption. The rise of data analytics and
Predictive models. The advancement of remote patient monitoring technology. The rise of national telehealth companies. MyLVHN app allows patients to access health information, schedule appointments, have video visits, and communicate with care team. Use of virtual visits technology during the COVID-19 pandemic in outpatient and inpatient areas. LVHN has robust data analytics. Both LVHN and regional competitors
used telehealth during pandemic. Environmental People are more environmental conscious when choosing products and services. Concerned about climate change. Less travel during the COVID-19 pandemic led to less gas use and less emissions.
Increased interest in alternative energy sources. Environmentally conscious choices of products and services. Remote work for non-
front-line workers helped conserve resources and decrease
energy consumption. Colleagues can work
from home, decreasing travel time and energy consumption. Use of environmentally conscious products. More recycling. Legal
Licensing challenges. Changes in state law effect on access to out of state providers. Maintaining HIPAA compliance, In response to covid, CMS launched its Hospitals Without Walls Program that allowed for care provisions in locations
LVHN providers were able to see patients outside PA using CMS waivers via virtual care. 9
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Liability, and malpractice coverage. outside hospitals in March of 2020. In November of 2020, CMS expanded to new
Acute Hospital Care at
Home Initiative giving
eligible hospitals further regulatory flexibility (Jercich, 2021). Suspending state licensing requirements so providers can practice in other states.
Challenges of tele prescribing. Issue Impact & Probability Prioritization Trend/Issue
Evidence Impact
Probability
Shift of care from inpatient to outpatient
Expansion of outpatient procedures and rise of Hospital at Home programs.
CMS, Medicaid, and commercial insurances are pressuring health systems to take on value-based contracts that aim to shift care away from the inpatient settings.
Patients prefer outpatient settings for convenience and lower out of pocket costs. 8
8
Telehealth advancement
Many home-grown systems surfaced during pandemic
Presence of national telehealth companies 9
10
Healthcare workforce shortage
Physicians’ shortage will be up to 139000 by 2033
according to AAMC study (Boyle, 2020).
Severe national shortage in nursing effect on inpatient care.
10
9
Shift from fee for service to value-based payment
Alternative payment models (MSSP, ACOs, MIPS…etc.).
Private insurances value-based contracts. 8
7
Increase healthcare cost
National Health Expenditure (NHE) grew 9.7% to $4.1 trillion in 2020 and accounted for 19.7% of GDP.
NHE is projected to grow at an average annual rate of 5.4 percent for 2019-28 and to reach $6.2 trillion by 2028 (CMS.gov, 2020).
7
9
Decrease in healthcare
CY 2022 PFS conversion factor is $33.59, a decrease of $1.30 from CY 2021 PFS conversion 8
7
10
reimbursement
factor
(CMS.gov, 2021)
Split E/M visits between physicians and APCs now will be billed under the person documenting the most substantial part of the visit (APCs reimbursed at 85% of physicians) Internal Analysis
Value Chain Competitive advantage and disadvantage Value Chain Component Value-Creating Strength Value-Reducing Weakness
Preservice
LVHN brand recognition. MyLVHN adoption by patients. Rapport with hospitalists prior to discharge. Pre-engagement specialists’ communication with patient prior to discharge to schedule the visit in the TOCP. Hospitalists discussing importance of TOC visit. Patients’ attachment to their PCPs. Patients’ poor understanding of the value of TOC visit. Point of service
Experienced hospitalist able to deal with acute issues. Easy to use technology. Convenience. Patient centered experience.
Patient connection to all needed resources to succeed in transition to home. Technologic difficulty on the provider or patient side. Inability to resolve complaints. Inconvenient timing of appointments for follow ups and testing. After service All follow up appoints and diagnostic appointment are scheduled for patients. New challenges related to recent hospitalization arising after the completion of TOCP
visit.
Culture Strong teamwork among hospitalists. Strong collaborative relationships with all members of the care team. Constant growth with minimal turnover. Competition with network PCPs for TOC visits Structure Interdisciplinary team of provider, nurse navigator, pharmacist, and care coordinator
Lack of social worker
Strategic resources Sustained positive margin with good outlook.
