By C.A. Wolski
Back In Black Formed in 1994 by the merger of two Spokane health care providers, St Luke¹s Rehabilitation Institute joined a health system, Inland Northwest Health Services (INHS), that was losing more than $6 million a year. The first years were bleak, with many, including St Luke¹s current director of outpatient services, Gary Smith, PhD, then chair of the Physical Therapy School at Eastern Washington University, wondering how Spokane¹s only freestanding rehabilitation hospital would survive. That pessimism has changed to optimism now, says Smith. Today, the question is not how long will St Luke¹s survive, but what can be added to the mix? The nonprofit institute is poised for the first time in its short history to begin operating in the black. Tom Fritz, St Luke¹s executive director, expects to stop the flow of red ink by the end of the year. The turnaround is not a miracle, but a result of St Luke¹s operating philosophy whose guiding principle is a focus on patient care. Accomplished by eliminating administrative overhead, improving communications with cutting-edge technology, and using staff resources more efficiently, Fritz comments: ³Our whole goal is to eliminate administrative overhead and focus on patient care. [Consolidating] the overhead from four hospitals to one has had a lot of savings.² Fritz has also worked to ease insurance claims, including the introduction of electronic claims. He has not cleared all the hurtles impeding St Luke¹s yet. He still faces economic challenges out of his control. Administrative requirements brought on by the Balanced Budget Act of 1997 are expected to cost St Luke¹s between $500,000 and $800,000 when they take effect late this year. These government requirements have ³nothing to do with patient care,² says Fritz, and will increase the administrative overhead he has tried to cut. When St Luke¹s was formed in 1994 as a freestanding hospital, it consolidated the rehabilitation services of Spokane¹s two major hospital systems‹Providence Services of Eastern Washington and Empire Health Services‹when they merged to become INHS. By combining the services provided in each system, the staff could be committed to their specialties and offer a depth and quality of service not available in hospitals that had only one or two dedicated rehab beds. ³Centralizing [allows] us to focus on quality care, not competition,² says Fritz. He notes that not just the patients¹ needs were served by the creation of St Luke¹s but also the needs of therapists and physicians as well, through creating an institution of which they could be proud. This is due in part to the high visibility of St Luke¹s in the Spokane area, which gives its employees a strong identity with the hospital and a connection with the community. Technology also plays a role in serving the patient and the bottom line of INHS and St Luke¹s. A network of 20 telemedicine sites across largely rural eastern Washington links hospitals throughout the INHS system to St Luke¹s. Therapists at St Luke¹s can do anything from teleconferencing with physical therapists in tertiary care hospitals, assisting them in setting up treatment regimens, to physical examinations of patients, to forming support groups. ³It really expands our ability to work with other hospitals in the system,² says Smith. St Luke¹s medical director, Bruce Becker, MD, recently examined one of his spinal cord patients via the telemedicine system and found that he was able to make a much better diagnosis of a skin problem. ³I sat and chatted with the patient, talked about the issues she had, and examined a skin irritation on her foot,² he says. ³The visit took the same amount of time as an office visit.² By eliminating burdensome trips into Spokane for routine examinations, Fritz says the telemedicine system, which will be expanded to 50 sites in the next 18 months, ³is a way to leverage our infrastructure so [any] shortage of specialists won¹t be a problem.² Insurers are also recognizing the value of telemedicine, accepting claims associated with it. Staying Connected St Luke¹s is also a part of a computer network that connects all the hospitals throughout INHS¹s 28-hospital network. The system is a key component in eliminating the administrative burden at all the hospitals. All patient records are available throughout the system. Patients have an individual identifier used to access their secure records. Each time the patient is seen, no matter where in the system, the same record is updated instead of building a duplicate one with each examination and at each facility. ³We will be able to create pretty good tracking throughout the system,² Becker says. ³No one will be able to fall through the cracks.² Becker says that it is not uncommon even in model systems such as the Rehabilitation Institute of Michigan‹a system Becker helped to set up-‹for patients to leak out of the system. ³The major failure of medicine is poor communication,² says Becker. ³This gives us a possibility to get feedback. The communication system was a big factor [in what brought] me here from Detroit. We actually are doing better than urban [systems] because of our communication system.