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Wellcentive’s Advance Outcomes Manager solution has helped the physicians of Lakeshore Health Network achieve significant improvements in both clinical and financial outcomes. Reimbursement and incentive payments have increased by over 30% since 2007, and member physicians have also realized year-after-year improvements in preventive care and chronic disease outcomes.

Learn more about how Wellcentive’s solutions have driven success for this prestigious physician-hospital organization. Download the case study today.

Closing Cap Gaps

At its most basic, patient outreach means notifying patients about gaps in their care and prompting them to close those gaps. The actual outreach can take on different forms, which I’ll discuss later in this post, but there are a few things we should cover first.

Meaningful Reporting

Before you can implement a patient outreach program, you need to be able to accurately identify patients who actually have gaps in their care. This requires patient-specific information about preventive care and chronic disease management services or treatments that have been provided, such as flu shots, colonoscopies for patients 50 and older, nephropathy screening for diabetics, and ACE-Inhibitors for patients with CHF and a low ejection fraction. It also requires accurate information about reasons why patients may not need or shouldn’t have what would otherwise be recommended, such as egg allergies, total colectomies, history of chronic kidney disease, or angioedema from ACE-Inhibitors (using my examples above).

This type of analysis not only requires a variety of different types of data, such as demographics, medical conditions, medications, care items, immunizations, and labs, but it also requires that this data is accurate, up-to-date, and complete. As a physician, the last thing I want to do is notify a patient who I think needs a mammogram only to upset the patient because she had the mammogram a couple of months ago or because she had a bilateral mastectomy for breast cancer and doesn’t need mammograms any more. Both situations would make the patient feel that I am out of touch with her care.

As I have discussed previously in the Wellcentive Blog, interfaces between your Population Health Management System and various clinical and administrative health care data sources, such as EMR, e-prescribing, lab, practice management, hospital, payer, HIE, and data warehouse systems can all help ensure that the data your care gap reports are based on is insightful and meaningful. More on this topic in future posts as well.

Locked and Loaded

Once you have confidence in your data, it’s time to start turning that data into information you can use to improve outcomes. It’s time to generate care gap reports from your Population Health Management System and get your patients engaged!

Let’s take a look a look at some of the different patient outreach methods we see physicians and their organizations using to close the patient outreach loop.

Fire As She Bears

Notifying patients about gaps in their care and prompting them to close those gaps can be done in a few different ways, and each method has an upside and a downside:

The cost/benefit analysis tends to favor automated or manual telephone outreach efforts. Manual calls tend to be more personalized and costly, and automatically generated calls tend to be more cost effective but less personalized. Physician offices tend to choose one of these two methods, and their choice is based on practice style, available resources, and the level of engagement with their Population Health Management System.

Hit the Target!

Regardless of which patient outreach method you decide to use, the important thing is to pick one and take a shot at patient outreach! Any of the above methods can really help you make a difference in your practice’s clinical and financial outcomes, and you can always change methods if you find that the one you try first isn’t the best choice for your particular CQI program.

My patients really appreciate the effort we go to in order to identify care gaps, notify them about these gaps, and proactively work with them to close those gaps. These efforts let my patients know that we care and are working for them, even when they aren’t in the office for a visit. This instills trust and confidence and helps improve outcomes as well as patient satisfaction. That’s a win-win!

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In this week’s post I’ll provide a brief overview of Basic Care Management, which is a Clinical Quality Improvement (CQI) approach suitable for physician offices large and small.  This type of program can really help you improve clinical outcomes with a minimal investment of resources and little impact on existing office workflow.  Really!

Care Management Defined

Not everyone defines Care Management in the same way, so let’s make sure we are all on the same page.  I believe that Care Management is the intersection of the Point of Care and Population Management health care delivery models and includes a variety of components:

• Care gap analysis
• Patient outreach
• Risk assessment
• Predictive modeling
• Complex case management
• Care coordination
• Transitions of care
• Patient education

The first three components are what I consider to be Basic Care Management.  These activities are also important parts of the Patient Centered Medical Home and are critical for the transformation of care from purely episodic care to a care model that also includes population health management.

