Elevating the Role of the Nurse to Support Value-Based Care
As healthcare has evolved toward a value-based payment model, we have seen many changes in how healthcare is delivered and by whom. We have seen progressive healthcare organizations embrace value-based care, shifting toward an interdisciplinary approach to care that leverages population health management, social determinants of health, and patient engagement to improve outcomes across the spectrum of care.
The role of the nurse elevates with value-based care. Nurses provide more patient-centered, efficient, and cost-effective care, from pre-appointment and intake to discharge and follow-up. In the primary care setting, progressive providers have increased patient access by conducting nurse-only patient visits during which registered nurses document patient histories, order lab or other diagnostic tests, and determine patient acuity.
To meet the increased demands of value-based care, nurses must work to the top of their licensure. Studies conducted several years ago indicated that, on average, nurses spend as little as 25% to 30% of their time at the bedside.1 On top of clinical workloads, nurses are responsible for care coordination and communication among an expanding care team. As the concept of the care team expands under value-based care to include nurses, physicians, therapists, and home care workers across multiple hospital and acute and primary settings, nurses struggle with the inefficient workflows associated with legacy communication devices and numerous clinical and communication systems.
Key to supporting the elevation of the nurse is the elimination of activities that do not directly contribute to the health and well-being of patients. The incorporation of innovative technology can assist in this effort. For example, advanced communication technology can help nurses communicate efficiently with other members of the care team including those off-site, such as home health nurses and healthcare professionals at specialized hospitals, skilled nursing facilities, and wound care clinics. Secure, automated text messages can also take over many of the time-consuming communication tasks to prepare or follow-up with patients. The ideal solution helps reduce non-clinical tasks to allow nurses to focus their time on only those patients who need additional care.
PerfectServe’s clinical communication and care coordination platform addresses the inefficiencies of work processes and administrative tasks to allow nurses to assume a more significant role under value-based care, including:
Care Team Coordination – Collaborate with providers inside and outside the network. Connect with on-call care team members as a group, or by name or role such as “On-Call Cardiologist,” ensuring a nurse can reach the right physician at the right time to improve outcomes without the inefficiencies of referencing call schedules or playing phone-to-pager tag with physicians.
Pre-Appointment Patient Communication – Automate the communication of day-of-procedure information, appointment reminders, and wayfinding to prepare patients for upcoming appointments or procedures.
Post–Appointment Patient Communication – Automate post-discharge communications to reiterate the care plan, send timely reminders (such as follow-up scheduling and prescription pick up), and assess patient health status and satisfaction with text-first survey questionnaires. Nurses can prioritize follow-up time to only those patients in need of clinical intervention.
Time-Critical Updates – Rather than force nurses to log into the EHR to check for results or orders, critical updates (orders and critical lab results) are pushed to the nurse and other care team members to speed up care coordination and delivery.
Real-Time Charting – A mobile, easy-to-use interface to access patient information and take notes, with text shortcuts, voice-to-text, and intelligent field mapping to reduce duplicate data entry.
Nurse Call, Alarms, Alerts – Nurses receive alerts on their mobile devices and web apps, where they can accept, escalate for assistance, or call back to speak with the patient.
By expanding the role and leadership of registered nurses and implementing improved processes facilitated by innovative technology, healthcare organizations can transform healthcare delivery, achieving improved efficiency and better outcomes at lower costs.
Improve Patient Experience Before, During and After Care
When it comes to communicating with patients, nothing beats the immediate connection of text messages. While email and phone calls face diminishing open and answer rates, 90% of text messages are read within 3 minutes.1
Combine the timeliness of texting with the relevance from patient context, and you have a powerful tool to communicate with a patient when and where it matters most. In this post, we will examine the opportunities to engage with patients across the spectrum of care, improve outcomes, reduce costs, and improve the patient experience.
Changing Patient Expectations
The healthcare industry has shifted from volume to value, working on the Triple Aim of improving patient populations, individual patient health and satisfaction, and reducing costs.2 At the same time as patient satisfaction is being linked to reimbursement, patient expectations for their healthcare experience continue to increase.
Patients, now responsible for a greater financial share in their care, are approaching their care experiences with consumer expectations. Patients expect convenience, personalization, and involvement in their care anytime, anywhere. With patient experience and satisfaction now moving targets, healthcare organizations need ways to engage patients in their care and to continually assess the success of their efforts.
Unfortunately, improving health system performance toward Triple Aim results has led to worrying rates of clinical burnout. With technology often cited as one of the leading causes of burnout, we are now seeing healthcare organizations focus on the Quadruple Aim, including provider experience and satisfaction.3 The Quadruple Aim recognizes the importance of usability, effective care processes, and improved clinical workflows to achieve Triple Aim results.
The patient engagement strategies below are designed with the Quadruple Aim in mind, reducing administrative burden with patient, population, and diagnostic-specific automations to engage with patients across the care continuum.
How a patient experiences their healthcare encounter begins long before the patient even steps through your door. From their perception of your website and scheduling processes to your preparation and intake processes, patients are looking for modern, seamless, and informative experiences.
