As the trend toward hospital mergers and consolidations continues, newly forming health care networks are developing multiple strategies to optimize their delivery of specialty care. This article briefly reviews the frequently described approach of centralizing specialty services and then uses the story of Carolinas HealthCare System to describe an emerging alternative strategy of decentralizing specialty services. We believe that growing hospital networks will need to adopt a combination of both approaches across different service lines in order to make the most of their newly acquired assets.
Centralizing Specialty Services and the “Volume Pledge”
One approach to improving specialty care within a network is to centralize specialty services within the network (Figure 1). The rationale for this redesign is based on the seminal work on high-risk surgery, which showed that hospitals with higher annual volumes have better outcomes than those with low volumes. To operationalize these findings, multiple institutions recently committed to “volume pledges” and are voluntarily restricting their most complex procedures (e.g., pancreatic cancer resections) to centralized high-volume centers within their network.
While there is emerging evidence that the centralization of specialty care improves outcomes following high-risk surgery, the strategy itself has two major limitations. First, models that centralize specialty care are not optimally patient centered. This strategy requires patients who need specialty services to coordinate care across different providers and take on the burden of associated travel.
Second, even if this approach is a successful strategy for organizing specialty service lines, it likely only applies to high-risk operations that make up a small fraction of the procedural caseloads at most hospitals.
Decentralizing Specialty Services and the Carolinas Levine Cancer Institute
An alternative and complementary strategy to improve specialty care across newly formed hospital networks can be achieved by decentralizing expertise (Figure 2). This approach may be particularly relevant to conditions for which providing optimal care is dependent on content expertise (e.g., choosing a chemotherapy regimen) rather than on the technical skill of an individual provider (e.g., complex cancer surgery).
Such a vision has been underway for the last 6 years at the Carolinas HealthCare System Levine Cancer Institute. When established in 2011 under the direction of Derek Raghavan, MD, the Institute had 85 employees, and most patients in the 38-hospital network had to travel to a centralized hospital for specialty cancer care. Over 4 years, through both expansion and acquisitions, the Institute grew to include more than 20 decentralized centers and clinics and 1,000 employees.
The Institute’s goal of providing uniform, decentralized services was largely in response to known barriers in delivering high-quality oncology care. First, there is wide variation in cancer care that is often inconsistent with current evidence and established guidelines. Second, the burden associated with the need to travel to a centralized oncology provider negatively influences patients’ ability to obtain adequate staging and treatment. Finally, even when patients can travel to dedicated specialists, they may end up with unnecessary or duplicate care from uncoordinated providers.
Four Strategies for Decentralizing the Delivery of Specialty Care
The Institute’s goal of delivering high-quality, decentralized specialty care across the network was achieved through the implementation of four strategies:
Disseminate Knowledge Expertise
First, the Institute needed to maximize its workforce by disseminating knowledge-based expertise uniformly. While there were oncology subspecialists at the main hospital center, many of the other general oncologists in the community had, over time, developed areas of content expertise.
Every cancer provider was encouraged to participate in creating care pathways for specific diseases based on known evidence-based guidelines (when applicable) and their own clinical experience. After development and agreement by consensus, pathways for each malignancy (including appropriate workup, preferred order of treatment options, and available research trials in the network) were integrated into the electronic medical record.
As a result, patients benefited from subspecialists’ decision-making expertise, which was then used to guide the delivery of care by a local provider.
Decentralize Infrastructure Investments
Second, leadership made strategic capital infrastructure investments to maximize the ability of patients to access cancer care and to participate in research trials. Services that were relatively rare and resource intensive, such as bone-marrow transplantation services, were kept at a single central hospital. However, more common (but also resource-intensive) services, such as serving as a facility to accommodate a Phase 1 clinical trial, were dispersed to two additional centers, with others planned. This meant that within the network there were now three sites with the infrastructure to manage the frequent lab draws and 24-hour staffing requirements necessary to run a Phase 1 clinical unit. By decentralizing these important services to multiple sites, more patients had access to trials without the burden of long-distance travel.
Optimize Care Coordination
Third, the Institute needed to invest in care coordination services across its now-larger network. Patient navigators were hired not only to coordinate services across different providers, but also to help patients locate needed services within the network closer to home. This investment allowed patients who had undergone a procedure (e.g., bone marrow transplantation) at a centralized center to receive follow-up care locally.
In parallel, significant investments were made in telehealth to better connect providers with each other. Each week, a network-wide digital tumor board allowed providers from any of the sites to present a patient scenario via network-wide secure videoconferencing and receive feedback on their care plan. As a result, providers could take advantage of the system’s expertise uniformly and coordinate care plans for patients seen at different sites.
Establish a Collaborative and Decentralized Culture
Finally, beyond structural and staff changes to the system, leadership also actively promoted a more collaborative and decentralized network culture.
To facilitate collaborative sharing of knowledge across sites, the network identified clinician experts along each disease care pathway who were willing to be contacted remotely by other in-network oncologists to support complex decision-making. Informal consultation (i.e., “curb-siding”) by email, over the phone, or through videoconferencing to leverage subspecialists’ expertise across the network was not only encouraged but was expected in order to help keep each patient’s care local. Moreover, to emphasize the decentralization of expertise, a system of distributed leadership was created, with section and division heads within oncology being located across multiple sites. Taken together, these steps enabled the leadership to focus on creating a collaborative and decentralized culture to facilitate the delivery of high-quality specialty care uniformly throughout the network.
Evaluating the Success of Network Redesign for Specialty Care
There are a number of ways in which Carolinas HealthCare (and other systems attempting to redesign specialty care within their network) can assess whether their new delivery models have improved patient care. Traditional measures, including outcomes (e.g., mortality rates, complications, etc.) and process measures, are necessary but are not sufficient.
Hospital leaders plan to go further by assessing patient-reported outcomes (e.g., patient satisfaction, quality of life, etc.) to determine the degree to which care is patient centered. Even if quality can be improved after large network consolidations based on process measures and outcomes, hospital administrators recognize that they must respond to the overall need for cost containment. Because decentralization has the potential to shift moderately complex care to lower-cost settings, this approach may realize the elusive goal of demonstrating how consolidation into a larger system can result in overall cost savings.
Combining Approaches to Redesign Delivery of Specialty Care
Centralizing and decentralizing models are not mutually exclusive, and it is likely that all major health care systems will need a combination of these approaches to accommodate the different volume and complexity across their service lines. However, in an era in which consolidations seem inevitable and knowledge expertise can move across geography more efficiently than patients can, we should expect large networks to leverage their resources to provide patients with uniformly high-quality specialty care that is located closer to home.
Acknowledgements: The authors are thankful to many people at the Carolinas Levine Cancer Institute who provided numerous interviews to inform this manuscript, including Derek Raghavan, Kevin Plate, Edward Kim, Kris Blackley, Mellisa Wheeler, Ed Copelan, and Brent Matthews. A.M.I. acknowledges funding from the Robert Wood Johnson Foundation and the United States Department of Veterans Affairs supporting his role as a Robert Wood Johnson Clinical Scholar. J.B.D. acknowledges funding from the National Institute of Aging of the National Institute of Health under award number R01AG039434-04.