Redesigning inpatient care: Transforming health care one unit at a time

The Accountable Care Teams model, ACT model for short, is based on three foundational domains (1) enhancing interpersonal collaboration between healthcare team members; (2) enabling data-driven decisions and (3) providing leadership.

The ACT model was developed at Indiana University Health Methodist Hospital with consultation from the IU School of Medicine's Center for Health Innovation and Implementation Science. The care model has been implemented across this urban hospital, which serves over 30,000 patients annually.

"The ACT model is front-line driven," said Areeba Kara, M.D., who led the study measuring the impact of the new care model. "ACT inoculates good practices, develops cultures of cooperation and enhances personal connections with the institution -- all contributors to better patient care and increased job satisfaction."

A variety of tools, which can vary by hospital unit or hospital, support these efforts. These tools could include daily huddles to discuss patient's needs for safe transition out of the hospital; hospitalist and specialist co-management agreements; monthly review of unit-level data including length of stay, tracking of patient satisfaction scores, readmission rates and other metrics; and provision of leadership by designated hospitalists and, where relevant, specialty leaders.

"This evidence-based care concept could be adapted by medical, surgical or other inpatient units anywhere based on the foundational domains supported by locally relevant and institution- specific tools," said Dr. Kara. She is a hospitalist with Indiana University Health Physicians and an Indiana University School of Medicine assistant professor of clinical medicine.

"We studied the outcomes of the ACT model across the entire hospital except the ICUs," said study co-author Siu Hui, Ph.D., a Regenstrief Institute biostatistician and professor emeritus of biostatistics at the IU School of Medicine. "ACT decreased cost by $649 per stay plus the significant amount saved by reduction in number of days spent in the hospital."

Almost all (95.8 percent) of care providers surveyed -- doctors, nurses and other practitioners -- agreed that the model had improved the quality and safety of the care delivered. More than 89 percent said it had improved communication with patients and families. About 82 percent said it had improved their engagement and job satistfaction. Three-quarters said it had improved their efficiency or productivity.

Authors of "Redesigning Inpatient Care: Testing the Effectiveness of an Accountable Care Team Model" in addition to Dr. Kara and Dr. Hui are Cynthia S. Johnson, M.A., of the IU School of Medicine and Richard Fairbanks School of Public Health, and Amy Nicley, R.N., M.S.N., and Michael R. Niemeier, M.D., both formerly with IU Health.

"The true value of the model may be in its potential to monitor and drive change within itself. Continuously aligning aims, incentives, performance measures and feedback will help support this innovation and drive," the authors wrote.

According to the Centers for Disease Control and Prevention, inpatient care accounts for almost a third of healthcare expenditures in the United States. In 2010, 35.1 million patients were discharged from the hospital after spending an average of 4.8 days as an inpatient.

"The ACT inpatient care model is a fine example of applying implementation science to the goal of decreasing length of stays and lowering healthcare costs in a localized real world environment," said Nadia Adams, M.H.A., executive director of the Center for Health Innovation and Implementation Science.

"We held weekly meetings with ACT model facilitators from IU Health focusing on developing tools, processes and strategies for rapid, efficient and sustainable implementation of evidence-based practices to help develop and implement reproducible approaches that could meet the challenge of dissemination and scalability across various types of health care systems," Adams said.