Healthcare organizations looking to transform their patient experiences can begin by engaging with patients before their scheduled appointments, including:
Care Preparation Instructions – reminders to fill or take prescriptions or start pre-operative instructions based upon procedure-specific pathways
Appointment Reminders – reminders of the date, time, and location of an upcoming visit with detailed wayfinding instructions
SDOH Support – leveraging social determinants of health (SDOH) data, reminders can include coupons for transportation to reduce no-shows
Patient Intake – send patients a link to electronic forms to support off-site check-in
In addition to automating preparation and intake, you can leverage automations to keep patients “in the loop” day-of-procedure. For example, scheduling delays can trigger a status message to patients to re-align their arrival time.
Hennepin Health, in partnership with Lyft, recently targeted patients with a history of clinic no-shows, allowing them access to a corporate Lyft account to get patients to their appointments. At the end of the 12-month trial period, no-show rates decreased an aggregate 27%, clinic revenue increased by $270,000, and ROI was 297%.4
Although the factors that influence a patient’s experience vary widely based on the reason and length of stay, we can follow the broad strokes of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey to identify a patient’s perspective on their care experience.5 The 18 substantive questions included in the survey focus primarily on communication with doctors, nurses, and staff during care and at the critical point of discharge. Outside of this, questions focus mainly on environmental factors such as cleanliness and sound level.
PerfectServe’s clinical collaboration solution is designed to enable fast, efficient communication that enhances care and improves the patient experience.
Integrate Nurse Call, Alert and Alarm Notifications
We centralize communication across multiple systems onto a single platform to simplify clinical workflow while eliminating extraneous noise. Nurses receive alerts on their mobile devices and web apps, where they can accept, escalate for assistance, or call back to speak with the patient directly. If the call button is non-urgent (such as a “water” request), it can automatically route to the Patient Care Technician, reducing nurse interruptions. Patients benefit from reduced ward noise and faster response times – critical factors in HCAHPS scores.
Family members play a crucial role in supporting patients during their stay at the hospital and in encouraging compliance with care plans. Healthcare organizations are recognizing the importance of supporting families as part of the patient experience as well.
With pre-configured pathways, families can feel more comfortable leaving waiting room areas knowing that they will receive an automated message with patient status and return time. If a patient’s family member calls into the main hospital call center and are connected to the appropriate nurse, the nurse can return the call with one click. To ensure the correct on-call nurse is contacted in the future, the return call number is hidden.
Following the most recent round of Medicare readmission penalties levied against 2,583 hospitals, preventable hospital readmissions continue to be top-of-mind.6
According to a study published in BMJ Quality & Safety, patients reporting high satisfaction and good provider communication were less likely to be readmitted.7 Decreasing preventable readmissions requires that patients understand and adhere to their care plan, that pain is managed, and that follow-up care is scheduled and attended in less than two weeks.8
Leading hospitals are leveraging text-first interactions to monitor care, assess pain, and send care plan reminders (such as filling or starting a prescription). Questions can be delivered one-at-a-time to encourage response or patients can be prompted to a secure web form for a full survey or to share detailed personal health information. Frequent check-ins not only increase patient satisfaction but also allow clinicians to escalate concerning responses to a secure chat session or phone call.
Park Nicollet Methodist Hospital adopted a text-first follow-up program that included a series of customized follow-up questions to assess a patient’s risk for readmission. 70% of questions sent via text message receive a response rate from patients. The PerfectServe dashboard collects and analyzes every patient’s response and nonresponse, segmenting the patient population into risk categories and automatically flagging patients that need immediate follow-up.
Park Nicollet’s results showed that patients who received and responded to text messages were 32% less likely to readmit than those solely contacted by phone. (These results are risk-adjusted to account for the relative complexity of each patient’s conditions.)
Patient Satisfaction Surveys
The goal of any patient satisfaction survey is to gain honest insight into the patient experience. Although the HCAHPS survey has incentivized improvements in patient experience, the response rate for patients has been on the decline, down to just 26.7% from July 2017 to June 2018.9 Administered 2 to 42 days after discharge, surveys do not yield the timely data hospitals need in order to act on patient satisfaction.
Given the high impact of HCAHPS results on a hospital’s financial performance, there is an opportunity to survey patients before the CMS to mitigate issues and improve patient satisfaction in advance.
To make patient satisfaction surveys actionable, healthcare organizations need easy, customizable surveys that target specific patient populations and encourage meaningful dialogue. Surveys can be automatically triggered after the healthcare encounter while the experience is fresh on the patient’s mind. Deploying text message surveys and text-first surveys is a cost-effective approach to obtaining these coveted patient insights.
Patients indicating dissatisfaction present a service recovery opportunity – contacting them to show concern and learn more about their experience will not only inform systemic improvement opportunities but also will likely change the patient’s impression of the organization.
PerfectServe allows hospitals to reach patients and/or families in real time before, during, and after care to better engage, activate, and assess patients in their care experiences. Post-discharge assessments present an opportunity to evaluate patient satisfaction and address patient concerns while there is still time to directly improve their satisfaction.
According to a study published in the Journal of the Royal Society of Medicine, patients tend to immediately forget 40-80% of information their care providers present to them – or, worse, remember incorrect information about care plans or follow-up care.1 In the era of value-based care, it’s important to find a way to ensure patient compliance with treatments to improve patient outcomes and avoid costly readmissions.
Engaging patients with messages and reminders sent as text messages offers healthcare professionals an opportunity to improve patient treatment compliance when, where, and how it would be most effective.
