Care [Almost] Anywhere
Trustee Talking Points
• Health systems are experimenting with new types of access that make care more convenient and less costly for consumers.
• Access points pioneered by entrepreneurs — including quick-care clinics, online and video visits, and home visits — are being embraced by traditional health systems.
• Low-cost venues that make it easy for patients to find care also support population health initiatives and the move to value-based payments.
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Calling the physician’s office. Making an appointment. Driving to a medical clinic near a hospital. Waiting.
Those well-worn steps for reaching health care services are falling away as health systems reposition themselves with bold new access strategies.
“What people really want is on-demand access,” says David James, M.D., CEO of Memorial Hermann Medical Group in Houston. “Particularly those who are well or have conditions that are stable — they just need to get things done, and time has become really important for them.”
Like its consumer-oriented peers across the country, Memorial Hermann is experimenting with new types of access — urgent care facilities, retail clinics, tele-visits and more — designed to make it easy for consumers to choose Memorial Hermann every time they need care.
“Everything is moving toward the home,” said Mike Waters, senior vice president of physician services at Renton, Wash.-based Providence Health & Services one of the largest health systems on the West Coast.
Providence reviewed its traditional access channels about three years ago and realized they did not line up with what consumers are looking for. Today’s consumers aren’t impressed with extended hours in a conventional medical clinic.
“We shifted our thinking from these more-traditional access points into creating a menu of different products so that consumers have choice,” Waters said. “A lot of people get hung up on whether we can provide same-day access. Frankly, what we’re hearing from consumers is they want care when they want it, where they want it, how they want it. So we need to provide them options.”
Novant Health, a 13-hospital system serving more than 4 million patients in North Carolina, South Carolina, Georgia and Virginia, considers its access strategy in terms of three broad categories of venues: acute care hospitals, ambulatory facilities — and everything else. “Whenever the patient is not inside our four walls, they are in what we would term a virtual venue of care,” said R. Henry Capps Jr., M.D., chief operating officer of Novant Health Medical Group.
That virtual venue includes e-visits and video visits, population health initiatives that proactively reach out to high-risk patients, an inbound/outbound call center that supports patient engagement, and online interactions via Novant’s patient portal.
“We’re working to make health care truly centered around the patient,” Capps says.
For each of these health systems, the new access points support the concept of the patient-centered medical home because electronic health record technology captures care at every venue. That allows care to be coordinated and managed outside the traditional primary care clinic. “We’ve got the clicks, and we’ve got the bricks,” James said. “It’s a way to take the walls off the medical home.”
Laying new bricks
In the highly competitive Houston market, Memorial Hermann is aggressively adding new types of facilities in high-traffic locations that can make it as easy to choose Memorial Hermann as it is a nearby freestanding urgent care center or emergency department.
“Two years ago, we opened our first convenient care center, and today we have four of them,” James said. “We have one urgent-care fully deployed, two coming out of the gate.”
Convenient care centers are one-stop shops that include primary care offices, “fast-track” primary care clinics open 12 hours a day, seven days a week, an emergency department, sports medicine and physical therapy, outpatient imaging and laboratory services, and swing spaces available to specialists on a rotating basis.
The convenient care centers are attracting new patients into the Memorial Hermann system. Indeed, James said, primary care offices in convenient care centers are growing at three times the rate of a new primary care clinic without the other services.
“When patients are done being seen either at the [emergency department] or the fast-track area, the question comes, ‘What about follow-up?’ and, ‘Do you have a doctor?’ ” James says. “We have a primary care site right there in the convenient care center.”
He said he expects the new urgent care centers to also attract new patients — at least 30 percent of people who go to an urgent care clinic do not have a primary care physician — as well as provide better service to Memorial Hermann’s current patients. Up to 30 percent of patients served by the system’s first urgent care center were directed by their physician’s office. This practice avoids high-cost ED visits while giving patients immediate access to care.
Novant operates 14 urgent care clinics in two of its North Carolina markets and has opened 10 Novant Health Express clinics in the past two years. Staffed by mid-level practitioners, the walk-in clinics are a low-cost way for the Winston-Salem, N.C.-based health system to provide simple, low-acuity services close to a patient’s home.
“Over the next five years, we are going to see smaller models like these — plus models we haven’t even thought of — wherever consumers are,” Capps said. “I think you will also see traditional primary care being delivered differently in a similar kind of geographic footprint, with convenience being a significant priority.”
