Behind the scenes, helping Penn Orthopaedics deliver orthopaedic services more safely, more efficiently, and more accessibly, is a vast administrative system that profoundly impacts the quality of care for patients.
These efforts—facilitated by the Musculoskeletal and Rheumatology Service Line administrative support infrastructure—help an ever-growing network of Penn and Penn-affiliated providers deliver world-class services in an increasingly complex and competitive environment.
The Musculoskeletal and Rheumatology Service Line
According to Neil Ravitz, Chief Operating Officer Dept of Orthopaedics; Chief Administrative Officer Musculoskeletal and Rheumatology Service Line (MSKR), while it is common to think of patient care as something that occurs primarily between patient and provider, that relationship can begin with a circuitous route. The Musculoskeletal & Rheumatology Service Line exists above the department level, formally integrating Orthopaedics, Physical Medicine and Rehabilitation, Rheumatology, and Pain Medicine and connecting to various others like Radiology, Neurosurgery, etc. As Ravitz explains, it is the responsibility of the MSKR service line to coordinate a network of Penn Medicine and affiliated providers—and in some cases, those with no formal relationship with Penn—to best sequence care for the patient.
“Orthopaedic patients are coming to us either because they’ve had an acute injury or because their pain/discomfort prevents them from doing the things they want to do. They may also be discouraged by the difficulty of finding time while balancing family and work demands.” – Neil Ravitz, COO, Penn Orthopaedics; CAO MSKR
It is designed to expedite the process of getting patients to the right provider, not by immediately directing them to a specific department but by first gathering information that will better determine that sequence. “The MSKR service line is set up so a patient calling about knee pain is first connected to the service line call center, where they will be asked questions—eg, What is your age? Can you still walk? If it’s a 25-year-old who hurt her knee playing basketball, and has discomfort but can walk, we know not to send her to the joint replacement or trauma surgeon.” Thus begins the process of organizing her care around a specific patient population with similar needs.
Sean Looby, Director, Service Line & Network Integration, MSKR, says the advantage of service lines is that they foster continuity of care in a way “hard handoffs” from departments do not. “The whole service line structure,” Looby explains, “is designed to enable a higher-level view of how patients actually access and receive ongoing care. It makes it possible for us to work with multidisciplinary teams to make those connections, to make sure everyone’s aware of what’s going on and focus on the patient populations that we deal with. We are then able to build programs and services around the patient.”
Expanding Access and Improving Patient Experience
Noting the competitiveness of the healthcare marketplace, Ravitz says, much like brand management in other industries, service line management is an important part of responding to the needs and preferences of its “customers,” creating and forcing alliances that improve their experience of care as well as improving their health. “The Penn brand carries a lot of weight for many people in the region, but there are many other competitive brands out there, so we need to distinguish ourselves in addition to having high-quality physicians and surgeons and advanced practice providers.”
The way this is done administratively, he says, is by adding to Penn’s quality dimension programs and access points that address how patients make their healthcare decisions. “Some are based on what they see from a marketing perspective, some is what their friends tell them, and some is their own belief system, and little things that affect their decisions like tolls to cross bridges and traffic on the Schuylkill Expressway.”
High on the list—especially for orthopaedic patients— is access. “If you can’t get in to see even the best physician for three months, that’s an inhibitor.” Ravitz says. “Orthopaedic patients are coming to us either because they’ve had an acute injury or because their pain/discomfort prevents them from doing the things they want to do. They may also be discouraged by the difficulty of finding time while balancing family and work demands.”
In response, he says, Penn has begun offering extended night and weekend hours. Another initiative, he says, is in response to the growing popularity of urgent care centers—especially for young people who often manage their care by using them for an acute issue, many of which concern orthopaedics, such as fracture, sprains, strains, torn ligaments. “We’ve begun to partner with urgent cares in the Philadelphia area and its suburbs—enabling them to send patients to us more easily.” This, he says, starts with allowing centers with whom Penn has no formal relationship to automatically electronically send patient images directly to Penn.
As part of the changing healthcare landscape, Ravitz mentions, too, how various alignments are forming as a result of consolidation in healthcare, offering opportunities to affiliate with new partners and reach out to displaced patient populations, to leverage and re-enforce the Penn “brand” in the region.
Describing this relationship as “bidirectional,” Ravitz says, “There are many good reasons to be aligned with a Penn facility. Some partners consider it advantageous due to its brand recognition, and there’s no question that it offers a higher level of service than is available at most local practices.” However, he says, the service line makes it possible to differentiate between patients who can and should be served by their community partner and those who can and should receive the kind of high level care, including limb salvage, that should be treated downtown at Penn.
In addition to offering extended hours and our work with our affiliated partners to better accommodate patients mentioned above by Ravitz, Looby says there are two initiatives in the works that also aim to improve patient access. “We are piloting telemedicine programs with several surgeons to offer post-op video visits for low-risk procedures and patients. In this way, a post-op patient that lives an hour away can be seen virtually so the physician can verify that everything is healing correctly and looks good, while avoiding the driving, parking, and time away from family or work. This should be a real value-add in terms of patient convenience and satisfaction. We are also reassessing algorithms that allow online scheduling, to ensure the right patients get to the right providers, all while allowing patients to schedule appointments with the click of a few buttons.”