Treatment Plan Communication
Traditional approaches to care plan compliance include verbal discharge instructions and sending patients home with discharge documents and information. Digital interventions can improve compliance with care plans, including:
Providing a digital format of care plan information that can be referred to anytime, anywhere
Clear, action-oriented reminders of care plan instructions when and where they are needed during the recovery process. For example, if a patient is to begin an exercise regime on day 3, a reminder can be sent that morning with a link to specific instructions or videos walking patients through the exercise program.
Provide timely guidance, tips, or exercise recommendations to support patient self-care
Handling some of this important patient information via text message can support the care plan at precisely the right time while also keeping the lines of communication open so that patients can text back or call in if they have any questions or need further information.
Automated Medication Adherence Reminders
Medication adherence requires that patients fill their prescriptions, understand directions, and take medication on time. Adherence rates for chronic conditions is about 50%, accounting for up to half of treatment failures and 25% of hospitalizations each year.2 Adherence interventions strategies for medication includes directly faxing prescriptions to pharmacies and leveraging reminders and single-response survey questions (“Have you picked up your prescription from the pharmacy?”).
Text messaging doubled the odds of medication and improved overall adherence rates by 17.8%3
Although there are many digital adherence technologies (DATs) that can automate reminders for medication, it’s important to support ongoing two-way engagement with patients, who may have questions or concerns about side effects, and to have a way to send survey questions to confirm compliance.
Surveys to Improve Compliance and Reduce Readmissions
In a recent survey, Dr. Ethan Basch, M.D., M.Sc., found that nearly half the physical and psychological symptoms of his patients went unreported.4 Improving patient outcomes requires capturing more patient-reported outcomes (PROs) in real-time to provide timely interventions.
After discharge and periodically through recovery, you can leverage automatic procedure-specific diagnostic surveys to assess progress and ensure understanding of the treatment plan. Patient-reported outcomes can be tailored to the condition or procedure in question, assessing general health as well as data specific to symptoms, side effects, or pain levels. For the management of chronic diseases such as diabetes, our own data suggests that securely surveying key health indicators can help improve a1c rates by 0.5 points or more.
Based upon patient responses and your defined rules, PerfectServe’s patient engagement platform will alert care team members if a patient requires follow-up. Based upon the familiarity and simplicity of text messages, the solution has the proven capability to reduce readmissions by as much as 30%.
“We have such a hard time getting some patients to answer a phone call, yet they will respond to assessments delivered by text. PerfectServe saves valuable time for our nurses every day and helps us reach those in need more quickly.” — Karen Loscheider, Manager, Triage Nurse, Park Nicollet Health Services
In addition to encouraging patient reported outcomes, patient satisfaction insight surveys also help you gather and act upon feedback in time to make a difference on a patient’s overall satisfaction, which can help reduce the risk of patient leakage and improve HCAHPS scores.
PerfectServe’s Patient & Family Communication solution can help you deliver a thoughtful, targeted set of prompts to support post-treatment care to reduce readmissions and improve outcomes. Our solution is proven and is live in more than 10,000 care locations, facilitating more than 42,000 patient interactions every day.
1 Roy P C Kessels, PhD. “Patients’ memory for medical information,” Journal of the Royal Society of Medicine. 2003.
2 Jennifer Kim, PharmD, BCPS, BCACP, CPP et al, “Medication Adherence: The Elephant in the Room,” US Pharmacist, 2018.
3 Thakkar J, Kurup R, Laba TL, et al. “Mobile telephone text messaging for medication adherence in chronic disease: a meta-analysis.” JAMA Intern Med. 2016
4 Ethan Basch, Md, MSc, et al. “Overall Survival Results of a Trial Assessing Patient-Reported Outcomes for Symptom Monitoring During Routine Cancer Treatment,” JAMA, 2017
Lessons Learned from an Important Voice in Cross-Organizational Communication
Charting the most efficient path for critical patient communications within a complex care team is a tall order. When a large and complex team of care providers must work together—which is not a rare occurrence—communication breakdowns are all too common.
Mary Hatcher, VP of Product Development PerfectServe
Preventing these complex communication challenges requires forethought about the solutions required to move information accurately and efficiently from one care provider to the next. Mary Hatcher, Vice President of Product Development at PerfectServe, recently authored a guest blog about on this very topic for Healthcare IT Today. Here are some of the key takeaways:
Complex communication challenges most often occur immediately after discharge, when a patient is moving from the hospital to another setting, or with patients who have overlapping chronic conditions that require multiple specialists
EHRs are not equipped to solve the communication issues that frequently arise during complex care transitions
Healthcare organizations need a standardized communication process with tools and infrastructure that connect all members of a patient’s care team
The use of web and mobile applications facilitates real-time communication and collaboration across different care settings
To learn more, read the full article titled “How Clinical Communications Technology Connects the Care Team In Complex Cases” at Healthcare IT Today.
4 reasons why patient education should be a priority
As providers continue to evolve away from fee-for-service healthcare and towards a value-based care system, patient education is becoming more important than ever.
Value-based healthcare’s focus on outcomes and, consequently, what happens outside the “four walls” of the healthcare organization, requires a renewed focus on patient education to help combat chronic illnesses, increase preventative care, reduce readmissions and lower expenses.
When it comes down to it, an informed patient who understands their condition and corresponding treatment plan is one of the most important factors in achieving the goals of value-based healthcare.
