Lower-cost Ways to Strengthen Patient Engagement

Snapshot

By engaging patients with new services and technology, hospitals are heading off costly interventions and building loyalty.

As Lisa Michaelis discusses various life coaching and wellness services offered by Mosaic Life Care, it might be easy to forget that she works for a hospital system.

Wending your way through a dicey divorce? Struggling with financial headaches or an onerous job? In the last year, the St. Joseph, Mo., organization has introduced memberships for life coaching to local residents, one service among a growing array the system is offering to reach people before they require more typical health treatment.

“Rather than waiting until somebody has a disease or an illness, such as a heart attack or a [gastrointestinal] bleed, we want to work with people on making a transformation before an issue leads to a disease or an illness problem,” says Michaelis, the system’s chief life officer.

Formerly called Heartland Health, the nonprofit system has been rebranding in accordance with this new philosophy, rolling its 352-bed hospital and 60-plus clinics in three states under the Mosaic Life Care umbrella. The overarching goal is to build “trusted and engaged” relationships with community members, Michaelis says. Ideally, she adds, “when they do need a wellness visit, they will think of one of our providers.”

Mosaic, which has a Medicare Accountable Care Organization and at least two other ACOs through commercial payers, is among those hospital systems that are using everything from high-tech to high-touch strategies to more closely connect with and support their patients, as reimbursement makes the transition from fee-for-service payment.

Some of the strategies involve expanding communication between patients and clinicians beyond the facility walls into the virtual world, whether that’s reading a doctor’s latest batch of notes or exchanging secure messages. In other efforts, health systems are striving to identify patients more prone to disregard or misunderstand the treatment plan, and limit potential obstacles in their path. Meanwhile, hospitals are using social media to try to more closely cement connections with existing patients and capture the attention of potential ones.

While sometimes used interchangeably, patient satisfaction and patient engagement are two distinct sides of the same coin that both have to be addressed by hospital leaders, says Meryl Luallin, chief executive officer of the consulting firm SullivanLuallin Group in San Diego.

“Not only do they have to have happy patients based on the service that they deliver to those patients, but they also have to have patients who are personally motivated to do what the treatment plan requests,” she says.

The business case is clear, according to Luallin. “In a fee-for-service environment, there was no incentive for making certain that a patient followed instructions,” she says. Plus, better communication won’t just prevent costly complications, it can help to build market share, she says.

One recent analysis that looked at nearly 400,000 Kaiser Permanente Northwest patients’ access to their medical information through an online portal found a strong retention link. Users of the portal, through which they could access test results and send messages to their doctors, were nearly 2.6 times more likely to stay with the nonprofit plan, according to the findings published in 2012 in the American Journal of Managed Care.

Virtual Engagement

Sometimes high-touch and high-tech can be combined, as Philadelphia’s Thomas Jefferson University is pursuing in a pilot virtual rounds project launched late last year. Through a video connection, family members can virtually attend hospital rounds to check in on their loved ones and ask questions of the physician, says Judd Hollander, M.D., associate dean for strategic health initiatives at Thomas Jefferson’s Sidney Kimmel Medical College.

By doing a better job of keeping family members in the loop, whether they are halfway across the country or can’t make it to the hospital for 6 a.m. rounds, the goal is to prevent the later confusion or misunderstanding that can lead to an unnecessary readmission, Hollander says. “If anybody has ever had family members in the hospital, we as physicians and care providers do a horrible job at communicating with the family members.”

In another video-driven pilot, physicians at Thomas Jefferson are hoping to reduce the number of patients who have to trek back to the hospital for a post-surgery checkup. With some minor procedures, such as the removal of a thyroid goiter, the healing of the incision likely can be checked out via video connection, as long as the patient hasn’t experienced any postsurgical problems, Hollander says.

With a computer set to beep once the surgeon is ready to visit via virtual consult, a patient can continue to recover from home, Hollander says. That approach, which ensures follow-up with minimal patient disruption, also is fiscally prudent, as surgeries typically are reimbursed with a bundled amount, he says.