Significant demand on hospitalists operations related
11
Presence of sophisticated data
analytic team to help with research and development. Availability of dashboards to track operational and outcome metrics. Presence of experienced providers and care navigation
team. to patient throughput. Strategic Thinking Map HM TOCP & VCC-Strength Strength
Value
Rare?
Easy/
Difficult to
Imitate
Sustainable?
Implication
Technological
infrastructure
readily
available High
No
Difficult No
Short term
advantage
Prior
experience
with the use
of technology High
No
Easy No
Short term
advantage
Team strong
clinical
experience
and flexibility
High
Yes
Difficult
Yes
Long term
advantage
HM TOCP & VCC-Weaknesses
Weaknesses
Value
Common?
Easy/
Difficult to
Correct
Sustainable?
Implication
Staffing
shortage
High
Yes
Difficult
No
Short term
competitive
disadvantage
Poor Patients’
adoption
High
No
Difficult No
Short term
competitive
disadvantage
Hospitalists
have
difficulty
generating
positive
financial
margin
High
Yes
Difficult
Yes
No
competitive
disadvantage
12
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Competitive Analysis
Structure Analysis using Porter’s Five Forces Analysis
HM TOCP and VCC
Porter’s Force
Threat Level
Analysis
Bargaining
Power of Customers
High
TOCP: o
Patients might prefer PCP or specialists for TOC visits.
o
Patient might prefer face to face visits over virtual visit. o
Technological challenges on provider and patient side. o
Patients’ concern about out-of-pocket cost.
VCC: o
Nurses might use pager instead of TigerConnect.
o
Nurses might contact the inhouse provider instead of VCC. o
Patients might decline the use of technology and demand face to face provider evaluation. Intensity of Rivalry
High
TOCP: o
PCPs at LVHN already use virtual tools for some TOC visits.
o
St. Luke’s and other reginal health network already employee telemedicine technology. o
Competition from national players such as telemedicine companies.
VCC: No real rivalry. Bargaining
Power of Suppliers
Low
Both TOCP and VCC: o
Competition for technology platform. o
Home grown technology is available. o
Staffing shortage might compromise the implementation and effectiveness of program.
Threat of New Entrants
High
TOCP: o
The competition is wide open as physical distance is not an issue.
o
Different technology is available for internal products or hospitals can contract with telehealth companies.
o
Domestic and international competition can be at play. o
Payers are more likely to compensate better for those visits.
VCC: No threat of new entrant. Threat of Substitutes
Moderate
TOCP: o
Face to Face visits with PCP or Specialists. o
Re-visit to ED. o
TOC visits at other institution.
In person work instead of VCC. 13
Competitor Strength and weaknesses for TOCP (no real competitors for VCC)
Competitor
Strengths Weaknesses
PCPs at LVHN
Established relationship with patients. Efficiency due to prior knowledge of patient history. Competing priorities of new patients, acutely ills, and patients with chronic conditions presenting to office. St. Luke’s St. Luke's partnered with American Well, a telehealth software and services company in Boston to expand
its staffing Patient might prefer to see their St. Luke’s providers. Might cost more than home grown program. Tower Health Uses best nationally known telehealth provider, Teladoc Health Inc. with decades of experience Patient might prefer to see their Tower Health provider. Likely costs more than home grown program. Teladoc Health & other national telehealth programs
Long record of accomplishment and experience.
Advanced technology.
Difficulty to compete for LVHN patients without engagement of LVHN. Doesn’t employee its providers directly. Retails (CVS, Walmart, Amazon…etc.)
Significant capital available for investment. Technological advancement. Lack of prior experience. Lack of physician patient relationship. Will compete for the same healthcare work force. Critical Success Factors LVHN
Hospital medicine Brand loyalty Innovative, resourceful, experienced, and flexible team Prior experience with telemedicine such as Tele-ICU, Tele-Stroke Team, RPM, LVHN@home, and Tele-Consults. Prior experience with the use of technology needed for both TOCP and VCC. Excellent informatic team and advanced data analytics. Strong collaborations across multiple disciplines including informatics, care navigators, PCPs, and specialists. Availability of advanced technology. Low staff turnover. Strong financial performance.