The other items listed here will be covered in the upcoming more comprehensive Care Management Series posts.

Care Gap Analysis

At its most basic, care gap analysis is simply the identification of patients who are due for some type of preventive care or chronic disease testing or treatment.  Examples include women due for mammograms, diabetics who need nephropathy screening, or heart failure patients with low ejection fractions who aren’t taking ACE-Inhibitors.

Many office-based CQI programs use technology to help them identify which patients have gaps in their care.  A good strategy is to perform this analysis once a month or once a quarter, and use this information as part of a proactive patient outreach program.  It’s not enough to know which patients in your panel are in need of care, you have to do something about it as well!

Patient Outreach

Notifying patients about overdue care can really help improve compliance and outcomes, and generally speaking, patients appreciate it when their physicians make the effort to let them know.

There are different ways to notify patients about gaps in their care.  Some offices use their population health software to produce patient reminder letters.  Letters are relatively expensive to send and easy for patients to ignore, so most offices find that some type of telephone call is more effective.  Some offices have staff members make phone calls using call lists and care gap reports, and others utilize integrated and automated care gap telephone outreach systems, which can be more cost effective.

Risk Assessment

Risk assessment for Basic Care Management generally means identifying patients at risk of sub-optimal clinical outcomes and is pretty straightforward:

• Diabetics with poor blood sugar control
• Chronic kidney disease patients with inadequate blood pressure control
• Coronary artery disease patients with elevated cholesterol
• Asthmatics not adherent with inhaled corticosteroids
• Heart failure patients with a recent discharge from the hospital

Other more complicated risk assessments also have value (more on Predictive Modeling and Complex Case Management in another post), but the low hanging fruit can often be found with more basic reporting on your patient panel.  The Quality Manager of your CQI program can use his or her office’s population health management system to identify these types of patients, and the physicians and office staff members can devote some time to help ensure that these types of patients get the extra attention they need.

You Can Do It!

A little extra work can go a long way to improving clinical outcomes and increasing reimbursements from Pay for Performance programs and Patient Centered Medical Home uplifts, so get started with your own Basic Care Management program today!

And The Starting Lineup Is….

Let’s take a detailed look at the different types of physician and staff CQI team members and their areas of responsibility for your CQI program.  Everyone is a starter and is in it to win it, so let’s make sure all the players know their positions:

An All-Star Team

As you can tell, there are a few key positions to fill on your CQI team, but your office probably already has most or all of the players it needs to win the game. Even if you have to play a man or woman down, use the people you have and put together a program as best you can. You may be surprised by the difference you can make for your patients – and your office’s bottom line!

Who Is This Quality Manager Anyway?

The first step is to find your Quality Manager, and chances are you already know just the right person.  Depending on the size of your office, your Quality Manager is probably someone who already works there.  You might even find the perfect candidate the next time you look in the mirror!

Often experienced and capable medical assistants or office managers are tapped for this work, so you probably don’t need to hire someone specifically for this role.  The Quality Manager’s responsibilities usually don’t require a full-time position, so this shouldn’t break the bank.  In fact, it should pay for itself with the increased reimbursement your office will receive by improving your clinical outcomes.

What Does the Quality Manager Do?

With the oversight and direction of the physicians and with input from the staff members, the Quality Manager is responsible for the administration of the CQI program in the office.  These responsibilities include:

That Sounds Like a Lot of Hats!

Well, it’s not so much a lot of hats as it is a new kind of hat for most offices, and it doesn’t take as much time as it might seem once your CQI program is up and running.  The Quality Manager can delegate some of the tasks to other staff members to work on during down time or when physicians are out of the office. The Quality Manager role is key for transforming the practice of medicine in your office away from an episodic care model and to a model that focuses on the full spectrum of CQI, point-of-care, population management, care management, and financial performance. As I’ve said in previous posts, physicians need to be champions of these efforts, but office staff members can make an enormous difference in the effectiveness of your CQI program.  The Quality Manager is the glue that holds it all together!