Joe Boyce, M.D., Mosaic’s chief information officer and chief medical information officer, shares Hollander’s passion for finding ways to help rather than hinder patient involvement in their own care. As a former flight surgeon with NASA, he’s already accustomed to thinking about better ways to provide care at a distance. “[It] depends upon the specialty, but sometimes you need to lay hands on [the patients] and do things, and sometimes it’s just, ‘Hey, how are you doing today?’ and the physical exam is secondary to the history,” he says.

A doctor visit, particularly for older individuals who require wheelchair assistance, can morph into a several-hour ordeal, Boyce points out. “Then you have a 15-minute visit which is basically, ‘How are you doing?’ It drives me crazy. It’s so disrespectful of the patient’s time.”

Ongoing Conversations

Mosaic Life Care is one of a handful of sites that are participating in the next phase of the OpenNotes project, an initiative launched in 2010 by Boston’s Beth Israel Deaconess Medical Center and two other medical sites that grant patients access to notes written about them by a clinician during or after an appointment [see Patients and Physicians: Trading Notes?, Page 17]. By the end of 2014, as many as 32 health systems, including the 150-plus medical centers operated by the Veterans Health Administration, were expected to have adopted the OpenNotes approach, providing patients with easy electronic access to their own medical records.

Patients who read their medical records can become more involved in their own care, even if they’re irritated by something that they’ve seen, says Boyce, whose system has provided its patients access to most doctor notes since 2011. In one case, a patient griped about being described as a diabetic, saying it was incorrect, despite being on insulin. In at least two other cases, patients objected to the label of morbidly obese, also not an error based on medical criteria, Boyce says.

“The thing is, were the providers having adequate conversations with that patient before?” he says. “If you think that the patient is really sick and he or she doesn’t, or vice versa, that’s a conversation that ought to happen.”

Other technological tools, such as secure messaging, also can help to strengthen ties with patients between appointments, particularly those with chronic health conditions, says James Ralston, M.D., an investigator at the Group Health Research Institute, which is affiliated with Seattle-based Group Health. The system, which includes 25 medical centers but considers itself primarily an outpatient organization, reported that it conducted nearly 2.3 million email exchanges and more than 28,000 virtual consults in 2013.

Ralston has been involved in several Group Health studies looking at increased clinical support with Web communication. One study, published in 2008 in the Journal of the American Medical Association, focused on strategies to reduce blood pressure to recommended levels. It found that better control was achieved if the patient not only monitored his or her readings at home, but worked with a pharmacist, first with an introductory phone call to review the patient’s history and establish a plan, followed by a series of online exchanges via secure messaging.

In that pharmacist group, 56 percent of patients were able to get their blood pressure under control, compared with 31 percent in the usual care group and 36 percent who did home blood pressure monitoring with access to an educational website, but no pharmacist interaction.

Ralston, who chafes at specific terminology such as engagement or activation, says his bottom line is reaching patients. “We’re trying to deliver the right care at the right time through the right means,” he says. “And today that means engaging online.”

Activating Patients

When hospital leaders are trying to figure out where to invest their staff time to prevent readmissions and other patient difficulties, it’s helpful to have a sense of which patients are more or less activated in the first place, says Valerie Overton, R.N., a nurse practitioner and vice president of quality and innovation for Fairview Medical Group, part of Minneapolis-based Fairview Health Services.

For the last five years, Fairview patients using the system’s primary care clinics have been asked to answer a series of questions to calculate what’s been dubbed their Patient Activation Measure, or PAM, score. That survey snapshot, which takes just a few minutes, is designed to measure “the patients’ sense of their knowledge and their skills and their confidence in managing their health,” Overton says.

Less activated patients consume more health care, according to an analysis involving 33,163 Fairview patients that Overton helped to conduct. Patients with the lowest activation scores racked up costs as much as 21 percent higher than those who had the highest activation levels, according to the findings, published in 2013 in the journal Health Affairs. That association held true even if the patients involved fell into a lower socioeconomic category.

With these results in mind, Fairview clinicians have begun to tailor the care they provide based on the patient’s activation level. In one project, the duration of physical therapy for patients with low back pain was adjusted based on their PAM scores. The initial results are promising, showing that better care is being delivered at a lower cost, Overton says.