Disease teams: Optimizing integrated care
Looby says, a key part of the service line structure that drives improvement initiatives are the disease teams built around defined patient populations that serve as a forum to integrate siloed services.
“Our disease teams allow us to standardize the way care is provided by laying out a pathway by which patients access services and move through their care in the most optimal way—whether it’s a surgical or nonoperative intervention. They also identify problem areas, gaps, and improvement opportunities to focus on as a team.”
Within orthopaedics, for example, there is geriatric hip fracture disease team, a major lower joint replacement disease team, and a shoulder replacement disease team. Each includes stakeholders and representatives from throughout that patient’s care—hospital and outpatient clinic employees, including the surgeon, physical therapy, nursing, rehab, pharmacy, anyone who should have a seat at the table and input on any sort of improvement for these patients.”
Looby describes how they work with different hospitals in the Penn system—all of which do things differently and serve different patient populations. In addition to the Hospital of the University of Pennsylvania, Penn Presbyterian Medical Center, Pennsylvania Hospital, this now includes Chester County Hospital, Lancaster General Health and Penn Medicine Princeton Health.
“One of the challenges of integrating services within such a large health system,” Looby says, “is making sure we’re leveraging the innovative work being done across the health system at these different hospitals that are geographically dispersed to raise the level of care across the entire health system. That includes disseminating best practices learned from each other and standardizing certain components of care that should be standardized.” This, Looby says, involves identifying things that should be done the same way across all hospitals and implementing them, but also recognizing and appreciating that there are innate differences that cannot be standardized and should therefore be optimized at the local hospital level.
Also in the interest of improving access for patients, says Looby, are the more, less formal relationships with community hospitals. “Most patients outside our service area don’t expect or need to drive downtown to Penn for orthopaedic care. Through our relationship with a number of community hospitals and provider groups, we can collaborate to improve the quality of care provided in their local communities while also offering streamlined access to Penn orthopaedic services and treatment options when their patients require it.” Among these affiliated providers are Bayhealth in Delaware, Cape Regional Medical Center in Cape May County, NJ, Princeton Orthopaedic Associates in Princeton, NJ, and Grandview Health, which is an hour away in Sellersville, Pa, and the newest member of the affiliate network.
Quality and Safety
Hannah Lacko, Director, Quality and Patient Safety, MSKR focuses on quality and safety programs and services that support the different patient populations identified and addressed by the disease teams. She described the many different orthopaedic initiatives that depend on the service line including those that address the current opioid crisis; seek to reduce hospital readmissions; and improve outcome in joint replacement patients.
A major program on the quality side, she says, concerns patients scheduled for knee or hip replacements, which are now the most common procedures in orthopaedics. “Based on literature and our own experience, patients who are prepared for what happens before, during, and after surgery have better outcomes, including fewer complications, reduced hospitalization, and lower likelihood of being readmitted.”
In response, she says, these patients are urged to attend “joints classes” with someone—a partner, caregiver, or family member, “so all are better prepared to help get through that period.” Lacko says improved access at these classes and increased emphasis on their importance have dramatically improved attendance. “It’s gone from about 15% to about 65%.”
She says in response to the widely publicized opioid crisis, Penn has joined the entire healthcare industry in re-examining its prescribing practices. “To protect our patients and reduce the amount of opioids we send out into the community, we have developed protocols and patient pathways to help determine the right amount of pain medication to prescribe. We continue to focus on reducing average pill per script—this year we’re focused on decreasing the number of initial prescriptions with 5-day supply or less, which is consistent with guidelines many states are starting to enact; in fact, New Jersey already has a 5-day supply law.”
Lacko says, too, a pilot program in which patients are contacted via text to find out how many of their pills they’ve taken is an important step in the effort to align prescription practices with need based on real data.
Noting that readmissions continue to be a major healthcare concern, she says, an effort to reduce them involves proactive advocacy: “We are following up with high risk patients via nurse navigators who checks to be sure they’re sticking to their care plan.”
Providing the best for our patients
A large part of coordinating these many players and initiatives, and to ensure that the patient experience is of equal quality no matter where in the system it is received, is the stuff of system integration. The service line deals largely with the downtown Penn hospitals as well as the regional hospitals, while the network goes beyond that in that it addresses “how we think about working with other providers and hospitals,” Looby explains.
The team therefore described what they call “three tiers of service line integration;” (1) the downtown-focused service line, quality initiatives, and disease team efforts, which cut across traditionally “siloed” academic departments to better serve defined patient populations; (2) integration and collaboration with the other hospitals throughout the Penn health system through disease team work and other efforts; and (3) the affiliate network, comprised of relationships with community hospitals and provider groups outside the health system. Working together to coordinate the efforts at these three tiers, is the overarching mission of the MSKR Service Line team and its services and relationships - to improve their ability to serve the health needs of the Philadelphia region and beyond.