- When Triad HealthCare Network (THN) became a Medicare Shared Savings Program accountable care organization (ACO) in 2012, the network’s director of accountable care operations, Elissa Langley, knew she and her team would need extensive patient outreach to achieve ACO success.
The Medicare Shared Savings Program (MSSP) makes ACOs accountable for healthcare quality, costs, and outcomes for patients within a fee-for-service population. This level of healthcare accountability requires program participants establish a care model that:
- Promotes accountability for a patient population
- Coordinates items and services for Medicare FFS beneficiaries
- Encourages investment in high quality and efficient services
The alternative payment model asks providers to bear some financial responsibility for the overall health and wellness of the Medicare population. Meeting the program’s 33 quality measures requires ACOs to establish methods by which patients can receive necessary preventive care. Therefore, MSSP participants must create strong patient engagement fueled by patient outreach.
At THN, facilitating strong patient outreach and engagement with wellness care meant automating the process with patient engagement technology Emmi Solutions.
“We really needed a way to try to reach out to our patients,” Langley shared in an interview with PatientEngagementHIT.com. “One of our very first campaigns was a pilot flu campaign in two of our practices. We were able to move the needle. Those two practices moved from the 50th percentile to the 60th percentile.”
Conducting meaningful patient outreach put THN in the top tier of MSSP quality performers in 2015, Langley noted. It also generated considerable cost savings.
But beyond the financial benefits for successful ACO participation, patient outreach has been the best solution for positive health outcomes, a key part of the patient experience.
“The recognition is that patient engagement and involving patients in their healthcare as proactively as possible is ultimately going to drive the best outcomes for patients,” Tonda Gosnell, THN’s Population Health Project Manager, said in the same interview.
“Many of our biggest successes have been with things like our flu campaign,” Gosnell added. “Reduction in flu diagnoses for patient members means less risk of hospitalization and further issues.”
The tool also increased the odds that the patient will actually visit the practice, a barrier ACOs have long worked to overcome. ACOs often have trouble motivating patients to receive necessary preventive care, or to receive medical attention when patients really need it.
ACOs sometimes bring this issue upon themselves by not being proactive with patient outreach.
“Often, it becomes a default in a practice space that people will come back when they need to come back,” Gosnell noted.
Instead, patients usually need prompting, like a phone call home that reminds them that they are due for a mammogram or that flu shot season is coming. THN’s patient outreach technology has helped make this outreach process more efficient, touching more patients and ideally preventing more avoidable conditions.
“This tool has really helped to change that paradigm when they get reminder calls that they are due for a mammogram or flu shot,” Gosnell said.
Relatedly, THN also uses patient engagement technology as a part of its risk assessment efforts. A patient with a high risk for breast cancer might receive more urgent or persistent mammogram outreach than those without risk.
Risk assessments for falls can help providers educate patients about mobility and put in place other arrangements such as at-home care that can help prevent a patient from falling.
“All of that information is an assessment in and of itself,” Gosnell explained. “It's critical for primary care providers to know about a patient’s fall because those are the risk factors for future falls.”
Knowing the information about a recent patient fall allows providers to act on that information. If Mrs. Jones has fallen, Gosnell offered, providers can identify actions to take, such as provide a walker or look at physical therapy options.
Prevention measures go beyond wellness reminders, the pair reported. Patient preparation, such as through educational videos, helps patients take care of themselves before and after a procedure. Currently, THN offers educational videos for total knee and hip surgery and colonoscopy prep.
Patients are empowered to engage with their providers when they know more about the procedure, Gosnell said.
“People indicate that it really prepares them well for the recovery period,” Gosnell said of the knee and hip replacement tools. “Folks learn more about unknown risk, things they hadn't known before. It provides them with new information and really increases patient confidence to ask more questions.”
Patient education videos have also shown to improve the patient experience with colonoscopies and total joint replacement surgeries, Langley stated.
“The video is about what to expect when you're getting a colonoscopy,” Langley said. “Those patients reported that their anxiety levels went down because they felt more confident and comfortable in knowing what to expect when going into that procedure.”
Patient outreach tools also prevent patients from going radio silent after a care intervention. In the days or weeks following a surgery, for example, it is ideal for the provider to hear from the patient about their recovery.
“Folks who have just come home from the hospital now answer the calls and are reporting back to us that they have symptoms or they started using more of their emergency medication or they've had a weight gain,” Gosnell explained, stating that all of those reports are important for providers to receive.
“It allows the care management to go back to the patients and help to really coordinate their care, get them back in to their primary, and if it's something related to a social determinant to address that social need,” she continued.
For example, if a knee replacement patient returns home and experiences a fall in her ice-covered driveway, open communication lines and patient outreach fills THN in on that fact. From there, the ACO can arrange for someone to salt the driveway and adequately remove snow, preventing the patient from falling again.
High-touch patient outreach does more than just support the financial and wellness goals within the ACO, Gosnell and Langley said. The holistic approach to patient wellness that spans more than just the office visit improves patient satisfaction, and makes patients feel more confident in the care that their providers deliver.
Patients who hear from their providers in between visits know their providers truly care, the pair offered. When a patient comes in for a surgery knowing exactly how the procedure will go, she is more at ease having some of her fears assuaged, Gosnell and Langley said.
THN’s patient outreach approach would not have been effective if the ACO had tried to be all things to all patients.
“This approach is not one size fits all,” Gosnell advised other ACOs that might be looking to improve their patient outreach. “We've been studying over time where a particular prevention approach works and what metrics it works for. The two I mentioned earlier – flu and falls – are big ones for us.”
In other practices, other prevention areas may be more important, and it is up to individual ACOs to assess their populations to ensure they are focusing their efforts in the right areas.
Gosnell also suggested ACOs look at other supporting tools. THN leverages point of care tools, care management tools, patient navigators, medication adherence dispensers, real-time notifications, chronic care symptom monitors, and telehealth to supplement their patient outreach efforts.
“This is just one tool in the toolbox,” Gosnell concluded. “We as an ACO are tackling tons of other strategies for engaging patients particularly around post discharge.”
Ultimately, creating the cost savings and creating the quality outcomes within the MSSP ACO arrangement was a high priority for THN. Using patient outreach technology, the ACO was able to meet those priorities, while also creating a positive patient experience that emphasizes meaningful engagement.