Optimal mix of physicians and APCs. Conclusion
The rise of the COVID-19 pandemic and the associated anxieties and restrictions kept many patients at home and created high demand for alternative way to deliver non-urgent health care. 14
As a results virtual care platforms and technologies became widely available through personal electronic devices and gained quick acceptance by the majority of population. Our Hospital Medicine team is looking to capitalize on this unique opportunity created by the pandemic to use newly available technologies to solve other challenges facing the team, namely the high readmission rates and nocturnists increased workload.
Hospital Medicine Virtual Transition of Care Practice (TOCP) will be a virtual clinic dedicated for the care of recently discharged medically complicated patients. Those patients are chosen based on LVHN created risk score calculated in EPIC, our EMR system, prior to patient’s discharge. The vision is that those patients are seen in this clinic within 24-48 hours status post discharge from the hospital. The providers in the clinic will review patient care progression and medications and ensure all needed follow up appointments and testing have been scheduled for the patient. The ultimate goals are to ensure patient safe transition home, improve satisfaction, and prevent readmission. The providers in this practice will also manage patients currently enrolled in LVHN remote patient monitoring (RPM) and LVHN@Home programs. LVHN@Home is a program that combines RPM services with nursing home visits. Hospital Medicine Virtual Command Center (VCC) vision is to establish a 24/7 centralized team that will help virtually manage all HM patients. The VCC team will triage all incoming patients to Hospital Medicine from our emergency departments, direct admission from community providers, internal transfers from ICUs, and external transfers from outside hospitals. They will also handle all non-urgent patient care issues on the medical floors at all LVHN hospitals staffed by our Hospital Medicine team. The TOCP will help improve patient access and avoid high-cost alternatives such as ED visits and hospitalization. Hospitalization has many negative impacts beyond the cost. Hospitalized patients are at risk of hospital acquired infections and other conditions. Elderly patients especially are susceptible to HAI, delirium, and deconditioning, which results in significant increase in post-acute care utilization. The TOCP can help connect patients to outpatient resources quicker and hopefully decrease readmissions and HACs and improve patients’ satisfaction and loyalty to LVHN. If successfully implemented, TOCP work can translate to financial gain by avoiding the costly CMS penalties for readmission, HACs and HCAHPS, which can amount to millions of dollars annually. Our VCC will help centralize our triage process, improving efficiency with less staffing. It will also help nocturnists concentrate on 15
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dealing with new admissions and emergencies, thus making them more efficient and decreasing ED crowding, which is a surrogate for length stay and other efficiency metrics that affect the bottom line for the network. The key strategic questions
Is Hospital Medicine the right team to staff TOCP?
Are TOCP and VCC programs worth the investment?
What is the appropriate staffing model?
What is the potential cost of the investment?
What are the key performance indicators to declare success or failure of programs?
References
Boyle, P. 2020. U.S. Physician Shortage Growing. AAMC. https://www.aamc.org/news-
insights/us-physician-shortage-growing
CMS.gov. 2021. Calendar Year (CY) 2022 Medicare Physician Fee Schedule Final Rule. https://www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2022-medicare-physician-fee-
schedule-final-rule
CMS.gov. 2022. Hospital Compare. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-
Assessment-Instruments/HospitalQualityInits/HospitalCompare
CMS.gov. 2020. NHE Fact Sheet. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/
NationalHealthExpendData/NHE-Fact-Sheet
Forster, A., et al. 2004. Adverse events among medical patients after discharge from hospital. CMAJ., 170(3): 345 Krumholz, H. 2013. Post-Hospital Syndrome-A Condition of Generalized Risk. N Engl J Med., 368 (2):100-102. Doi:10.1056/NEJMp1212324
Misky, G, Wald, H., and Coleman E. 2010. Post-hospital transitions: examining the effects of timing of primary care provider follow-up. J Hosp Med
., 5(7): 392
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