Crete hospital completes its own health reform

2011-09-14T08:00:00Z 2011-10-01T12:07:46Z Crete hospital completes its own health reformBy MARK ANDERSEN / Lincoln Journal Star
September 14, 2011 8:00 am  • 

Even as Congress bogged down in attempts to find broadly acceptable fixes for health care, Crete's hospital and physician clinic combo quietly did it.

The results coming out of Crete Area Medical Center back up that bold claim, demonstrating marked improvements for patients with diabetes, high blood pressure, heart failure, high cholesterol and pneumonia.

"It's astounding when you think about it," said Dr. Tim Lieske, a BryanLGH Health System board member impressed by the hospital's rural affiliate.

Over the past two years, patient compliance on routine visits for high blood pressure improved by 36 percentage points to better than double the national average; compliance on high cholesterol visits, up 40 percentage points. Proof of diabetes control as measured by blood A1c levels was 17 percentage points better than the national average.

And then there are these astounding numbers.

* Nationally, 23 percent of heart failure patients discharged return quickly to a hospital, some say because of poor patient followup. At Crete, which cares for as many as 10,000 people, none of the recently discharged returned.

"That's literally unheard of," Lieske said.

* Nationally, for pneumonia, 17 percent quickly get readmitted. At Crete, that's also zero.

Eventually, there will be readmissions, said Crete center CEO Carol Friesen, but that doesn't diminish the accomplishments.

The numbers not only suggest better patient outcomes but considerable savings. Health care costs for a diabetic patient run more than twice that for someone without diabetes, and every avoided readmission for heart failure or pneumonia saves taxpayers or insurers $8,000 to $9,000.

"If they can increase compliance and keep A1cs down," Lieske said, "the amount of savings and better health for these patients will be phenomenal."

Dr. Russell Ebke, who led the clinical changes at Crete, brightened at a suggestion the quick gains demonstrate a plenitude of low-hanging fruit for improving the nation's health care quality and efficiency.

BryanLGH Health System CEO Kim Russel said those results could be replicated in Lincoln.

"I think we can do a lot of it in Lincoln," Russel said.

Lieske was more circumspect, noting the need to coordinate a great number of physician groups and other independent health care contractors.

"It would be wonderful if we could all do that," he said.

It's a BryanLGH goal, he said, to better integrate care, creating seamless transitions for patients as they move among the hospital, home and clinic.

Just about every hospital has that goal, either because of the growing evidence to support it or because of the pending punitive measures included in health care reform.


Eight years ago, BryanLGH built the replacement for Crete's small, 50-year-old city-owned hospital.

From the start, it was designed as an integrated hospital wrapped around a physician clinic to better coordinate patients with chronic diseases.

"Chronic disease, as a nation, it's crippling us," said Friesen, Crete's CEO.

It consumes 75 cents of every $1 spent on health care, and it kills seven out of every 10 Americans.

The nation's health care system, said Ebke, was designed to provide acute care, treating the illnesses and injuries common to earlier generations. Health care then was more a case of one and done.

Chronic illness, things like complications from diabetes and heart failure, demand a highly orchestrated and ongoing approach, heavy patient involvement and strong emphasis on communication among a provider team.

Communication is a key element, Friesen said.

"That's one thing we really tried to change."


Crete's new care model, called a medical home, belongs to an evolving health care trend driven by needs to improve care and reduce costs -- a complex alchemy that doesn't often occur together.

The medical home wasn't born in reform legislation, and there are mixed opinions about whether the new rules actually will promote it.

Russel, who in the past has noted difficult challenges posed by the legislation, said it takes a theoretical approach to forcing health care market changes.

"These guys have implemented a medical home and quietly put it in place," she said.

It wasn't mandated, she said, but resulted because doctors and staff said, "'We're going to do it.'"

At their base, Ebke said, physicians want to provide excellent care.

Health care providers, Friesen said, know where the flaws exist.

Take, for example, the path of a heart-failure patient.

Despite the abundance of chronic disease, people still wait until they feel symptoms before calling their doctor, Ebke said.

If they feel fine, he said, "Why look?"

High blood pressure often has no symptoms, he said, but when patients take control of it, they won't develop heart failure -- explaining the value of improving patient compliance on routine visits for high blood pressure by 36 percentage points.

Once someone gets admitted to a hospital for heart failure, he said, management gets complicated.

People go home with prescriptions for several medications but don't know which one is for what.

"We know that 40 percent of the prescriptions written never get filled," Ebke said.

People don't recognize the importance of monitoring salt and fluid intake, the critical need to check their weight every day.

"It's a complicated process," he said. "You can't learn it all in one bite."

People go home from the Crete hospital with their follow-up appointment in hand, he said.

Everybody gets called within three days, taking an approach that's low-tech, low-cost and high touch. Do they feel better or worse?

Questions are welcomed.

"People often times feel intimidated," Ebke said.

If a person has a difficult case of congestive heart failure, they may get a call daily.

Hospital patients who see physicians from outside the attached clinic also get attention.

"If you don't hear from your physician, call us back," Ebke said.

The medical home isn't an unwelcome approach to providing care, he said.

"People want that kind of health care. Enough people recognize that's the way it should be."


Crete set out to earn formal recognition for its medical home in 2009. This spring, Friesen expected recognition as a Level II medical home from the National Committee for Quality Assurance. Instead, Crete became Nebraska's first Level III, putting it on the tour for hospital officials seeking to improve their numbers.

One of them sought advice from Friesen, who told them to call back once they implemented an electronic health records system.

It's not possible without one, Friesen told them.

"You have to have data," Ebke said.

Without electronic records, Russel said, they couldn't know who was falling out of the system, who needed extra outreach.

For example, Ebke said, he can get a list of diabetic patients who haven‘t been seen in the last nine months.

They can begin to get at the question, Friesen said, "When we helped you with specialty care, what happened?"


Reach Mark Andersen at 402-473-7238 or

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