Here are four reasons why patient education should be a strategic priority for healthcare organizations across the nation.
Last year, the U.S. Department of Health and Human Services (HSS) noted that by 2018, 50 percent of all Medicare reimbursements should be tied to value-based care. The HSS also wants value-based reimbursements for 2016 to come to 30 percent—in other words, the HSS plans for healthcare organizations throughout the country to begin transitioning away from fee-for-service and towards value-based care.
With the traditional fee-for-service model, providers received compensation based on volume: they’d see as many patients as possible, and order tests and procedures without regard to cost. With value-based care, alternatively, providers will begin to focus more so on evidence-based medicine, preventative and tailored treatments, and, of course, patient education, in order to increase quality of care while also keeping expenses down.
Increasing patient education efforts through social media campaigns, text-based outreach platforms, informative web videos, email marketing, podcasts, community lectures, and brochures are examples of inexpensive means for a provider to adapt to the new value-based model without having to completely restructure their organization.
Preventing chronic illness
Back in 2012, roughly half of American adults—or approximately 117 million people—were diagnosed with one or more chronic illnesses or health conditions. In fact, that year, one out of every four adults had two or more chronic conditions.
Currently, approximately 133 million Americans suffer from one or more chronic illnesses like diabetes, depression, or asthma—and the numbers are only increasing. Seventy to 80 percent of total health care costs are directly tied to the treatment of chronic illnesses. In short, the treatment of chronic illnesses is a major concern for the American medical community.
One of the most successful means of combating chronic illnesses is through patient education. Certain diseases, such as diabetes, can’t be treated through medical attention alone; patients require self-management, such as proper diet, to treat these illnesses as well. Studies have shown that patient education delivers results.
A review of over 40 studies on diabetes patients noted that when providers encouraged “patient-oriented interventions,” patients’ health improved, and some even established positive glycemic control. Patient education should be viewed as a strategic weapon in the fight against the progression of chronic diseases in the United States.
Unnecessary patient readmission is a costly issue that currently plagues our nation’s healthcare system. In fact, it’s estimated that these readmissions cost the U.S. government roughly $17 billion each year.
Additionally, it’s estimated that one out of every five Medicare patients will be readmitted into a hospital within a month following treatment. Readmissions, either due to over-cautiousness, carelessness, or patients relapsing, are a sizable expense that healthcare providers need to avoid.
But how can providers cut down on readmissions while also avoiding additional expenses?
Patient education can help providers to inform patients on the proper self-managed care needed to avoid readmissions. Additionally, with increased patient education efforts, providers can help patients understand the care setting most appropriate for their condition.
Uninformed patients sometimes seek treatment in the Emergency Room (ER) for minor issues when an Urgent Care Center, for example, would be much more appropriate. The ER is one of the most expensive healthcare settings, and patients should only seek it out when necessary—and not for minor concerns. But patients continue to seek ER treatment in ever-increasing numbers. In fact, ER visits have risen steadily over the last few years. According to a survey of 2,098 ER physicians by the American College of Emergency Physicians, three-quarters of the doctors surveyed noted that visits rose steadily from January 2014 to March 2015. Additionally, one-quarter of doctors noted a “significant increases in all emergency patients” since 2014.
Educating patients on when and where they should seek treatment will help to streamline the overall healthcare process and lower overall ER visits.
Primary care doctors are increasingly short on time. Since fee-for-service care is structured around the concept of treating as many patients as possible, doctors usually try to squeeze in a high volume of patients during their workday.
In fact, in 2014, general practitioners and family physicians reported seeing an average of roughly 90 patients each week. It’s typical for doctors to also schedule short, 15-minute appointments, but some physicians try to keep appointments to no longer than 11 minutes. These short appointments not only make it difficult for patients to communicate with their doctors, but doctors are becoming burned-out with the rapid-paced appointments: A 2012 study noted that 30 percent of doctors between the ages of 35 and 49 plan to retire within the next five years.
With value-based care, doctors will begin to treat fewer patients, focusing more so on achieving positive results as opposed to booking a steady stream of appointments. However, in order to help doctors free up their time and avoid burnout, healthcare providers should focus on increased patient education. Informed patients will ask fewer and more pointed questions, and they’ll have a better idea of what’s ailing them, which will help to keep appointments short.
Lastly, relapses and readmissions should decline, helping to free up doctors’ schedules.
Higher quality of life
Lastly, patient education delivers results, and after becoming educated about their conditions and required treatments, patients generally have a higher quality of life. For example, Gallup polled a group of patients who received medical device implantation.
For the patients who “knew what to expect after surgery” (i.e. they received effective patient education), 72 percent were satisfied with their results, and only 8 percent reported problems after the device implantation. For the patients who didn’t know what to expect, only 39 percent were satisfied with their results, and 27 percent reported issues.
Informing a patient—or, in other words, educating them properly regarding their treatments or illnesses—helps to improve their overall quality of life.
As the nation’s healthcare reorients towards value-based care, patient education will become especially critical. When used correctly by providers, patient education can be a valuable tool, helping to increase efficiency and boost quality of care. Educating patients doesn’t have to take a great deal of additional time or effort.
A thoughtful, patient-centered strategy coupled with the application of innovative technologies can make a significant impact. Patient education, thanks to the push towards value-based care, is taking its place as a strategic imperative for healthcare providers throughout the nation.
