September 27, 2017 | Written by: Judy Murphy
Categorized: Blog Post | Value-Based Care
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Judy Murphy is the Chief Nursing Officer at IBM Global Healthcare.
At its core, patient-centered care is a straightforward concept: healthcare providers are positioned to drive outcomes if they provide care that is respectful of, and responsive to, individual patient preferences, needs and values. When balanced against the realities of healthcare economics, however, consistently delivering tailored care specific to each individual patient becomes a bit more challenging.
That’s where technology comes in. While it is simply not sustainable – or even advisable – for each provider in a healthcare organization to take a completely customized approach to each patient, it is possible to leverage today’s analytics and automation technologies to take a systematized approach to putting the individual patient at the center of all healthcare decisions.
Take, for example, the patient-centered medical home (PCMH) care delivery model, designed around patient-centered care. Following this approach, all patient care is coordinated through a multi-disciplinary clinical care team, where the primary care physician acts as a sort of team quarterback for the patient’s overall health and wellbeing. The approach has become a centerpiece of the value-based care movement through its inclusion in the Medicare Access and CHIP Reauthorization Act (MACRA), which is incentivizing primary care physicians to adopt the medical home model.
As more primary care providers implement the medical home approach, many of the challenges and recipes for success have begun to emerge, serving as a roadmap to success.
Building Blocks – Locking Down Annual Medicare Wellness Visits
One of the central building blocks of the PCMH model is the Medicare Annual Wellness Visit, which allows the clinical care team to gain information about each patient, including medical and family history, health risks, and specific health outcomes and goals. The purpose of the visit is to assess physical, emotional, and psychological risk factors with an eye toward developing a personalized health and prevention plan. The Center for Medicare & Medicaid Services provides significant reimbursement to physicians who provide these types of wellness visits.
While this may seem like a simple enough process to implement, it actually requires a fundamental shift in behavior among both physicians and their patients. That was the challenge faced by The Polyclinic, a physician-owned and operated multi-specialty clinic with 15 locations throughout the greater Seattle Area. A pioneer in value-based care, The Polyclinic was the first Medicare Shared Savings Program (MSSP) participant in the state of Washington. Despite their commitment to accountable care, the organization struggled initially to ensure all of their patients came in for Annual Wellness Visits.
The primary obstacles were twofold: 1) many of The Polyclinic’s providers were not well-informed regarding Annual Wellness Visit eligibility, protocols, and benefits, and thus were unable to communicate the value of these visits to patients, and 2) many patients who were encouraged to come in for the visits were either ill or too physically fragile to physically come into the office for assessment.
The solution to both came in the form of technology designed to automate and enhance eligible patient selection, outreach, and data analysis. Deploying a centralized, web-based suite of IBM Watson Health Population Health Management tools, The Polyclinic was able to generate the hard data it needed to improve patient outreach and systematize the communications process to improve overall patient engagement. Specifically, The Polyclinic created eligible patient cohorts among its entire patient population, deployed personalized notifications for those eligible patients, created scripting for providers and staff to ensure consistent pre-visit education, and analyzed data for potential gaps in care based on evidence-based guidelines.
In 2015, just six weeks after rolling this program out across a pilot group of six providers, The Polyclinic scheduled more than 400 Annual Wellness Visits –surpassing the total number of wellness visits conducted during the entire prior year. The Polyclinic ended 2015 with 2,622 Annual Wellness Visits. By the end of 2016, just one year after implementing the technology for primary care providers, The Polyclinic had completed approximately Visits, realizing a $1.3 million increase in associated revenue.
Toward the Future of Patient-Centric Healthcare
The Polyclinic is not alone in the discovery that the right technology can help dramatically improve patient engagement as part of building a PCMH practice. The Bassett Healthcare Network, for example, adopted a similar set of technologies to aid in its pursuit of National Committee for Quality Assurance (NCQA) PCMH Recognition renewal. Focused specifically on spotting and addressing gaps in care, Bassett targeted its outreach and engagement campaign on non-compliant chronic patients, ultimately helping physicians continually achieve mid-to-upper 90 percent booking ratios among target patients.
As more primary care practices continue to fine tune these technologies to improve both targeting and active communication with patients, the central promise of value-based care – to balance delivering the best possible outcomes at the lowest possible cost – is coming into focus. With the right technology to assist, physicians and clinical care teams do not need to commit to high-risk treasure hunts to find that elusive balance between providing more personalized and more cost-efficient care. They need the right tools for the job.