² Becker was medical director at the Rehabilitation Institute of Michigan from 1993 to 1999. The communication and rehabilitation process begins the moment a patient is admitted to an acute care hospital. The staff at St Luke¹s is notified, a therapy team is formed, and a plan is put in motion. Usually the patient¹s family is contacted within the first few days after the patient is admitted. Part of this speed is due to the fact that hospital stays for most injuries have decreased in recent years from 4-6 months to 4-5 weeks. However, the expedited rehab helps reduce complications and secondary injuries, and preserve more function. ³It gives patients things to work on,² says Becker. He adds that few of these patients‹most with extensive, life-altering injuries‹get depressed, and most do get better throughout their rehabilitation. ³Rehab really isn¹t a gloomy specialty,² says Becker. ³Human resilience still constantly amazes me.² St Luke¹s has three inpatient wings: spinal, traumatic brain injury, and cardiac. According to Becker, orthopedic and stroke inpatients make up about 60% of the patient base with spinal and traumatic brain injury patients making up the remaining 40%. About 30% of St Luke¹s patients are pediatric. Fritz says that the reason St Luke¹s is still operating in the red is because of its commitment to providing pediatric services, which are generally reimbursed only 23 cents for every dollar. ³We¹ll take the hit. We have to offer children¹s services,² says Fritz. The payor mix breakdown is: 50% Medicare; 17% managed care programs; 13% Medicaid; 12% insurers; 6% labor and industries; and 2% government-funded programs. Absence of Competition Apart from private rehabilitation practices, St Luke¹s has no hospital-based competition in the Spokane health care market. The staff and administration welcomed the elimination of competition, as did the state of Washington, which issued St Luke¹s the only antitrust exemption in the state. ³Doctors don¹t like health care competition,² says Becker. ³Combining the two systems has been helpful, giving us neutral ground to build collaborative practices.² This collaborative approach infuses every aspect of St Luke¹s business. Treatment at the 102-bed institute is multidisciplinary and team oriented including a physical therapist, an occupational therapist, a recreational therapist, and, if necessary, a speech- language pathologist. ³I think that this approach is more common in facilities that [deal] with more complex problems,² says Becker. ³It just works better.² St Luke¹s offers a wide variety of rehabilitation services including: cardiac programs, sports-related injuries, work-related injuries, and orthopedic injuries. Among its various therapeutic programs is aquatic rehabilitation, which was another reason Becker joined St Luke¹s staff. The pool allows patients to begin their recovery more quickly‹up to 3 days after surgery. ³The patient can¹t overload the joint,² says Becker. ³I think it speeds up healing in joint injuries and trauma.² Like the inpatient services, the goal of outpatient programs is to return patients to the highest level of functioning possible. With more than 1,800 visits in March, Fritz notes that outpatient services is one of St Luke¹s growth areas. This does not include the patients St Luke¹s staff helped via its telemedicine system. Outpatient services are also available at five other Spokane-area hospitals and include physical, speech, occupational, and recreation therapies and psychology. Community Integration St Luke¹s patient care does not end at the boundaries of its campus. There is also a commitment to the larger community. St Luke¹s sponsors adaptive sports programs for the community, teaching people with disabilities how to do everything from camping to hunting to skiing. It also sponsors several sports teams including a quadriplegic rugby team. St Luke¹s offers the only training program for children with disabilities who want to take part in the junior Bloomsday Run, an annual Spokane event. A child with a disability is paired with a nondisabled partner and train for 5-6 weeks before the race. This year, about 15 children trained by St Luke¹s took part in the race. As St Luke¹s services continue to grow in both quality and reputation, new territories will open up. ³We see ourselves moving in the area of workplace injury prevention,² says Fritz. Additionally, St Luke¹s patients can expect more focus on chronic pain management, more speech-language pathology including research, more clinical care, more follow-up, and an expansion into sports medicine with a focus on women¹s health. Smith, who was one of the people wary about St Luke¹s future 5 years ago, says that his worries have changed. ³My biggest problem is finding space,² he says. C.A. Wolski is associate editor of Rehab Management.
