Dr Kyle Lamb Discusses Transitional Care, Super-Utilization in Value-Based Medicine

Kyle Lamb, MD, associate medical director of population health at the Vancouver Clinic, explains the interworkings of how transitional care can help manage super-utilization within clinics and prevent patients from becoming super-utilizers.

Transcript

What are some trends the Vancouver Clinic is seeing regarding how super-utilization within health systems has changed over time?

Sure, interesting question, because so much has changed with COVID-19. I think the thing that we are seeing is later presentations of chronic disease that would have often been seen initially in the clinic are showing up for the first time in the hospital setting without prior triggering event. This has changed a lot of how we invest resources in those types of patients and increased the burden on the inpatient system.

What we've done through transitional care is try to move as much of that inpatient work to the outpatient setting, to both reduce the cost of the care that's delivered, but also to improve the patient-centric elements of the care, delivering it in a way that fits the patient's needs in many cases and is coordinated in a fashion that fits with what the patients really want. Which is to be able to be at home, to be able to manage with frequent touchpoints with a variety of different clinicians and staff, to get the the most out of what we can deliver with today's health care in a very unique setting, which is what we deliver in transitional care.

How can an integrated transitional care model assist health systems in addressing super-utilization?

For us, transitional care has been a key element in connecting what we do on the inpatient side with the outpatient side. As a multispecialty clinic with a very large primary care network, we are really invested in taking care of our patients more holistically. For us, transitional care allows us to move from the inpatient setting to an outpatient setting the types of services that are typically delivered only in the inpatient setting. So, things like IV [intravenous] diuresis, things that can include antibiotics, and things that are hard to deliver in traditional primary care [during] weekly or twice-weekly visits with frequent lab draws and very frequent patient contact. For us. transitionl care is able to deliver those elements and is essential to our strategy for value-based care.

For us to be successful in value-based care, we know we functionally have to reduce ER [emergency department visits] and hospitalization. To be able to deploy some of those inpatient treatment modalities in an outpatient setting allows us to deliver what patients need when they need it and where they want it, which is something that's really important for our patient population.

What should the Vancouver Clinic do going forward to further reduce super-utilization?

I think, for us, we think a lot about how technology can help us reduce super-utilization. We feel like we have the clinical tools that we need to do that and are building some of those out in new ways. Things like hospital at home and for us, hospital SNFs [skilled nursing facilities] are foundational to our clinical elements that we're building out to reduce super-utilization.-

But we think technology will have a big contribution to the future of how we manage super utilization. One of the areas we're aggressively pursuing is remote patient monitoring, and I think that's just the tip of the iceberg of what technology can help us do. We think there's a lot around the use of population segmentation data and analytics to better help us use technology to influence clinical decision-making, but also to identify patients that we need to apply more traditional clinical management to.

With super-utilization, the key is the patient identification. And for us, we think about it being as early as possible before they become a super-utilizer. That's the optimum time to deliver an additional basket of services to that patient as opposed to after we've seen those super-utilization events.

So, for us, technology can help us move further upstream to deliver care before a patient becomes a super-utilizer and invest in them at exactly the time that they need us to invest in their care to change their outcomes.