Starting last year, PAM scores have begun to be incorporated into discharge planning. Those patients with low scores might receive more support, such as the delivery of post-discharge medications to the home, she says. “I think patient activation and patient engagement are really going to be critical to financial performance in the future, as well as to performance on patient experience in the future,” Overton says.

Mosaic’s Boyce, who talks about “positive stickiness,” also believes that engaged patients will help to build market share. Rather than creating hurdles for patients, such as limiting access to their own medical records or making it difficult to shoot a quick question to a clinician, health system leaders should induce them not to stray, he says.

“Why wouldn’t you want to appeal to patient engagement and activation and build the system that they are asking for?” he asks. “Make yourself sticky through competing and providing better service.”

For Mosaic Life Care, that interactive approach has paid off. During its first year of operation, the system’s Medicare ACO reaped $8.53 million in savings, with a projected reimbursement of $5 million through the Medicare Shared Savings Program. 

Charlotte Huff is a contributing writer to Trustee.

Patients and Physicians: Trading Notes?

The OpenNotes initiative, when it was first rolled out to more than 100 primary care doctors, largely garnered positive feedback from patients, who felt that easy electronic access to their health records improved their health savvy.

But they wanted more. Roughly 60 percent felt they should be allowed to add comments, according to findings published in 2012 in the Annals of Internal Medicine. Only one-third of doctors agreed.

Now, both sides will begin to test the idea. Leaders at Boston’s Beth Israel Deaconess Medical Center who launched OpenNotes in 2010, recently received a $460,000 Commonwealth Fund grant to work with four other medical sites. Precisely how and to what extent each site will enable patient access was still being worked out as of late 2014. But the goal was to explore a variety of approaches, says Jan Walker, R.N., co-director of OpenNotes and a faculty member of the department of general medicine and primary care, Beth Israel.

The hope is that giving patients the opportunity to add detail will encourage them to read their medical information more closely, she says. “They might catch mistakes. They might register some feedback.”

That sort of interaction opens the door to other possibilities, such as asking patients to sign off on their treatment plans, Walker says. “Certainly the pros are that patients are theoretically more engaged. They agree with what the plan is. They understand what the plan is, and then hopefully they carry it out. Perhaps six months from now, both the clinician and the patient will look at this thing that they both agreed to and say: ‘How did we do?’ ”

Mosaic Life Care, one of the five participating sites, already gave patients an opportunity to input notes in the fall of 2013, says Joe Boyce, M.D., the system’s chief information officer and chief medical information officer. Part of the challenge is determining the scenarios when it’s appropriate for patients to add details, he says. “What we did not want is a patient putting down something on some portal saying, ‘Hey, I’m suicidal,’ and nobody is looking at it.”

These days, Mosaic’s patients on the portal get a reminder before an office visit to fill out a pre-visit questionnaire, describing why they want to see the doctor, along with the opportunity to enter or update their family and personal health history. In some cases, the final version might be more complete and accurate if patients can fill it out at their leisure at home, Boyce says. For instance, a patient might take the time to verify the name of a prescription in his or her medicine cabinet, or check with a family member to see if an uncle died of a heart attack or a stroke.

Despite their popularity, it’s unclear how and to what extent patient portals tied to electronic health records improve care, according to a review article published in 2013 in the Annals of Internal Medicine. To date, only a limited number of high-quality studies have been published that looked at patient outcomes, and they often lack necessary detail about context and implementation, according to the researchers.

While the approach isn’t right for all patients, the leaders at Beth Israel feel as though they are only starting to explore how electronic records access can improve care collaboration with patients. “It’s in the Model T stages for how transparency will evolve,” says Tom Delbanco, M.D., the project’s other co-leader.

Just as no medicine is risk-free, easy access to doctors’ notes and other medical information might present some unexpected side effects for patients, ones that researchers hope to identify as the study progresses, he says. “This is a very large shift in care — we are learning,” Delbanco says. “We’re going to hurt some people. But we’re going to help far more.” — C.H.