1.5.13

REACHING OUT

(Published in Johns Hopkins Children's Center Magazine, Spring 2013)

REACHING OUT:

Johns Hopkins pediatrics, once considered a Baltimore-only brand, is coming soon to a neighborhood near you.

--by Mat Edelson

At what point does desire become a movement, or the compassion of one morph into a clinical and administrative force helping countless thousands? These are not academic questions, but rather the current point in time at which the 20-year-old Johns Hopkins pediatric network finds itself. The network, whose grassroots could in all fairness be described as a dozen different deals made by a dozen different doctors in a dozen different ways, is nonetheless impressive in its scope, providing clinical services at more than 25 sites across Maryland. Nor does the network stop at the Free State’s borders. From Florida to Chile and the United Arab Emirates, hospitals and their leadership are reaching out to Johns Hopkins for pediatric expertise and faculty. In return, Hopkins is gaining a clinical and financial foothold in far-flung communities that once thought of Hopkins pediatrics as being a Baltimore-only brand. With $12 million in annual revenue and counting, one thing is for certain: This is a network worth watching.

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They say all politics is local, but pediatrics may be even more neighborhood-oriented. At the heart of the Hopkins pediatric network is the bond between families, their local pediatricians, and the down-the-block community hospitals and clinics that service these physicians and patients. In the 1990’s, long before the network even had a name, Hopkins pediatric administrators realized they’d have to scatter their clinical seed deep into Charm City’s suburbs and beyond if they were going to keep East Baltimore’s pediatric beds filled.

“Pediatrics is local and our pediatric hospital admissions are far more dependent upon community referrals than adult admissions,” says long-time Johns Hopkins Children’s Center Administrator Ted Chambers. “Since a pediatrician might admit only four or five patients a year out of hundreds and hundreds of visits, the idea for us was to cast the net as wide as possible to feed a hospital the size of Hopkins that handles 10,000 pediatric discharges annually. That was the original premise for establishing the network.”

That, and the fact that Hopkins pediatrics operates in one of the most competitive environments for beds in the country. Unlike, say, Cincinnati, where pediatricians needing a hospital have little choice but to send their patients to the only tertiary game in the region – Cincinnati Children’s – a Maryland pediatrician has numerous options.

“We have University of Maryland downtown. Children’s National in D.C,. CHOP (Children’s Hospital of Philadelphia) and Dupont to the North, Children’s of Pittsburgh to the west, and Inova in Virginia,” says Chambers. “And Sinai skims some cases as well. That’s a lot of excellence, a lot of hospitals. It’s why we have 205 beds instead of 400. You couldn’t. There’s too much competition.”

Thriving in that kind of competitive environment meant developing an operational strategy that capitalized on Hopkins’ strengths and the community’s needs. Chambers looked at the landscape and saw that, on the whole, suburban areas and their hospitals lacked the specialty care that area pediatricians desperately desired. At the same time, changes in the nation’s medical system – which will accelerate under the Affordable Care Act – dictated that care that could take place at the community level would be reimbursed more than if those cases were automatically transferred to tertiary centers.

Given those economic and clinical realities, Chambers’ marching orders to the Children’s Center’s specialty divisions were to find clinical opportunities in community settings, work with local pediatricians and hospitals to treat in the community whenever possible, and bring the truly tertiary and quarternary cases back to Baltimore.

Those were the networks’ immediate goals, but Chambers also had long-term aspirations as embryonic partnerships evolved into trusting relationships. They involved injecting Hopkins academic, educational, and research energies into the community, and, in turn, being looked upon by regional providers as the “go to” hospital for their most serious cases. This model depended upon the Children’s Center implementing infrastructure updates to the hospital itself to better serve regional needs, with Chambers targeting the call center, patient transport, and internal patient flow as being prime areas of improvement (see sidebar).

Chambers’ faith in the faculty was such that he let them develop their community leads. The result has been relationships that began in a rather ad hoc manner, but grew into much, much more. Those casual conversations between old classmates, the concerned midnight call regarding a confounding and perilous case, a wish to keep a kid with a simple surgical issue close to home – all laid the groundwork for formal partnerships in hospitals such as GBMC, St. Agnes, Suburban, Howard County, and Frederick Memorial..

