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51 Executive Briefing At TeamHealth, our purpose is to perfect our physicians' ability to practice medicine, every day, in everything we do. TeamHealth offers outsourced emergency medicine, hospital medicine, anesthesia, orthopedic hospitalist, acute care surgery, obstetrics and gynecology hospitalist, urgent care, post-acute care and medical call center solutions to ap- proximately 3,300 civilian and military hospitals, clinics, physician groups and post-acute care facilities nationwide. Post-discharge planning. The first element influenced by IDT rounds is the decision about where a patient should go after they leave the hospital. IDT rounds provide a forum for all the caregivers involved in a patient's care, including nurses, physi- cal therapists and family members, to jointly discuss next sites of care and evaluate the patient's individual post-acute needs early on in the discharge planning process. This can help the care team identify the optimal next site of care and design care around that setting as soon as possible. Medication management. Medication management is the sec- ond element of value-based care that can be enhanced by IDT rounds. Dr. Deruelle recommends including a pharmacist on the rounds when possible to discuss medications on a daily ba- sis, particularly in discussions surrounding discharge. Studies have shown involving a pharmacist during the rounding pro- cess can improve patient care and reduce costs. For example, a 2003 study demonstrated the rate of preventable adverse drug events can be reduced 78 percent when a pharmacist is involved in rounds. A 2010 study demonstrated hospitals can save $16 for each hour a pharmacist works reviewing patient cases while on rounds with a hospitalist. Patient hand-off. The last element of care redesign where IDT rounds come into play is the hand-off and discharge process. Having the patient and their family or caregivers present during the rounds, particularly as they approach discharge, can make a world of difference in closing gaps in care that occur during care hand-offs. "The last few IDT rounds during the hospital stay provide an excellent opportunity to tighten up that plan and make sure it's achievable from everyone's standpoint on the team," Dr. Deruelle said. IDT rounds can help optimize a key cost-saving opportunity — the post-acute care setting Improving communication between stakeholders is crucial to develop effective care plans that account for patients' individu- al needs. This not only helps produce better patient outcomes, but can also reduce the costs of post-acute care. Outside of implants and supplies, the post-acute setting rep- resents the No. 1 opportunity for hospitals to lower costs within bundled payment programs. Almost half of overall savings as- sociated with the CJR bundled payment program implement- ed at San Antonio-based Baptist Health System was attributed to post-acute care spending reductions, according to a study published in JAMA Internal Medicine in February 2017. When included in the bundle, average post-acute spending declined by more than $2,440 per case, primarily due to lighter use of inpatient rehabilitation and skilled nursing facilities, according to the study. IDT rounds can help hospitals reduce post-acute spending by enhancing communication between caregivers. With the teams of teams present during IDT rounds, all the key players know as soon as possible what barriers are present to certain next sites of care, and can work to eliminate those obstacles if pos- sible. According to Dr. Deruelle, the goal for every patient is to go home. "We believe patients should go home if they can go home," Dr. Deruelle said. "We don't accept that a skilled nursing facility is any safer in and of itself than a home discharge if the right support can be provided." In fact, studies have shown patients who receive home-based care may achieve the same quality results as those who go to an inpatient rehabilitation facility, and often at a lower cost. For ex- ample, patients who were sent home after a knee surgery and received at-home physical therapy experienced no difference in complication rates within six months of surgery compared to peers who were sent to an inpatient rehabilitation facility, ac- cording to a 2015 analysis of data on more than 2,400 patients who received knee surgery at New York City-based Hospital for Special Surgery from 2007 to 2011. "Many patients believe they will do better after knee replace- ment if they have rehabilitation at an inpatient facility because they will receive more physical therapy," Douglas Padgett, MD, the lead investigator of the study, said in a statement. "However, in terms of early complications and outcomes at two years, we did not find an advantage." Providers must be engaged in the process to drive out- comes To ensure IDT rounds are successful, hospitals must approach the care redesign process thoughtfully. It is a significant shift in thinking to consider responsibility for patient outcomes ex- tends beyond discharge and that it's everyone's responsibility — not just that of the physician, nurse or family. To help this new mindset sink in, it is essential to gain buy-in from IDT round leaders. Physicians ideally lead the rounds, sometimes with a nurse co-leader, according to Dr. Deruelle. The key to gaining clinician support is to demonstrate that IDT rounds are not added work — they ensure the patient is at the center of their care and ultimately improves value. Dr. Deruelle advises hospitals to remember the education com- ponent of care redesign — including both content creation and dissemination. Content needs to be available "so there is a full and complete understanding of what the outcomes are that we want to achieve, why we want to achieve them and why care redesign and IDT rounds will help us get there," he said. Tool kits and modules should be available electronically, but training should always begin in-person. If affiliated hospitals and staff are included in the training process, that's even better, he said. "At the end of the day, one of the most powerful messages is that these models can help improve value for patients," Dr. Der- uelle said. "It really gets our providers engaged because they know we are doing it for the right reasons." n