In a value-driven world, achieving the triple aim of healthcare is of paramount importance to enhance care continuum.
A major component of driving value in care is the patient experience which can be improved with smart strategies to engage patients. Ensuring that patients walk away from the hospital/clinic satisfied and with their needs fulfilled is vital for any given health care provider.
Mercy ACO Iowa recognized a methodical approach to enhance clinical engagements with patients which eventually improved the quality metrics and patient satisfaction levels. “This is really about being proactive but also maybe even at times having to be reactive in closing those gaps, so we have multiple outreach strategies,” said Derek Novak, Vice President and Chief Operating Officer at Mercy ACO Iowa. “We just kind of face the fact that a lot of investment already went into play as well as we wanted to bring in a multitude of data sources.”
Abundance of data may sometimes lead to analysis-paralysis
Derek believes that there will always be an abundance of data that may sometimes lead to analysis-paralysis. Mercy ACO comprises six regional chapters, 195+ participant organizations covering Nebraska and Wisconsin, 27 critical access hospitals, and more than 3,500 providers, therefore, it had almost 200 million records to streamline for information on patient population.
Since Mercy ACO has numerous participants, they have several different EHRs spread across the network. Mercy ACO leveraged Innovaccer’s technology platform, Datashop for actionable insights. “What this allows us to do in bringing all of this data into one source is, it gets us a more complete patient profile. It allowed our care management staff and our health coaches work off and improve patient engagement because they're able to see what happened,” continued Derek.
Mercy specifically zoned in on three measures, out of all the value-based contracts namely, annual wellness visits, ED utilization, and ADTs.
Engaging patients through ADTs helped in reducing the readmission rate by 7.14%
Mercy ACO has 27 critical access hospitals and 35 hospitals which included ADT (admission, discharge, transfer) notifications to all members of the care team. They obtained standardized reports and started utilizing that data to engage patients, wherein care teams received flags every time there was an emergency department utilization. Scheduling was done for health coaches and staff stationed in hospitals and clinics to know the time of admission & discharge of patients. Standardized care process flows were made for admission, discharge, and “back to medical home,” which means getting the patients back into their primary care visit. All these processes helped them in closing gaps in care and in chasing as many as 65 quality metrics.
The ACO made similar process flows for the emergency department as they are treated as high-risk patients. This brought down the ED utilization by 6.65%. Derek Novak says, “It is making a difference in every individual’s lives, that may seem like a lot of numbers, but there are a lot of personal stories behind them.”
Increasing primary care visits is crucial to closing gaps in care
This was Mercy ACO’s key strategy from the very beginning when they had received the Innovation grant. For this, the ACO implemented multiple outreach strategies. Ensuring that there are no gaps in care, the strategy had to expand beyond just health coaches and involving the care staff in the process. It also includes identifying patients that are flagged as they have multiple chronic conditions.
The results of this strategy saw an increase in primary care services on a per 1000 basis of 14.26%. Besides, working of quality metrics to close gaps in care, they increased the number of annual wellness visits, which is highly favorable for the patients. This involved sharing claims data and other information with providers to drive performance levels up. There was a 9% increase in 2017 as compared to last year, and currently, annual wellness rate stands at 31%.
Communication with patients was enhanced through virtual handoffs & social media-like profiles
“Virtual hand-offs” were started to replace the emails/phone calls to bring patients back to the care sites. The virtual hand-offs and tasking of patients from the acute sites back out to ambulatory sites warrant solid communication between patients and providers. While at the same time, it ensures that the organization remains patient-centered. It was important to ensure that patients are not falling through cracks as hospitals don’t always contact the clinics.
Mercy ACO’s technology partner, Innovaccer, also helped them create a social media-like patient care timeline as an internal mechanism to understand the patient population better. A transparent timeline like this informs the entire care team as to which members are particularly engaged with which patients. Providers get insights into patient’s personal information outside of the demographics. For example, who is their next of kin? What are their preferences/limitations? etc., Further, providers learn about patient goals as that information is logged into the systems.
Community resources helped in figuring out the social factors affecting clinical outcomes
Datashop generated an electronic directory of community resources by obtaining information from sticky notes, Rolodexes, rough scraps of paper, etc., for Mercy ACO. This was done in order to look at non-clinical, but relevant resources to engage patients while also address the social factors affecting them. The outcomes showed how virtual rolodexes helped the ACO in geo-tagging resources and their relevance in locating the patient. They could also identify potential resources as they engaged with their patients to ensure that the patients are utilizing those resources to limit their non-clinical barriers.
In terms of connecting with community resources, the ACO continues building rolodexes.
“Communities are often really eager to be engaged because it is part of their mission that really links well up with our mission,” says Derek. Further stating that, “in the process of going from selecting a vendor to developing your own approach, it’s important to remember that it’s flexible enough to mimic your process flows, instead of moulding your processes to their workflows.” Care organizations should, therefore, work to improve past processes and make sure that it is not the other way around. Because, in the end, it is all about population health and improving the lives of the communities.
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