Managing the surprisingly troublesome impact of real-time healthcare on clinical decision-making
We live in an age of instant gratification. From the texts we send friends and family to the orders we place on Amazon.com, we’ve come to expect immediate results: instant responses, next-day shipping, etc.
The idea of immediacy in healthcare communications is not new. In fact, in 2015, healthcare analyst Gartner outlined a vision for what it dubbed the “real-time health system”—a landscape where healthcare professionals will be constantly aware of what’s happening within their systems and with their patients.
As a person living in the digital age, you’ve probably experienced real-time awareness in other parts of your life: the repetitive dings of received text messages, the intermittent beeps of calendar alerts, the near-constant hum as your smartphone vibrates over and over to let you know your mother, children and cousins have uploaded photos to Facebook, Instagram and Snapchat. In fact, as I’m typing this piece, I’ve heard alerts for two personal text messages that I’ve yet to look at (the temptation is maddening), four work-related emails (that I did have to stop and look at), a notification that someone commented on a thread I replied to on Facebook and more.
While there’s definitely a benefit to each of us knowing what’s happening in our expanded universe in real time—and we can easily draw a direct line to the benefits that doctors, nurses and patients would experience if they could communicate instantaneously while coordinating care—the influx of information is simply overwhelming.
And when alarm fatigue sets in, important messages get missed, the communication cycle breaks down and what was once a valuable resource becomes a liability. Overwhelmed and inundated clinicians cannot optimally use their invaluable expertise to make effective clinical decisions that deliver great health outcomes.
Aggregating, analyzing and managing the distribution of clinical information
Managing the flow of data and alert fatigue is a real challenge that clinicians and the IT teams that support them need to understand. Clinicians need “just the facts, ma’am,” so to speak, and they need to know which set of facts pertain directly to them and the patients for whom they are caring. Receiving more than enough information is not always a good thing, especially when the situation calls for fast thinking and quick decisions.
Investments made in technologies implemented over the past several years have enabled healthcare as an industry to generate very large amounts of digitized clinical information. The challenge is to aggregate this patient data in real time to generate new knowledge about a patient and distribute it in a way that does not inundate the clinician recipients with unnecessary information. Physicians and nurses should receive information they need in order to act in that moment. Everything else is noise.
Learn how a care team communication solution can enable your clinical integration strategy. Get a demo.
Implementing communication-driven workflows
Once new knowledge is made available and deemed relevant to a given clinical situation, it’s important to enable workflows that drive this information to the right care team members, who can take action in that moment. Hospital-based communication workflows must encompass all modalities, adhere to strict security mandates and facilitate reliable exchanges among clinicians across boundaries (e.g., acute, pre-acute and post-acute care settings). This kind of clinical integration is the future of healthcare communications.
If clinicians are inundated with unnecessary information, messages and alerts, combined with a communication workflow that creates barriers to a) finding the right care team member to contact, b) finding the contact method that the clinician prefers and c) knowing whether the intended recipient received the message, the workflow is flawed and is inhibiting the decision-making that leads to higher standards of patient care.
Leveraging clinical expertise
The personal judgment of experienced healthcare professionals is irreplaceable in effective, real-time decision-making. Technological advances are no doubt improving healthcare, but human intuition can never be replaced by a new device or software. However, that intuition can be inhibited by technologies if they are not strategically implemented and managed. In this sense, real-time healthcare could, ironically, be eroding quality.
To truly leverage the hundreds of collective years of clinical expertise housed in the minds of your hospital’s medical staff—the expertise that yields great outcomes—you must remove the barriers to effective communication. Collecting patient data in real time is an important part of that. But analyzing and aggregating that data into digestible, valuable pieces of information that can be easily shared and collaborated on is the follow-through that is often overlooked.
The gravitation toward instant gratification isn’t going away. And it’s important to understand that the concept doesn’t apply simply to generating patient data as healthcare events are occurring, but also to the ability to extract the significant portions and begin collaborating with the broader care team to interpret the data and derive a plan to deliver high-value care.
MACRA legislation passed in April 2015. When the initial version of the rule came down, the industry collectively braced for declining revenues, the avalanche of administrative paperwork and the increase in overhead costs that would be required to comply.
When the final rule was issued in October 2016, the tempered requirements seemed to point toward fewer projected negative payment adjustments in 2019, the target year for MACRA’s first Quality Payment Program distributions, and the tension subsided a little.
Even with the new allowances in reporting and threshold scores, the MACRA structure makes clear that there’s an abundance of work to be done, especially around efforts to promote care coordination and communication.
Year 1: 2017-2018
Now that we’re already into 2017, the first official reporting year, tensions are rising again because, even though most physicians acknowledge they are going to participate, the majority have not yet plotted their course or defined a compliance strategy.
And if you’re in the group that hasn’t figured it all out yet, the good news is you’re not alone.
According to a recent poll conducted by The Health Management Academy, almost half of the physician and practice leaders who participated are not moving very quickly toward adopting value-based payment models. In fact, only 4% claimed to be moving “very quickly” while almost 40% admitted to moving “very slowly” toward value-based care.
Somewhat surprisingly, the same is true even for large hospital systems. These organizations are perceived to be the driving force, the ones moving the fastest toward the end goal of value-based care, and yet, per a similar poll, few of the large systems are moving very quickly.
The Quality Payment Program, however, is going to be the catalyst for healthcare organizations, both large and small, moving more aggressively toward these models in the next couple of years.
