Accountable care organizations are tasked with providing more coordinated, higher quality care while lowering costs. Essentially, they are tasked with providing more for less.
To solve this paradox, it may seem like providers need an army of staff or five more hours each day. This does not have to be the case, however. To successfully improve outcomes, providers need to engage the patient.
We checked in with Tim Hernandez, MD, medical director of Community Health Network, a Medicare Shared Savings Program ACO based in the St. Paul-Minneapolis metropolitan area, to better understand what patient engagement really means and how ACOs can leverage it to achieve the triple aim.
CHN marries two primary care groups: Entira Family Clinics and Health East Clinics, an independent group of family physicians and an integrated group of primary care physicians, respectively. Despite saving $1.4 million in its first participation year, CHN didn't reach the threshold to share in savings. So it began to work on targeting specific patient populations to improve engagement. Through a partnership with Pharos Innovations, CHN focused on two populations: patients transitioning out of the hospital and patients with congestive heart failure. CHN was able to reduce all-cause admissions for patients in the program by 41 percent in one year. By the end of 2014, its second year in the program, it created more than $5 million in savings and earned more than $2 million in shared savings. The ACO is now working to apply its patient engagement strategies to additional patient populations.
Here Dr. Hernandez shares what patient engagement means to him, what it looks like at CHN and the hurdles the ACO has faced on the journey to improved outcomes.
Question: Being in Minnesota, what benefits and/or challenges does this market present?
Dr. Tim Hernandez: Both organizations are in the east metropolitan neighborhoods of the Twin Cities. The two groups serve about 250,000 and 300,000 patients. Our ACO serves 15,000 Medicare beneficiaries.
What's unique about Minnesota, and particularly the Twin Cities, is it's very competitive with many tight vertically integrated systems. We have some very large hospitals and provider systems that have been together for quite some time. For groups like mine — physician-owned, single-specialty groups — this market provides some interesting challenges to implement population health initiatives with limited resources.
Q: What does patient engagement mean to you, and what does good patient engagement look like?
Dr. Hernandez: For me,patient engagement is how we, as providers, interact with our patients in a way that gets them involved and enthusiastic about their health. In a perfect world it would appear as patients interacting proactively with us in some fashion, rather than what we traditionally see — when they come in if there is a problem or they need a medication refill, those visits driven by specific medical issues.
Q: Who should lead patient engagement initiatives?
Dr. Hernandez: It's a team effort. As providers, we need to have systems in our organization that make it easy to engage patients. Part of this is access, so when patients are engaged it doesn't always mean a visit. It could be a phone call, email, teleconference, etc. It really involves administration, hospital system partners and specialists in a concerted effort.
Q: Have you had any pushback from the physicians?
Dr. Hernandez: Absolutely. It's a change in culture, moving from a dyad of one patient or their family or significant other and their provider, to a team-based approach. It's different than the way most physicians are trained. Traditionally, it has always been a physician's responsibility to fix problems. Now we are saying, "No, we are going to provide resources that will help you do your job more effectively."
Q: How have you worked to help physicians accept this change?
Dr. Hernandez: The other dynamic going on, and this is true across the country, is tremendous burnout among physicians. The key is finding that sweet spot of resources and services for physicians and other providers. If you can demonstrate these resources are value-added, and unload some work — the administrative burden, particularly — and physicians are able to do what they have been trained to do, which in primary care is establish relationships with patients and help diagnostically, then physicians are able to see the value and the lightbulb goes on.
Q: What is the biggest challenge you've faced or are facing in engaging your patient population?
Dr. Hernandez: There are a couple of challenges from the patient standpoint. Culturally, they are used to coming to the doctor when they have problems, especially in the Medicare population, and certainly for younger folks too. They are comfortable coming in for their for annual exams, but they are not always comfortable having other people ask questions about their care, having members of the team call and see how they are doing, having a care manager call to see if their medications are working properly, etc. Although outreach is critical, people are not always comfortable with it. As they see the value of talking to staff they begin to see that we are interested in their welfare as a clinic and an organization. This helps patients become much more engaged.
That's from the patient standpoint. The other barrier, from the provider standpoint, is letting go of things they traditionally felt were in their purview and acquiescing to protocols and guidelines they think are necessary to make the system work.
Q: How are you addressing these challenges?
Dr. Hernandez: In the clinic we do a lot of what's called a "warm handoffs," where patients are introduced to the care manager in person, so they can put a face to the phone call before they go home. Physicians introduce them as members of the team so patients don't feel they are being shoved off to someone else.
Q: If you could give one piece of advice from your work with CHN in patient engagement, what would it be?
Dr. Hernandez: As you initiate any program, spend time connecting the dots with providers and staff so they understand why you are doing it. And from the patient side, present that team concept at the time of the appointment.
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