Create Easier Access
In terms of outreach, perhaps no Children’s Center physician understands the importance of being accessible to the community more than pediatric cardiologist Joel Brenner, who has been offering his services around the state since 1977. To Brenner, the equation is simple: “The reality is, pediatricians will send their patients to the most convenient place they can get the fastest appointment. We need to meet that requirement,” says Brenner, who has certainly done his part. Brenner services community clinics and hospitals in Westminster, Frederick, Bel Air, Cumberland, and Towson. He says the community pediatricians he works with are enticed by lower community based costs, easier access to care, and telemedicine technology linking remote sites directly to the Children’s Center.

“We have a huge infrastructure built into our outreach,” notes Brenner. “I was in Frederick doing echo(cardiograms); that machine plugged into the wall is also being read back at Hopkins, by echo physicians downtown. I know we’re providing a better product, as opposed to the single community providers who take and read echos by themselves. We have extra coverage, extra depth, which protects against erroneous readings.”

Share Surgical Services
At GBMC, the need was surgical. Strategically, outpatient pediatric surgery is an area of great interest to community hospitals like GBMC, but it’s also a bit tricky, as few hospitals have pediatric intensive care units (PICUs) for cases with complications. GBMC, under former Hopkins Robert Wood Johnson fellow and Bayview faculty member Timothy Doran, had built quite a surgical practice with a crackerjack pediatric surgeon who was handling about 800 cases annually. When he announced his retirement, GBMC administrators had a choice: Hire an independent surgeon with no tertiary care links, or align with a surgeon who could handle all cases regardless of acuity.

Doran reached out to Ted Chambers with the idea of finding a hybrid surgeon who would handle cases at both GBMC, and, when necessary, the Charlotte R. Bloomberg Children’s Center. That surgeon turned out to be Jeff Lukish, who now works half-time at GBMC, but whose salary is paid for by Hopkins.

“It’s a win-win,” says Lukish, who has helped build regional outpatient surgical suites at GBMC, Howard County General Hospital and Anne Arundel Medical Center. “If you are a mom or dad and you have a child with a hernia, something straightforward, it is right to care for that kid in an outpatient center in their community because it is less stressful, the OR’s are not as booked, and the child gets in and out in a very efficient manner.”

“If you structure it right, everyone benefits,” agrees Tim Doran. “The advantage for us is we can offer bread and butter pediatric surgery procedures here, but we can also have them evaluated here, and, if need be, take them downtown for surgery at Hopkins.”

Build Intensive Relationships

Another key area of community partnerships for the network is consulting and, in some cases, building and running neonatal intensive care units (NICUs). Hopkins neonatologist Ned Lawson has worked with hospitals including Sibley, St. Petersburg’s All Children’s, and Frederick Memorial on their NICUs.

“Neonatal units are very popular among hospital administrators because they tend to be very, very profitable.” says Lawson. “Another reason is obstetricians (OBs) don’t like to refer mothers (outside their region). If they’re having a premature delivery that really wouldn’t work well in the hospital because it doesn’t have a NICU, that OB will be in the face of administrator saying ‘You must develop a NICU so I don’t (forfeit) a delivery.’”

For Frederick Memorial, developing a NICU relationship with a tertiary care center such as Hopkins dovetails with its own strategic goals. Utilizing Hopkins’ expertise, they’ve steadily advanced their NICU’s level of acuity, where they are now certified to deliver babies as young as 28 weeks. This allows OBs to do higher-risk deliveries locally, and keep mothers and their newborns united. 

“If a mother has twins, and one is fine to go home but the other needs a NICU and is sent elsewhere, the mother is now divided between two babies,” says nurse Katherine Murray, who is the service line director for Frederick Memorial’s Women and Children’s Programs. “Plus, there was an outcry from patients about not wanting to have to travel to Baltimore.”

The success of Frederick’s NICU, which is run by Hopkins’ neonatologists, is a model of how relationship building is expanding the overall pediatric network. Murray says when other medical centers with the hospital wanted to move into pediatrics, they called on her to explore possibilities with Ted Chambers. 

“Now our sleep center is both adult and pediatric, we’re working with pediatric cardiology to do telemedicine echocardiograms, and we’re trying to do an arrangement for pediatric neurology,” says Murray, adding, “But it all started with the NICU.”

Knit the Network
Between wants and needs, supply and demand, and the sheer breadth of its reach, by 2010 Hopkins pediatric network had matured to the point where it needed organization lest it be crushed by its own weight. Internally, formally recognizing and naming the network two decades ago gave it important standing as the third pillar alongside the Children’s Center hospital and the Pediatrics Department. So too did Ted Chamber’s hiring of Deann Gavney as the network’s administrator, responsible for streamlining the contracting process and creating economic efficiencies of scale. Chambers candidly admits that, prior to Gavney’s arrival, the rapid growth of the network was becoming problematic.