Located in Dearborn, Michigan, Oakwood Accountable Care Organization, LLC is a collaboration between physicians andOakwood Healthcare Inc. that currently has over 1,000 physician members. Wellcentive’s solutions will help this organization address the clinical integration and population management requirements that have been established for ACOs.

“I knew they were the solution we’d been looking for,” said Dr. Mark Bustamante, the Oakwood ACO’s Chair of the Quality and Utilization Committee. “Wellcentive’s data aggregation technology will allow the Oakwood ACO to integrate multiple systems, including the several EMRs and Practice Management Systems used by our membership. The aggregated data from labs, pharmacies, and payers – combined with built-in HEDIS measures – will provide the Oakwood ACO’s physicians with the information they need to deliver more proactive, comprehensive, and collaborative patient care.”

Frank Murphy, Wellcentive CEO and Chairman of the Board, added, “Wellcentive’s Advance Outcomes Manager™ solution delivers the tools the Oakwood ACO needs to succeed with this important next step in their evolution as an organization. More and more organizations are seeking to become ACOs, and Wellcentive is poised to become the leading solution for ensuring their success.”

Wellcentive’s industry-leading data mining and reporting capabilities will also allow the Oakwood ACO to efficiently report to payers on performance metrics for their patient population. “By easily collecting all the required information, we will be able to better meet payer requirements,” Dr. Bustamante said.

Accountable Care Organizations are meeting the challenges of the shift in healthcare towards quality-focused payment models. Wellcentive is empowering this evolution by making coordinated, proactive care more efficient and cost-effective. “Wellcentive delivers what we need to meet our requirements, including clinical integration and comprehensive population health management,” concluded Dr. Bustamante. “We’re confident that we’ve found the right solution, and we look forward to a bright future with Wellcentive.”

A Matter of Motivation

One obvious difference between your ability to motivate physicians and to motivate staff members, is that the physicians generally run the show (please don’t show my office manager this post) and the staff members ultimately work for the physicians – even in an employed physician model.

One approach is to simply mandate staff cooperation with the CQI program, but it is probably better to get the staff on-board with the concept and empower them to participate.  Like physicians, most medical staff members generally like helping patients and making a difference, and my experience is that they appreciate the opportunity to become more proactively engaged with patient care.

Let’s spend a little time talking about the barriers perceived by staff members and some ways to effectively address them.

“I don’t have time”

This is probably the most common barrier to overcome, but a well-organized CQI program in a physician office can help a lot.

The Solution:  Create new processes that compliment existing workflows so your staff can efficiently and effectively participate with your CQI program.  For example, gaps in care can be addressed by front office staff when patients check in for appointments, by phone staff who take prescription refill requests or book appointments, by medical assistants when they bring patients to exam rooms, and by an office Quality Manager using population management and patient outreach efforts (more on the Quality Manager role in a future post).  Working together can really make a difference!

“I might make a mistake”

Many physician offices we encounter do not empower their staff members to work with any sort of autonomy.  But is clearing every single order with the physician efficient and practical?  I don’t think so.  If I had to micromanage everything about my practice I would be able to see about a dozen patients a day.  There just isn’t time.  With the proper policies, procedures, and directives in place, medical staff members can make a huge difference in the effectiveness of your CQI program.

The Solution:  Provide appropriate direction and empower your staff members to take action when action is needed!  For example, if you want your women patients 40 years and older to have an annual mammogram unless they have had bilateral mastectomies, then let your staff members take that directive and run with it.  When Mrs. Smith calls for her Losartan refill, and the phone staff member sees that the patient is due for a mammogram based on these criteria, then let your staff member book the mammogram.  You don’t need to personally authorize every order if you publish your directives using point-of-care decision support tools and empower your staff to take action.  Staff members generally get a lot of satisfaction from discharging that responsibility, especially when they are kept in the loop with monthly outcomes reporting for your office.  Let them see how their work translates into improved clinical quality!