Other people’s bricks
Providence will open 50 Express Care clinics by mid-2017. Of these, 25 will be embedded in Walgreens stores in three of Providence’s large markets; the other 25 will be freestanding locations in almost every market in which the huge system operates.
This is just the first phase of Providence’s major push into neighborhood clinics, staffed by nurse practitioners and physician assistants, designed to increase access and support population health management. Some Express Care clinics will be in suburbs where Providence does not now have a presence; others will be situated to relieve pressure on traditional primary clinics that struggle to meet the quick-care demands of their patients.
In the years ahead, Waters said, the system expects to open many more Express Care clinics — and he expects them to eventually provide chronic care management as well as the episodic services that walk-in clinics typically provide.
The Providence Express Care clinics in Walgreens stores will be owned and operated by the health system, not the retail chain, and equipped with Providence’s EHR system. The health system was attracted to Walgreens in part because the company’s site-selection approach mirrors what Providence wants to do.
“Eighty percent of the U.S. population lives within five miles of a Walgreens, so certainly this aligns very nicely with one of our key strategies, which is bringing care closer to home,” Waters said.
Another attraction: A Walgreens customer typically visits a store 20 to 30 times a year, making it convenient to pause at the Express Care clinic for a bit of chronic care management. “This is a key component to our larger population health strategy, where we really want to create healthier communities,” Waters said. “What an amazing opportunity for us to better manage a patient’s diabetic needs through these sites.”
In Texas, Memorial Hermann teamed with RediClinic, a chain of retail clinics, to maintain a presence in 23 H-E-B grocery stores in the greater Houston area. The RediClinics are promoted on Memorial Hermann’s website — and the system’s nurse triage phone line — as easy-access sites for simple diagnosis and treatment plans, vaccinations, sports physicals and other low-acuity needs. Services are provided by RediClinic-employed nurse practitioners who have access to Memorial Hermann’s EHR system.
“Whatever happens at the retail clinic becomes part of the medical record, and it’s still monitored and managed by your primary care physician,” James says.
Turning to ‘clicks’
Many consumers prefer to avoid driving to a medical facility entirely, and health systems have taken notice. Virtual access to care through video, email, online chat or mobile visits was pioneered by technology companies working outside traditional health care organizations, but many health systems are jumping in.
Novant introduced e-visits and video visits two years ago, and Capps expects their use to grow as patients and providers gain experience with the technology. “Patients love the asynchronicity of e-visits — the ability to send a message, go about their life and have their personal physician interact back with them a little bit later,” he said.
UPMC in Pittsburgh introduced its UPMC AnywhereCare eVisits for primary care in 2013 and expanded to e-dermatology last year. Primary care eVisits are staffed by a mix of nurse practitioners and physicians, while e-dermatology provides direct-to-consumer online access to a board-certified dermatologist.
“We always had the vision that we would expand the platform to facilitate subspecialty services as well as provide new access points for population health, to connect at some point with wearable devices, and just provide better coordinated care altogether,” said Natasa Sokolovich, executive director of telemedicine at UPMC.
For example, e-dermatology visits allow patients to ask a doctor if a worrisome mole warrants an in-person visit — and it allows follow-up care for patients being treated for psoriasis, acne and other ongoing conditions. Patients fill out a questionnaire, upload three images of their skin condition and submit payment; within three business days, the physician provides a diagnosis and treatment plan.
UPMC offers AnywhereCare in Pennsylvania and Maryland. In Maryland, state law requires a synchronous, live audio-video-enabled visit as part of an online visit; in Pennsylvania, patients have the option of scheduling a video visit as part of their eVisit.
“Interestingly enough, what we found is that, even with that option available, we have very few consumers who are selecting that,” Sokolovich says.
Novant has used video visits for chronic disease management and is exploring use cases for unplanned care.
Memorial Hermann is in discussions with several independent providers of tele-visits — and evaluating its in-house telemedicine capabilities — with a plan to launch its own telehealth initiative, using its own physicians and care protocols. Once in place later this year, Memorial Hermann’s urgent care physicians will use the technology to conduct side-by-side tele-visits.
“Of course, people can walk in physically to the urgent care center to be seen, but the same physician can go to [another] room where there is a kiosk and see a patient virtually,” James said.
New kinds of home care
Another way to make life easier for patients: Help them to manage their chronic conditions via remote monitoring. UPMC has provided at-home monitoring for congestive heart failure patients for a while, but it is expanding the program this year to include patients with chronic obstructive pulmonary disease and diabetes. Palliative care and geriatric care will be added in the future.
