In 2018, Duke Health's specialty practice pioneered a unique model to deliver care outside of clinic for specialty care patients. While central triage in primary care is widely tested and proven, its application in subspecialty medicine has been challenging due to its nuanced nature of subspecialty care.
Traditionally, patients could either schedule an appointment to be seen or call the clinic nurse, who was caring for patients in clinic, for specific follow-up questions regarding a previous visit or medication. However, the last 15 years have seen a dramatic increase in connection and access points for patients and their care teams, due to the proliferation of digital communication tools like EHRs, mobile devices, and web-based tools. Consequently, providers now receive messages from patients' 24/7 regarding their questions or concerns.
Clinicians, particularly physicians, are successful because of their incredible attention to detail and desire to serve their patients. They rarely decline additional work if requested by their patients. Yet, the care team's capacity to manage all requests is reaching its limit, resulting in work and follow up care requiring increasingly more late-night and weekend hours.
Specifically, it is estimated that for each hour spent in the clinic, there is at least another hour of non-patient-facing work to complete. Examples of these activities:
- Completing the documentation and required coding for patient visits
- Meeting additional insurance company requirements for authorizations, denials and billing
- Completing increasing amounts of required forms for various purposes and needs
- Attempting to annotate study results and medical interpretations that are released to patients immediately when available
- Managing inbound patient messages through patient portals
- Responding to symptom-based or care-related telephone call questions
In addition to the increase in volume and scope of non-visit work, patients now expect comprehensive, accurate, and very quick responses to their questions, similar to experiences with retail and other simpler commodity services, Amazon, Google, or Apple.
The complex dynamics described necessitate evolving the operating model to support our clinicians, staff, and patients to recognize the changing environment. It is imperative for all healthcare systems to provide accurate and timely responses to patient inquiries, complete the required insurance processes, submit forms on behalf of our patients, and continue picking up phone calls when patients reach out for help—all while continuing to care for the patients scheduled to be seen in the clinic. However, this growing body of work should not continue to fall so specifically on each individual clinician to power through and figure out.
To address this challenge, we piloted the Specialty Engagement Center in 2020, starting with Endocrinology. This department had over 10,000 ambulatory patient visits a year across four clinic sites, each with a different approach to phone triage, in-basket support, forms management, and medication management. Over a year, the Endocrinology Clinical Leadership with support from the practice leadership team reviewed the current state, standardized protocols and standard work for the teams managing in-clinic and out-of-clinic work, and created a structure to measure the results, including phone calls, in-basket message volume and response, and quality assurance on the response and support provided.
The results over a six-month period in 2022 included:
- A reduction in the percentage of calls abandoned from 25-30% pre-implementation to 4-5% post-implementation
- A 40% reduction in in-basket messages routed to physician inbaskets, improving physician satisfaction
- An improved patient experience by implementing on demand/real time video visits with a team of Nurse Practitioners and Physician Assistants for patients who called or messaged with issues appropriate for video visit care
- A quality improvement in calls from <60% to over 90% through process adjustment, staff training and ongoing coaching
Ultimately, this created a system and standard for our patients and care team that enables better care regardless of the clinic they were last seen. This model allowed our in-clinic teams to focus on the patients in front of them, confident that out-of-clinic patients were quickly getting what they needed. This addressed the key pain point of in-basket management for our physicians, standardizing and managing staff workloads, deploying best practice technology, providing access to same-day/next-day APP video visits when needed, improving the timeliness of completing requests from insurance companies, and enhancing the patient experience outside our traditional clinic setting. While the change management process to standardize previously unstandardized work is very challenging and requires incredible work from the clinical leadership, the results, if done with discipline and diverse involvement, can be incredibly powerful on many fronts.
Based on this result, we have been in the process of adding many other services to this model in a thoughtful and systematic way and continue to see very positive results across a diverse set of specialties.