Should We Create a Cardiovascular IPU?
We are considering transforming our hospital-based Heart Institute into a truly integrated practice unit for cardiovascular disease. The fundamental challenge is to fully integrate the finance, administration, and clinical care of two of the highest performing departments in our hospital.
We are considering transforming our hospital-based Heart Institute into a truly integrated practice unit for cardiovascular disease. The fundamental challenge is to fully integrate the finance, administration, and clinical care of two of the highest performing departments in our hospital. Our hospital is a non-profit, tertiary level academic affiliate operating within the constraints of a global budget (fixed revenue). One important aspect of our system, and a potential opportunity, is that our global budget does not apply to outpatient services. Some of the main challenges we are considering include:
- Best model for unified governance of the Heart Institute that cuts across traditional departmental lines.
- Align physicians and advanced practitioners from different departments
- Align support staff from different departments
- Achieve full clinical integration of inpatient and outpatient services for cardiovascular disease. Specifically, we are well positioned to integrate our clinical inpatient services through existing Heart Institute practice in the hospital. Our outpatient care, however, remains isolated along traditional departmental lines. Surgical and non-surgical services are provided in separate locations. Even within medical cardiology, there is not a unified clinical pathway for all patients according to specific cardiac diagnosis. Care is principally determined at the individual physician level.
- Integration and alignment of Cardiac Anesthesia into the CV IPU
- How to incorporate endocrinology into the IPU in a way that creates meaningful engagement but remains cost-effective for the hospital as well as the individual practitioners
- Integration of allied health professionals into the IPU including physical therapy/rehab, pharmacist, dietician, social worker, and psychological counsellor to provide complete care
- Incorporation of a new CV Clinical Research Unit
- Best way to track quality, PROMs, and cost-efficiency for each subspecialized program within the IPU
- Should everything in the outpatient space be co-located? Does this contribute to integrating care? Is this worth the cost?
- How do we construct the IPU to decrease overall expenses?
Participant comments on Should We Create a Cardiovascular IPU?
Hoag Health in California is doing some great things with their focus on Clinical Institutes and IPUs. Based on the talk I heard from Dr. Michael Brant-Zawadzki from Hoag (Executive Medical Director of the Neurosciences Institute at Hoag), it sounds like they are relatively far along with their Neuro Institute/IPU and also with their Heart and Vascular Institute/IPU model development. He would be a good person to reach out to at Hoag to find out who to talk to at Hoag about their CV IPU model. He was very open to sharing what has worked well for them and what has not worked well.
We have done some work to transform our cardiac care into an IPU. I think the first thin g is to have large enough volume. We had about 2,000 open heart surgeries in three locations and close to 10,000 cath procedures. First thing was to get people to talk to each other. Everyone wanted to make TAVI or AFIB ablations. We are experts at fragmenting care rather than aggregating care. We put everything together – Cardiac surgery, interventional cardiology, clinical cardiology, cardiac surgery ICU, telemetry unit etc. We also had full time related specialties such as pulmonary physicians. Important was to have the customer service people and scheduling as part of the IPU as opposed being part of the hospital administration. We also had the housekeeping and cleaning personnel be inhouse in order to follow certain specific guidelines. We left functions outside of the IPU such as finance, accounting.
At Radboudumc we are also in the process of developing IPU’s for several patient areas (also cardiovascular) and are looking at best practices. Our conversations with Michael Okun from University of Florida Health helped in understanding the development process of their IPU’s. They started developing an IPU for Movement Disorders already in 2002 (https://movementdisorders.ufhealth.org/about/). He advised to define a transition phase and give the professionals space and time to go ahead. His biggest challenge was to let each IPU see that the future is in their own hands: watch, dream, plan. Once they saw the opportunities most of them moved automatically and only few people did not step in the bus. The largest work was to unravel finances from departments to the IPU’s and create joint facilities where it makes sense.
The main risk is that you create a small hospital for each IPU, that is probably not efficient. So the real challenge is to create small ecosystems within the structure of the larger organization.
The main purpose of an IPU is to organise the care around the patients medical conditions. In larger institutions this often conflicts with both the physical as well as the functional organization. It might help to use elements of ‘systems thinking’ here. In particular the principle of ‘maximal cohesion, minimal interfaces’ is helpful in rethinking your processes and responsibilities. By doing this you can define what processes and responsibilities you would like to group in the IPU and which ones can ‘live outside of the IPU’. For the last category, you then need to define clear interfaces in terms of agreements with the ‘mother hospital’. In my opinion those agreements will be mainly on using facilities, IT, general staff. And ofcourse on budget constraints and on general (hospital wide) quality indicators that you as an IPU need to comply with.
HBS has stuff on this: https://www.isc.hbs.edu/health-care/vbhcd/Pages/integrated-practice-units.aspx
I see a lot of positive developments and opportunities to create a cardiovascular IPU and it will be a nice adventure.
However, I also see one more additional challenge. In the Netherlands, our cardiologists and cardiothoracic surgeons focus predominantly on the heart and comorbidity is often not weighed in the (very) protocolized treatment schemes. E.g. for a very minor nonSTEMI with borderline troponine elevation full dose aspirin/clopidrogrel/nadroparin is given to a DM1 patient that just had a cerebral bleed (CVA) four days ago. What kills first? How is feedback established for (readmission for) a gastrointestinal bleed after warfarin initation, etc. In the Netherlands the complications of cardiovascular treatment (e.g. readmissions) are often not admitted to the cardiovascular IPU but to other deparments (acute care department or general medicine). Not sure if this is the case in the USA, but how to maintain a holistic view and proper feedback channels on outcome (complications) to weigh treatment against comorbity in an increasingly older and complex multi-morbid population.