The MACRA structure and how you fit in
By now, you know that reimbursements are going to be variable based on performance, even if you’re still practicing in a fee-for-service structure and, like most, have not yet begun practicing in the more advanced tracks.
There are four participation categories, which fall underneath two broad tracks—the Merit-based Incentive Payment System (MIPS) and Advanced Alternative Payment Model (APM) track.
The two categories in the middle of the chart are bridge areas, and won’t apply to many providers right now, but they can be considered as stepping stones from MIPS to the Advanced APM track.
The MIPS track equates to fee‑for‑service, and most physicians will, at least initially, fall into this track. They’ll balance their steps toward embracing more downside risk by continuing to practice fee-for-service medicine, and so they must prepare to report performance metrics and have payments adjusted based on those metrics in 2019.
On the other end of the spectrum is the Advanced APM track. To reach “Advanced APM Qualifying Clinician” status, physicians must engage significantly in certain downside risk-bearing payment models. In this track, participating physicians will enjoy fewer reporting requirements and more financial incentives, while still being held accountable for delivering high-value care. The only way to sustain a profitable practice in this track is to eliminate wasteful workflows that result in inefficient and unreliable communication processes among all members of the broader care team, even if they are not directly affiliated with your practice.
Year 2: 2018-2019
In the first months of 2018, physicians practicing in the MIPS track—again, that will be most of you—will be required to report metrics in three performance categories based on at least 90 consecutive days of work. This should come as more good news, because if you haven’t started measuring yet, or you’re not impressed by your initial metrics, you still have time to pivot before the data is due in early 2018.
CMS will use that data to give each physician a composite score, which will determine the payment adjustment he or she receives in 2019.
The Quality Payment Program’s initially proposed rule was accompanied by disheartening projections in terms of payment adjustments, particularly for solo physicians and small practices. While the finalized October 2016-issued rule basically guaranteed that all physicians who submit any performance data will receive at least a neutral payment adjustment, physicians are still bracing themselves for less-than-average profit margins.
As MIPS is largely a budget-neutral program, less risk equals less reward. Since fewer physicians will be subject to negative payment adjustments in 2019 (see Image 3 below), fewer dollars will be available to distribute to those who perform well.
Simply put, the best way to ensure your adjustment is as high as possible is to garner a high composite score.
Effectively coordinating care with your patients’ broader care teams as accurately and efficiently as possible to reduce waste and unnecessary overhead costs is a good first step toward achieving high scores in all four MIPS performance categories.
Back to the present
One of the goals of MACRA is to drive the costs out of treatment while still providing high-value care. Physicians will be in a much better position to deliver this dichotomy, and advance to a more rewarding reporting track, when the barriers to real-time care coordination have been broken down.
Seamless care team communication and collaboration among interdisciplinary, and often disparate, providers will be a foundation on which you can lay the groundwork for improved care coordination, which leads to less waste, improved efficiencies, and ultimately better outcomes, all of which underlie value-based care and the successful reduction of healthcare costs.
Source: “Making Sense of MACRA” webinar. The Health Management Academy and PerfectServe. March 2017.
The role of secure communications in your clinical integration strategy
If you could take one solution with you on your journey to clinical integration, what would it be?
Clinical integration is the unification of healthcare data, services and coordination across acute, outpatient and post-acute care. It portrays an environment where waste and inefficiency are all but eliminated from healthcare communications, costs decrease and care improves. It’s the future of medicine.
You wouldn’t be far off course if your first thought was to rely heavily on the EHR to support your clinical integration strategy. While the EHR is a valuable tool for sharing patient information within hospital systems and broader care networks, it lacks a fundamental quality that bridges the gaps between Meaningful Use and true clinical integration.
Fully realized clinical integration can only occur when the barriers of communication have been broken down, and interdisciplinary clinicians can accurately and reliably coordinate care in real time across organizational and geographical boundaries. As with most things related to healthcare communication and the sharing of information across disparate networks, securing those communications has been and will continue to be a primary focus for healthcare IT leaders. In an environment where healthcare organizations are driving toward an end-goal of clinical integration, enabling secure communications alone just isn’t enough.
To achieve clinical integration, clinicians need a solution that enables immediate, accurate, reliable and secure communications.
Immediacy in healthcare communication
Real-time communication is a crucial element of delivering high-value care. In the most critical emergencies, every second counts. The time that clinicians waste identifying the right on-call care team member to contact, and then trying to reach that person, can quite literally be the difference between life and death. Even in non-emergent situations, early detection and treatment are well-known effective preventers of worsening conditions.
Yet it’s all too common for inefficient and broken communication workflows to create time-consuming hurdles for clinicians to clear—sometimes even to just begin the conversation.
Clinically integrated settings approach clinician-to-clinician communication with a sense of real-time urgency. That’s not to say that every message should be sent with an emergency status, just that the process of identifying the provider you need to connect to and the delivery of that message should be seamless and immediate.
Reaching the right care team member on the first attempt should be an important metric for all hospital systems. To keep performance numbers high in this area, you must ensure clinicians always know exactly whom to contact for any given medical issue.
However, most clinicians today initiate time-sensitive contact to the broader care team by thumbing through a lengthy paper-based on-call schedule, making a call, and then waiting to receive a response.