“It’s like Sherman’s March to the Sea. Sometimes you get beyond your supply line,” Chambers concedes. “In our case, we got beyond our infrastructure. We could not manage this enterprise the way we needed to. We were not paying attention to details like we needed to, because it had all been built ad hoc.”

Creating transparency and putting the network on sound financial footing will allow for Hopkins to plan partnerships that might initially run in the red, but have solid long-term potential. Such was the case with Howard County General’s Pediatric ED. Originally a tiny three-bed unit, administrators hoped to expand it. But instead of doubling the unit’s size, which would have pleased the powers-that-be, Hopkins’ ED staff invested in a brand new 12-bed unit.

“They said, you could expand to five or six beds, but really the long-term need is 12. And maybe you won’t use all these beds right away, but we think this is where pediatrics in the community should go and will go,’ says pediatrician Dave Monroe, director of the Children’s Care Center at Howard County: “They built us a gorgeous unit and within a year it was actually filled-up.”
            
Adds Peter Mogayzel, vice chair for the network, “The hope of the network is that as we merge all the finances together from different outreach programs, some will do better than others and therefore we can offset a loss with a gain. So overall we can provide more services than if each venue needed to show a financial gain on its own.”

Nonetheless, Mogayzel adds, the goal is not to saturate the state with Johns HOpkins clinical services but to work with community pediatricians to strategically fill specialty services where such care is needed. 

"We are looking to the private practice pediatricians to identify the services that are really needed in their communities, the services that would be most beneficial to them, Mogayzel says. "It doesn't help them much if they need a pulmonologist and we give them a cardiologist."

Indeed, there’s more than money to this story, as Chambers recently realized when he was deep into discussing the network’s cash flow with Hopkins new 3.0 operating committee.

“All the leadership was there. They stopped me in the middle and said, ‘You have to think more broadly than just dollars and cents,’” recalls Chambers. “They said ‘We have a tripartite mission. So when you’re running this network, it has to have a research component – clinical trials involving big populations – and wherever you go you have to have an educational and clinical safety component. Part of the goal is to upgrade the quality of pediatric care in the community; you have to leave that program better than you found it.’”

Export Education and Research
In some cases, that education occurs within Hopkins’ walls, where Critical Care Medicine physician Betsy Hunt uses the Simulation Center she directs to train area pediatricians, like those at Suburban Hospital, on protocols. These include pediatric advanced life support for children who are critically ill.

But just as often, that training occurs at the hospitals within the Pediatric Network. St. Agnes has long been the home to Hopkins’ hospitalist residency program, with Hopkins hospitalists also running the unit. Compared to rotations that occur within the academic setting of the Children’s Center, the pediatric residents that come through St. Agnes, to a person, say they enjoy an unusual level of autonomy.

Working with hospitalists, “the residents really run the show here. They enjoy the sense of responsibility and the pressure that goes along with it,” says former resident and current St. Agnes hospitalist Eric Balighian. “It’s different than at Hopkins; there’s not always the best pediatric pharmacist or best pediatric respiratory therapist in the world just down the hall. The residents are forced to think about things themselves and come up with plans and they appreciate learning about how pediatrics is really practiced in communities, as opposed to Hopkins, which is unique. Here residents really get to focus on clinical diagnosis.”

That education is supplemented by Hopkins faculty who lecture at community hospital grand rounds. St. Agnes’ grand rounds are often attended by area pediatricians, offering them the added benefit of familiarization with Hopkins staff.

Then there’s the research side, which brings Hopkins drive for patient- and family-centered care into the hospitals with which they partner. At St. Agnes, “we just recently incorporated something that they’ve been doing at Hopkins called the PHACES (PHotographs of Academic Clinicians and their Educational Status) project, where they have the pictures and names of all the attendings, residents, and medical students on the wall of every patient’s room,” says hospitalist Sheila Hofert, who is working on her own research project, gauging the best way to deliver bad news to patients.

Structurally, the network has made important internal changes, for those times when community patients are referred to beds within Hopkins. The call center and patient flow to open beds have been revamped, as has the transport system to ensure rapid response whether by air (helicopter) or land (with specially-equipped ambulances capable of transferring babies weighing under a pound). Bruce Klein, director of Pediatric Transport Medicine, says their goal is not only to be fast but to make that call as comprehensive and collegial as possible.

