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Aine Cryts is a freelancer based in Boston. She is a frequent contributor to Managed Healthcare Executive on topics such as diabetes, oncology, hospital admissions and readmissions, senior patients, and health policy.
Successful health systems share their tips.
One of the best ways to engage physicians and other clinicians in health system initiatives is to ask for their help and insight, says Zoe Tenney, a family nurse practitioner and clinical quality supervisor at Blue Hill Memorial Hospital, which is part of Brewer, Maine-based Beacon Health, the accountable care organization (ACO) arm of Eastern Maine Healthcare Systems.
Equally important is the language used when interacting with physicians, adds Tenney. “Don’t talk in terms of insured lives or other executive-level terms,” she says. Instead, point out a real clinical problem that needs to be solved-and ask for their ideas on ways the health system can solve it.
That approach is what Tenney says led to more effective STD screening at Beacon Health, more specifically, chlamydia screenings for women between the ages of 16 and 24. Chlamydia is a growing problem in Maine. The Portland Press Heraldreports that cases in the state increased 76% between 2010 and 2017, according to the Maine Centers for Disease Control and Prevention.
To help address this problem, Blue Hill has revamped the wellness visit for young women in this age range, which starts with a letter that is sent to the patient’s home-most likely, this letter is read by the patient’s parents. Included in that letter, which orients the patient regarding what the annual visit will cover, is a statement that all women between the ages of 16 and 24 will take part in an STD test during the visit.
Normalizing the STD test is important, says Tenney, because then the young woman and her parents won’t be alarmed when it shows up on the explanation of benefits from their payer. Screening as many young women as possible is helpful as well, because many won’t be honest about their sexual activity, she adds. When the patient arrives for her annual wellness visit, a medical assistant then takes a urine sample as a standard protocol.
Blue Hill has a goal to screen at least 35% of current patients in this age range annually. One of the challenges Tenney and her team face is convincing college students to come in for screenings; it’s also difficult because many of these patients are self-pay and decline because of the cost associated with the test. (She adds that some patients are tested anonymously outside the clinic, which means those numbers aren’t available.)
A health system spokesperson says that Blue Hill has a monthly meeting that involves all staff members-including clinicians-where quality improvement plans, such as this revamp of the young women’s annual wellness visit, are developed. At these clinician-led meetings, performance improvement plans are finalized. “Without the [clinician] commitment to quality improvement and engagement, the goal couldn’t be met,” the spokesperson says.
Currently, Blue Hill screens 28% of young women for chlamydia, says Tenney, who notes that in January 2017, clinicians were screening just 17%.
Beacon Health has also collaborated with physicians in its approach to improving care for patients with chronic obstructive pulmonary disease (COPD), says Will Seavey, PharmD, BCPS, director of pharmacy and care delivery. Called a COPD exacerbation kit, it uses an order set in its EHR that provides a nurse with standard guidelines for assessing a patient’s COPD. Depending on the result of the nurse’s assessment, a patient may receive an antibiotic and/or steroids for treatment. A patient’s physician must approve in advance that a nurse can do the assessment, which is noted in the EHR.
Before this protocol was put in place, physicians performed all assessments, which ate up their time and made it difficult to get patients in for same-day appointments, says Seavey. And even when the practice could accommodate same-day appointments, squeezing in patients through the day completely threw off the physician’s schedule.
The biggest impact? Access to same-day appointments means fewer expensive emergency room visits, says Seavey. (While he was unable to provide specific metrics, a health system spokesperson says that the hospitals and primary care clinics that use the COPD exacerbation kit most often have lower admission rates for COPD than the health system’s average.)
Seavey says that in order for the COPD assessment to be successful, physicians need to develop trusting relationships with nurses on the team. But getting physicians onboard with the new tool “wasn’t a big stretch,” says Seavey, particularly because it would help save them time. “Clinical providers want to do the right thing. They want to do the best by their patients. It’s not hard to get the message through,” says Seavey.
Another facility that’s demonstrated success with provider engagement is Stanford Children’s Hospital. One way it engages physicians is to ask them to prioritize the problems they want to solve within their specialties, says Andrew Ray, director of professional revenue cycle.
For example, the urology department wanted to get patients with testicular torsion, where blood supply is cut off from the organ, into surgery faster (in fewer than seven hours, because patients have approximately 12 hours to receive surgical treatment before risking permanent damage).
To identify how to best treat this condition in a timely manner, members of the urology team did a literature review and visited facilities that were successfully triaging their patients with this condition. What they learned has resulted in significant improvements in coordinated care between the hospital, operating rooms, urologists, and nursing staff, says Ray.
Ray says the two main changes are quicker and better identification of testicular torsion-which required training of the triage clinical staff-and then providing a more clear protocol for how to take action. This includes communication to the urologic surgeon on duty, mobilization of the operating room team, preparation of the operating room, scheduling adjustments with the operating room, and patient transport to the operating room.
He adds that operating room availability is “always a challenge.” Getting clinical and operating room scheduling staff in agreement on these cases is key.
“In the typical triage sense, the most urgent/emergent needs are handled before planned or routine needs, so a lot of that was facilitated by education and gaining consensus with [clinical] and operational staff on the need for urgent treatment for this condition. That allows for effective triaging of patient operating room needs and current cases,” says Ray.
David Hanekom, MD, CEO at Arizona Care Network, a 5,000-clinician ACO that treats patients in Maricopa and Pinal counties, notes that 90% of its physicians are independent, which means they don’t work for the network. This can be particularly challenging, because the ACO has to provide these independent physicians with a reason to want to be involved in ACO-related initiatives, he says.
To encourage care coordination and improve care quality, physicians the health system provides monetary incentives if they meet standards related to:
Since the health system needs to communicate with a broad audience of providers, it also focuses on ongoing communication, from e-mails to regular in-person meetings to site visits to address issues at the practice level.
Other features of Arizona Care Network’s success include publishing quality data based on the above metrics for individual providers to see where they rank vis a vis their peers, and care management, which includes nurses and behavioral health specialists who assess social determinants of care, ensure patients understand their care plans, and remove barriers for patients trying to adhere to their treatment plans, says Hanekom.
Arizona Care Network has been able to reduce hospitalization, emergency room utilization, and heart attacks among Medicare patients with screening, hypertension control, smoking cessation, and other care coordination activities. From 2016 through 2017, UnitedHealthcare members attributed to the ACO’s providers had a 10.4% reduction in inpatient admissions for heart-related events and a 13% reduction in the need for cardiac bypass and angioplasty.
Aine Cryts is a writer based in Boston.