Reaching providers on the first attempt is important, but it’s just as important to reach the right provider—the one who can act on the medical issue at that moment—via his or her preferred method of contact.
It’s not uncommon for providers to have a different preferred contact medium for every variance of their schedule. And it’s not uncommon for those schedules to change at a moment’s notice. Yet many hospitals, in both small and large systems, only print the schedule and patient assignment lists once per day.
Clinicians in this setting have no way of knowing if they are accurately reaching out to the right providers via the right contact method. Manually producing a list of whom to contact and how is a process riddled with opportunity for inefficiency and inaccuracy.
If your clinicians depend on inaccurate call schedules or outdated, cumbersome processes to drive clinical communications, your communication workflow isn’t reliable.
When clinicians can immediately contact the care team member they need via that provider’s preferred contact method, communication workflows become reliable and trustworthy, which leads to high adoption and improved patient care, no matter the care setting.
From improved care coordination to reduced costs
Inefficient communication workflows not only interfere with the realization of clinical integration, but also they inflate healthcare costs. For example, if a radiologist identifies a critical result in an outpatient test, the radiologist needs to contact the patient’s PCP so action can be taken right away. If the communication is not immediate, accurate or reliable, the process breaks down and the delay could result in medical complications for the patient that end up costing more to treat.
Moving a patient safely through the admissions, treatment, discharge and post-acute care processes requires a tremendous amount of coordination, good communication and a sound clinical integration strategy. The tools you use to support that communication and collaboration will play an important role in your success.
How much is your answering service really costing you?
The inevitable mistakes made by a traditional after-hours answering service aren’t often attributed to significant costs that may be undercutting the success of your practice. But if you consider that quality communication between members of your staff and your patients—especially after-hours—is a fundamental pillar of patient care and safety, you’ll start to see that little mistakes can add up to big costs.
Physicians and group practice administrators throughout the country will attest that answering services make mistakes that cause clinical communication breakdowns. The human error factor in the answering service equation means lost or delayed messages, wrong patient names, inaccurate symptom descriptions and more. For a long time, it’s simply been considered the status quo. There didn’t seem to be any real way around it.
So an industry-wide acceptance that on-call duty will be frustrating for physicians, and that mornings—especially Monday mornings—will always present some answering-service-related issues for the practice administrator to handle has taken hold. And while these inconveniences may not seem like a big red flag, it’s wise to get a good look at how far-reaching the impacts really are.
Are your patients getting the best care, even after hours?
Patients will generally stay loyal to a practice because they trust their doctor. But if they feel like their medical needs are not given the same sense of urgency that they’re feeling—or worse, if their questions go unanswered—that trust can quickly dissolve into frustration and fear. For some patients, despite their relationship with the physician, this can be a reason to leave the practice and find a new provider.
So, while you may or may not lose the recurring revenue of a loyal patient, you have to consider the cost of that patient’s negative experience.
It’s difficult to tie a hard cost directly to the frustration of wading through miscommunications to get to the bottom of an issue. And it might not be possible to calculate the profit margin impact of the feeling that you cannot deliver the level of patient care you want because there is a weak link in your communications process. But the time you spend managing answering service mistakes is time that could be spent on patient care, so the equally important consideration here is the quality of that time.
The time you spend feeling frustrated and inconvenienced—by non-emergency after-hours calls, for example—does have a cost. It’s a personal calculation and it has a real impact on physician satisfaction.
Are you at risk for fines, penalties or lawsuits?
Some unlucky practices have discovered one of the answering service industry’s best kept secrets: subcontracting.
Some of the answering services that exist today are actually not answering services at all. They are simply businesses that subcontract the work out to another answering service—one that may or may not adhere to HIPAA compliance standards. It’s a risk that no practice leader would knowingly take. With so many unknowns, a practice in this situation is at real risk for fines and other breach penalties.
And then consider this worst-case scenario: a patient unknowingly suffering a stroke calls after hours to report blurred vision and confusion; but because the answering service’s on-call schedules are not accurate, the patient’s message isn’t delivered to the correct on-call physician for another hour. At this point, given the time sensitivity of this issue, the practice could be at risk for a malpractice suit.
An incident like this—however unlikely it may be—could mean a tangible financial loss for your practice.
But that’s not all.
Are you protecting your reputation?
Imagine a critical care surgeon with his own practice who routinely performed emergent consults for local hospitals…until they stopped calling. The hospital felt his answering service was unable to deliver messages in a timely manner, and so they found other practitioners to fill that need.
Your credibility as a caregiver in your local healthcare community can be negatively affected if outside consultants and hospitals cannot reach you quickly in times of emergency. The professional impact of a tarnished reputation is beyond quantifiable. And if the reason is answering service communication delays, it’s also unacceptable.
Are you sure you’ve uncovered the hidden fees?
Most answering services are up front about their fees, but physician leaders and practice managers seldom realize how many fee-based activities they’re actually charged for on a single after-hours call:
There’s a fee for taking the message.
There could be a fee for relaying that message to the right clinician.
There could be another fee for relaying the clinician’s instructions back to the patient, if that’s the case.
There could be yet another fee for recording and logging the conversation as a whole, or a fee for recording and logging each communication.
These little fees can add up over time to a surprisingly significant amount.
Imagine an on-call weekend when non-urgent prescription refill messages are deferred until Monday and the physician’s days are spent as planned (i.e., enjoying time off unless there are true emergencies).