“This allows a shift from bricks-and-mortar to direct-to-patient home care,” Sokolovich says. “By leveraging our biometric capabilities, we can help patients avoid being unnecessarily admitted for a chronic condition that is not well-controlled.”
The service includes remote monitoring of biometrics and a group of clinicians dedicated to supporting patients at home. The clinicians monitor alerts that indicate a key biometric is outside the normal range and contact patients to get more information. The clinicians can coach patients on how to adjust diet, medications or other factors to improve their health status — or encourage them to seek immediate care in the emergency department, if needed.
Meanwhile, Providence is experimenting with in-person home visits in its Los Angeles and Seattle markets. “We are piloting a home visit product where a nurse practitioner actually arrives at your house and provides care to you,” Waters says.
The technology platform was tested in a previous pilot; now, the health system is trying to learn what kinds of consumers want this model of care. Possibilities include busy moms who need care for a sick child, consumers who want high-touch concierge-type services and patients who have trouble traveling to medical appointments.
Waters is confident that home visits will find their place in the market — and that payers will eventually support that model of care. “I think it’s early on, so payers’ willingness to pay for certain types of care is evolving,” he says. “Telehealth is a great example: It is now paid for by most of our payers. We believe the same thing will happen for home visits.” — Lola Butcher is a contributing writer to H&HN. •
[PULLQUOTE]
“Today’s consumers aren’t impressed with extended hours in a conventional medical clinic.”
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[print hed]Fixing the schedule
[webhed]3 Ways to Improve Patient Access
[web subhed]Fixing scheduling can go a long way toward improving the hospital experience.
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Building new facilities and adding online and video visits are not the only ways to increase access and make life easier for patients.
“You don’t always need to invest a lot of resources in bricks and mortar,” says Brad Boyd, president of Culbert Healthcare Solutions in Woburn, Mass. “Organizations can do a tremendous amount with what they have already.” Among the factors to consider:
1. Scheduling practices: Boyd frequently finds scheduling templates are not set up for optimum productivity, prompting long waits for an appointment — and patients who forgo care or go elsewhere.
2. Physician compensation: “We see organizations where physician schedules have been set up based on their compensation model,” Boyd says. “If their compensation models are really out of alignment, that physician is never able to see the number of patients you’re expecting them to see.”
3. Centralized scheduling: Patients who are treated by several different physicians become frustrated with the challenge of calling different practices to schedule multiple appointments on multiple days. A centralized approach allows the patient to talk with one representative from the health system who can coordinate all the appointments. “That one-call-does-it-all is much more efficient from a patient perspective,” Boyd says. “And from a health system perspective, three different practices are not all verifying one patient’s insurance eligibility because it’s being done once in a centralized manner. Those process efficiencies and staffing efficiencies reduce costs.” — Lola Butcher •
[Trustee Talking Takeways sidebar]
[print hed]Trustee Takeaways
[webhed]Improving Patient Access Has Far-Reaching Effects
[web subhed]Making health care easier can helps hospitals in any number of ways.
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New access strategies that take care closer to home address several trends:
Physician shortage
Providence Health & Services, one of the largest provider organizations on the West Coast, handles more than 3.5 million primary care visits each year and is adding 40,000 new patients a month. Retail clinics, home visits and online access are expected to add up to 1 million new slots in the next few years.
Improving value
Like many health networks, the UPMC system in Pennsylvania is seeing inpatient days decline even as its patient population grows. Low-cost access via telehealth allows the system to treat patients more efficiently.
Patient choice
Some patients value having a relationship with their care team; others prioritize cost and convenience and don’t care whether their doctor knows them personally. “You have to design venues of care and opportunities of care that meet folks wherever they are,” says Hank Capps Jr., M.D., chief operating officer of Novant Health Medical Group in the Southeast.
Value-based reimbursement
Contracts that base a provider’s pay on the quality and cost of care delivered require that providers find a way to hold patients closer. “If a patient leaves your health system because they can’t get timely access or they just had a bad experience, the leakage isn’t just about losing the revenue for that visit for that patient,” says Brad Boyd, president of consulting firm Culbert Healthcare Solutions, based in the Boston area. “You lose the ability to manage quality, you lose the ability to manage cost. So, in a value-based care reimbursement model, you are really losing your ability to operate effectively.”