The Kansas Heart and Stroke Collaborative stands as a success story on a collective effort to help residents in smaller Kansas communities receive lifesaving care.
The program started through a federal Centers for Medicare and Medicaid (CMS) Innovation Grant, directed by Robert P. Moser, a Greeley County native who practiced medicine in Tribune for 22 years. He became secretary of the Kansas Department of Health in 2010 and joined the University of Kansas Health Care System in 2014.
“The focus is to improve the quality of care outcome and lower total costs of care for patients suffering heart attacks or stroke,” Moser said. “We developed the model using subject matter experts from the University of Kansas and Hays Med.”
The program started with 13 counties in southwest Kansas, including 11 critical access hospitals. After just a year, CMS asked the collaborative to expand, and it is now in 56 counties, Moser said. In 2016, it was expanded to address sepsis.
Stroke numbers in the region and how hospitals were treating patients reflected some of the challenges of rural health “such as mostly volunteer EMS, few ambulances that have an ability to do a 12-lead EKG and the large percentage of patients who arrive by private car instead of 911,” Moser said.
There are also the challenges to the hospitals in reaching out for higher level consultation and the distance to heart catheterization, or cath, labs.
“We knew according to national benchmarks if it was more than an hour away it was unlikely to get a patient to a cath lab in 90 minutes or to begin intervention in 120,” he said.
Whether a patient should be given a clot-busting drug is a critical determination needed within the first hour of a stroke, before moving to the next level of care. That decision requires a CT scan.
“Less than 3 percent of eligible patients who had a stroke and could qualify for clot-busting were getting it,” Moser said. “We had to look at how they were being assessed on arrival. We found most had protocols in place, but few were collecting data to look at how they were doing as far as national benchmarks.”
The collaborative helped the hospitals track and audit their data and to look for ways to improve their performance.
“We saw improvement in getting clot-busting drugs to patients, which went from 3 percent to 18 percent,” Moser said. “They’re doing a great job with that.”
They also developed delivery care models for each site and provided education to providers.
“When I was in practice in Tribune, we’d be invited to regional meetings and we’d take the information back to our providers,” Moser said. “Many times you could only take one or two people out at that level. We took the system to the community and invited in EMS and long-term care to the training, as well as providers and support staff. We wanted everyone to hear the same information on protocols and what’s best for the local system.”
The collaborative also worked to implement some other care components in transitional care.
“You’re sending folks out of the community to a larger health care provider, sometimes an hour or two away,” Moser said. “When they come back to get re-established with their local health care, sometimes it took a while, which contributed to higher readmission rates. We used regionalized practical nurses at each site, who’d get in touch with the district manager with the hospital where the patient went. Some are in northwest Kansas, some in Colorado, some in Nebraska, and numerous sites across Kansas.”
The nurses had to establish relationships with the district managers, and then with patients when they returned home to help with medication regulation, sometimes including bed acquisition and transportation for follow-up care.
They also were allowed to establish new billable practices for sustainable chronic care management beyond 30 days, including regular meetings of at least 20 minutes between providers — usually RN’s — and patients, to help them with self-management. The meetings could be face-to-face or electronic.
“That delivery model took off quickly, and CMS asked us to look at scaling up after the first year, expanding into other communities,” he said. “We then added another time-critical diagnosis: sepsis.”
Recognition of sepsis in participating hospitals went from 66 percent to 88 percent this year, he said.
Now the collaborative is working on developing a new claims payment system for rural hospitals. Last year it was used by two hospitals, with one showing achieved savings. In 2018, the payment model was being set up in 33 counties.
At the end of 2017, the group received another three-year award to explore business sustainability through peer management and chronic peer management, and collaborative members continue working on adding other medical conditions to their program, including heart failure, trauma and palliative care.
As a result, the organization changed its name from Kansas Heart and Stroke to Care Collaborative, Moser said.
Besides improved patient care, a benefit noted for hospitals that are part of the collaborative is that it has become a recruiting tool in that the system helps take some of the burdens off rural providers, Moser said, and it’s helped standardize care costs.
“We are continuing to expand,” Moser said. “We had a couple of counties that reached out last month to want to join our care collaborative, who want to work on quality improvement around their time-critical diagnosis. We’ll do an onboarding site visit and sit down with their administration and provider leadership, and layout our model … and look at how each will be modified to adapt to their local reality.”
The organization is willing to take on other newcomers, Moser said. Members also are looking at how the model might be expanded into other care areas, such as addressing the opioid crisis.
Besides the federal funding, the program has received support from the University of Kansas and the United Methodist Health Ministry Fund.