Imagine walking into the practice every morning knowing that all your patients received the care or assurance they needed after hours and there will be no complaints to handle.
You can take a hard look at your answering service’s monthly invoice to understand the hard costs, but those are not the only ones to consider. The less quantifiable effect on your patient safety and satisfaction levels, your physician satisfaction levels, your compliance risk and your professional reputation are serious issues you should consider—because they really do cost your practice.
Optimize rapid response team efforts with automated, real-time communication
Agnes Cappabianca worked as a stroke nurse manager at NYU Lutheran Medical Center, a Brooklyn-based teaching hospital. She was in the middle of a shift when the unthinkable happened—she suffered a stroke and found herself admitted to the hospital as a patient in her own ward.
The hospital’s rapid response team (RRT)—one that Agnes had helped train and prepare for these critical situations—sprang into action. Within 30 minutes, the team had final results of her CT scan and blood tests and began to administer tPA treatment.
Her role in advocating advances in stroke care within the hospital seems to have saved her life.
The primary goal of rapid response
The American Heart Association and the American Stoke Association® have warned since 2010 that “the benefits of tPA in patients with acute ischemic stroke are time-dependent.” The associations’ guidelines recommend a door-to-needle time of 60 minutes or less for the treatment to be effective.
In most hospital settings, the process for communicating the needs of a newly admitted stroke patient to care team members is manually intensive. These workflows usually have many steps, numerous decision points and multiple handoffs—creating many opportunities for communication breakdowns and delays in a situation in which every second counts.
One of the primary goals all RRTs strive for should be to reduce the number of steps in the communication process—including the number of decision points, communication handoffs and number of people involved in transmitting the information.
Some hospitals have achieved this goal by implementing a unified communication and collaboration solution that automates many of the steps in the RRT process, such as sending notifications to all team members—including team leadership—at the same time. With just one call, schedules are analyzed and the appropriate care team members are identified and contacted simultaneously—based on their preferred contact method.
This eliminates numerous steps and players from the communication processes and makes significant strides toward improving patient outcomes by speeding time to treatment.
Building an effective rapid response protocol
Pre-planning is required for a communication platform to optimize the capabilities of RRTs. Evidence based guidelines and individual hospital protocols determine the number and composition of responding teams. Some hospitals assign different care team members to different teams depending on urgency levels.
For example, Henry Ford Macomb Hospital in Clinton Township, Michigan, has two RRTs. One is dedicated to Level II traumas and does not include an anesthesiologist in the alert system because Level II trauma patients rarely require advanced airway management. However, the Level I trauma RRT—the team assigned to the most critical cases—does include an anesthesiologist.
Deciding whom to alert depending on the urgency of the situation is a key factor in RRT success.
Another important factor is identifying timelines for each care team member’s arrival at the patient’s bedside. For St. Rita’s Medical Center, a 419-bed hospital in Lima, Ohio, the pre-set arrival time for the rapid response nurse is three minutes; it’s five minutes for their 4A nurse. St. Rita’s also set guidelines for both the physician arrival and ordering of the CT scan at 10 minutes.
An effective communication platform feature that aids RRT outcomes is an automated callback and escalation process. This eliminates critical minutes being wasted on resending notifications and manually escalating the issue to another provider when team members do not arrive on time.
The proof is in the results
St. John Hospital and Medical Center (SJHMC) in Detroit aimed to comply with the guidelines set by The Joint Commission and the American Heart Association/American Stroke Association, all of which call for having CT scans interpreted within 45 minutes of the patient’s arrival and having treatment administered within 60 minutes.
SJHMC implemented PerfectServe and used the flexibility of the platform to develop its stroke team protocol. The protocol called for alerts to a multidisciplinary team of nurses, physicians and staff from neurology, the ED and neurosurgery, as well. Each team member’s preferred method of contact was configured in PerfectServe Synchrony so that when a stroke alert is sent from the ED, each member (or their on-call counterpart) is contacted via their preferred method.
The ability to contact team members directly on their personal mobile devices, as opposed to using overhead paging systems, eliminates the potential for missed pages.
After the system and process were implemented, SJHMC saw significant improvements in time to treatment for its stroke patients. The on-call neurologists’ response times dropped 90%, from 22 minutes to just 2 minutes.
Their door-to-CT scan completion time decreased 41%, from 78 minutes to 46 minutes.
Additionally, SJHMC was able to administer life-saving tPA to three times more stroke patients than they were before.
Making lasting, life-saving process improvements
Most hospitals in the Unites States have some version of an RRT in place for major medical events. Some hospitals have even included local EMS organizations in their rapid alert processes in order to improve speed-to-treatment times.
There’s no question that streamlined and automated communication aids RRTs in their work to lower mortality rates for stroke patients and other traumatic injuries.
Rapid response alerts have proven benefits for clinicians, too. Having a rapid response alert program in place eliminates stress and frustration for the ED staff, which usually has the primary responsibility of initiating treatment to stroke and trauma patients.
In addition to simultaneous instant alerts to appropriate response team members, PerfectServe’s rapid response alert system also sends activation notices to hospital leadership. These notices include the time the alert was activated and the time each care team member arrived (as input by the nurses involved). This additional insight into rapid response operations gives healthcare leaders the opportunity to identify problem areas and make lasting process improvements that ultimately save more lives.