“We’re trying to make those calls efficient, pleasant, providing everything an outside referrer might need in a single call, including speaking, ideally, to the receiving physician and the transport nurse,” says Klein. 

With transports reaching new highs – Klein says a second 12-hour team was recently added to handle the volume of transports during the week – the network is poised to further extend its reach. Discussions are underway with Suburban and Anne Arundel hospitals to expand their specialty outreach, which Peter Mogayzel says could greatly benefit Eastern Shore patients: “If you lived in Salisbury and needed specialty care, you used to have come to Baltimore, to Orleans Street to be seen. And now we’re saying, ‘No, you don’t necessarily need to do that. You can come to Annapolis, because that’s a lot closer and easier for you, and we’ll have a number of subspecialties there.’”

Think of it as Hopkins on-call. Coming soon to a neighborhood near you.
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(sidebar)

A “Yes” Approach to Service
Any organization is only as good as its infrastructure, so administrators for the Johns Hopkins pediatric network have beefed up three key areas to ensure that regional patients transferred to and from East Baltimore receive top quality service. It all starts with the call center, where referring physicians and nurses now have a one-stop shop for a child in need. By dialing 410-955-9444, or 1-800-765-5447 outside of the Baltimore area, everything from emergency transport to doctor’s appointments can be scheduled, with all calendars system-wide being kept within the call center. Not always known for its customer service – several area physicians interviewed said they had encountered inconsiderate and inaccurate service in the past – the Call Center is moving in a positive direction under the data-driven leadership of customer service professional Latisha Smith.

“The goal is that callers are not kept waiting, not going to voicemail, and not holding for long periods of time. We want to get scheduling done in a timely fashion,” says Smith. “We’ve set up phone metrics where 80 percent of our calls have to be answered within 30 seconds, and less than 3 percent of our calls end up being abandoned (where the caller hangs up). We’re also saying ‘Thank you,’ getting callers’ names and telephone numbers, getting them into the right clinic and meeting our goals for each individual agent.”

Once those calls are received, it’s often time for the emergency transport team to jump into place. Under the guidance of pediatric emergency medicine physician Bruce Klein and Medical Director Kristen Nelson, the transport operates between East Baltimore and 50 regional hospitals. Interestingly, Klein says that only 30 percent of all transfers go directly to the Pediatric Intensive Care Unit; the rest are handled by subspecialists within the Children’s Center.

The heart of the transport team is the specialized group of 12 pediatric transport nurses who head out by ambulance, helicopter, or, in long-distance cases, jet to make sure each child’s transport goes smoothly and safely.

“The nurse is involved in the initial call, so we get a very detailed description of the patient’s medical needs and a system-by-system evaluation,” says interim nurse transport manager Philomena Costabile. “We like to say we are prepared in knowing what we are going to get when we get to the hospital, but sometimes that is not exactly the way it goes down. That’s why we work with a team. When the nurses go out, there is always a paramedic and an EMT on board, so collectively it’s our responsibility to assess the patient, do any medical interventions necessary during transit, and communicate back to both Hopkins and the original facility.”

In concert with the transport is the knowledge that bed space will be available upon arrival. Efficiently managing patient flow to discharge so those beds are open is the focus of a collaborative initiative of four med-surg unit medical directors. Susan McFarland, Alia Irshad, Jessica Komlos, and Sybil Klaus have been tasked with getting patients ready for discharge before noon, which is considered the golden hour for opening beds.

Currently, more than 83 percent of all Children’s Center discharges take place after 12 noon, so there’s plenty of room for improvement. Alia Irshad says the changes taking place include early morning team meetings on each unit involving nurses, social workers, and customer service representatives, “to figure out the barriers to a kid’s discharge,” she says, noting that, in the case of children moving to rehab outside Hopkins, timely communication with those rehab centers to fulfill their information requirements for accepting a new patient is vital.

“This allows our ICU beds to open up," says Irshad, "which facilitates transfers not just from our OR and ER, but from community hospitals.”

In the case of children waiting to be discharged home, McFarland notes that case managers and social workers have improved efficiency by taking care of any home care, pharmaceutical, insurance and other needs well ahead of time.  McFarland also cites a hospital-wide service excellence intitiative to conclude physician rounds by 10 a.m. each day, freeing up staff to release patients earlier in the day.

"Based on our data review, the medical teams are meeting this new goal of finishing rounds by 10 a.m.," says McFarland. "But there is still work to be done by all involved to find innovative and efficient ways to reach our goal."

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