“What’s in it for me?”

Physicians are being increasingly incented to deliver high-quality healthcare, so why shouldn’t your staff members be incented as well?  Your staff members are an important part of the office-based CQI program, and they will be more engaged if they realize some tangible reward for a job well-done.

The Solution:  Implement an office-wide CQI rewards program that is tightly linked to outcome measures that result in increased reimbursements for the office.  If certain outcomes are met, throw a party, give gift certificates, or hand out cold, hard, cash.  In my primary care network, we decided a few years ago that a percentage of the physician performance revenue the network receives (e.g., P4P) will be shared with the medical staff members.  This has elevated the importance of the CQI programs and increased staff member engagement.  These rewards foster a team-oriented approach to improving quality, which is in keeping with the care collaboration that is really necessary to do this right.

There are other barriers your staff members may perceive, but these are some of the most important.  Understanding the barriers and proactively addressing them can help get your staff members on board, so you can serve your patients to the best of your abilities.

Next Week’s Blog

I’ve been threatening for a few weeks now to discuss the role of the Quality Manager in an office-based CQI program, and I am going to make good on that promise next week.  Stay tuned!

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As I said in the first post in this series,

“Ambulatory clinical quality improvement programs need to be driven by physicians and their staff members if maximum improvements are to be seen.”

If physician engagement is so important, why are some physicians reluctant to actively participate with a CQI program? Physician naysayers are usually rather vocal on this topic (shocking, I know), so let’s discuss some of the most important barriers we encounter and how you can help your physicians see the light:

“I don’t need to change.”

We hear this a lot, and it is arguably the most difficult to address, because a transformation in thinking and care delivery is needed.  As I said last week, a successful CQI program has both point-of-care and population management components.  Many physicians think that because they nail the point-of-care part they don’t need to think about their patients as a population.  If you take great care of each patient at every encounter, then your patient panel must be in fine shape, right?  Wrong.

You don’t really know how your patient population is doing until you peel back the covers and really look.  When they see the data, most physicians are surprised that their outcomes aren’t better.

The Solution:  Show your physicians their outcomes!  Make them see where improvements can be made and how they stack up against their peers.

“I don’t trust the data.”

Of course, the first reaction a physician will have when you show him or her a suboptimal outcomes report is, “Well, obviously the data is wrong.”  End of story.  Done.  Finished.  Thanks for stopping by.

The Solution:  Before you have the conversation about outcomes, make sure the data used to produce the outcomes reports are accurate, up-to-date, and complete.  This requires software that can aggregate and normalize data from disparate systems and a proactive data management program, which usually involves the electronic receipt of Actionable Data from various clinical and administrative sources.  More on data management in future posts.

“I don’t have time.”

Let’s face it.  Physicians are busy!  There are ever increasing demands on our time, especially for non-clinical activities that don’t seem to benefit anyone (Don’t get me started!).  Asking physicians to do one more thing is a tall order.

The Solution:  Design your program to engage office staff members to help with the CQI process.  Staff members can ensure gaps in care are filled at every patient encounter, including simple prescription refill phone calls, using standard protocols “blessed” by the physician.  A Quality Manager can help lead the charge and organize the process, and this all means less work for the physician as well as improved outcomes!  More on this later.

There are other barriers, of course, like not wanting to use technology, staffing concerns, impending retirement, etc., and some of these will be addressed in future posts.

The argument for physician engagement with CQI programs is really quite compelling, so hopefully the information in this post and previous posts has helped you know a little more about how to get your physicians on the bus!

Next Week’s Blog

In next week’s post, I’ll tackle barriers to staff member engagement in CQI programs and talk about how these barriers can be overcome.