One way the Coleman DPI™ can reduce Emergency Room visits and help with Payment Reform
Frequent and unnecessary emergency department (ED/ER) visits are a major problem for patients, family budgets, national health care economics, and doctor’s offices which are trying to provide continuity of care for their patients. It’s not news that medical costs are at an all-time high in part due to a rise in the frequency of ED “misuse”. Now CMS (Centers for Medicare and Medicaid Services) has announced that Alternative Payment Methods for primary care providers is just around the corner. In this world of Pay for Performance and Value Based Payment, it is critical that primary care provider offices get out in front of ED (Emergency Department or Emergency Room ) utilization by patients. Those unnecessary ED visits can end up adding extra costs to the health care delivery system overall and will ultimately decrease the amount of quality incentive money provide to a primary care practice.
There are a variety of reasons that patients continue to use EDs for “non-emergent” needs–one of which is that patients with chronic conditions (whether insured or uninsured) are often uncertain about how to navigate the enigmatic waters of our health care system. Or conversely, they are all too familiar with the limited availability of clinic appointments and are accustomed to the long waits (upwards of two to four weeks) before they can see their primary care provider. In these cases, patients feel that they have limited options and choose to go to the local ER for more urgent but non-emergent needs.
Overall, the challenge lies in our systematic failure to adequately connect patients to primary care. It is possible to dramatically reduce ED visits by setting and implementing a well thought-out strategy–or a set of proven tactics tied to the overall strategy–to shift both a doctor’s office’s culture and their provider accessibility to reach the desired goal: increasing access to primary care services and preventive care in a timely manner.
The Rapid DPI™ Methodology & Training
The Coleman Rapid DPI™ (Dramatic Performance Improvement) method focuses on creating a model of processes and implementing recommendations that directly affect the patient flow such that patients feel welcome and cared for—almost instantaneously. This proven method is effective because it is based on the philosophy that changes are made more effectively on a watch, rather than on a calendar; that changes made in Real Time can yield dramatically improved, tangible results.
In order to decrease ED (also, commonly referred to as ER, or emergency room by non-health care providers) visit frequency, a clinic must focus on improving access, enhancing teamwork and communication among their staff, casting a vision to dramatically improve the patient experience and bridging the gaps between primary care and use of ED through outreach and inreach within the clinic (as well as outreach to the larger community). This is done through calculated steps towards connecting patients to primary care by employing the following techniques and best practices.
The lack of primary care appointments coupled with quick band-aid like fixes usually result in established systems that don’t accurately reflect patient demand and clinic capacity (See “Amp Up Patient Access“). Many Community Health Centers (and Safety Net Clinics) have high overall no-show rates (20-30%) and a wait for Third Next Available Appointment (or TNAA—a measure created by the Institute for Healthcare Improvement to gauge access) of greater than two weeks.
A high No Show rate may imply that a clinic can accommodate more patients because there is unused capacity (appointments) within the schedule. If the TNAA is greater than two weeks then many patients who judge themselves as having non-critical needs may just book an appointment over the phone (at two weeks out) rather than asserting a need. As a result they may end up in the ED before the scheduled appointment date. This lengthy wait for appointments doesn’t work best for patients and it doesn’t always serve them well. For example, if a diabetic patient calls today and wants to see their provider because they are wondering if they are experiencing adverse effects from Metformin then it will be about two weeks before they can see their doctor for this problem. They might find themselves going to the ED (increasing expense, increasing risk of confusion, and breaking continuity of care) versus waiting to see their primary care provider.
If there is a high No Show rate along with a long wait for future appointments, then clearly there is a discrepancy in capacity or a lack of ability to coordinate that capacity and demand. Why would the patient have to wait weeks for an appointment to see their doctor if there are patients who are not actually showing up to their scheduled appointments today?
A high No Show rate leads to a false sense of the office being overrun with patients (who are on the schedule) and leaves clinic staff feeling besieged by the schedule and running around through the chaos of over-bookings with mismatched demand and capacity. At the very same time, patients feel a lack of access to their doctor (or NP, PA) while administrators lament a paltry productivity rate.
Operationally, these slots that go unused are seldom offered to patients who have called or attempted to walk-in for an appointment because we don’t know until that time slot has passed that it will be unused. This can be addressed through better planning and eliminating confusing late policies. (See “Those Darn No Shows”)
The very first step in reducing ED visits is to improve access. In order to do so, the clinic must drive down their No Show rate as this reveals true capacity. Some clinics that have undergone a Coleman DPI have found success in reducing their No Show rate by implementing the following best practices:
Confirmation Calls: One of the main root causes of No Shows is that patients have little investment or connection to the clinic. The solution is to build better relationships with patients. An increased connection to the patient also sets the stage for stronger Care Coordination efforts. Robust Confirmation calls are more than just reminder calls—they are brief but well scripted calls to focus on building relationship with the patients and gleaning more information from them to help streamline their visit. (See “Amp Up Patient Access“). The more sophisticated the model of care, the more that Robust Confirmation calls are seen by the entire Patient Care Team as an opportunity to reach the patient and improve their health outcomes rather than just confirm a scheduled appointment.
Simplified Patient Scheduling: We often find that varying appointment slots types and lengths exist to compensate for deficiencies in the system (such as lack of teamwork or lengthy registration process for some types of visits) or to account for the fact that each patient’s need is unique. Yet average length of time face-to-face with a provider is known and can be used as an appointment slot estimate. Simplified Patient Scheduling is a Coleman concept of reorganizing the schedule to make it less time consuming and less rule intensive for schedulers to book a patient (rather than hunting in the future for a particular “type” of appointment) and opens up more available appointments. (See “Simplified Patient Scheduling”)
Jockey-ing the Schedule: One of the barriers to access is that often the schedule is seen as static—which doesn’t reflect the moment-by-moment changes that happen in the clinic. Jockey-ing the schedule essentially means riding the schedule actively, dynamically, to make it match reality and all the while thinking preemptively. This includes anticipating changes in the schedule in order to maximize available capacity and resources to match the ever changing patient needs.
Raking Forward: A strategic way to avoid missed opportunities and maximize capacity is to deliberately look ahead as a team and identify patients in the schedule to “rake them forward” or call to offer an appointment as the schedule opens up. Incidentally, this works well with the best practice of scrubbing the schedule—a process that entails looking at the schedule in advance and identifying patients (while employing critical thinking and discernment) who may not need or will not show up for this appointment.
One reason these access improvements can fail when implemented in isolation is that when access is initially opened (using Simplified Patient Scheduling, No Show Reduction, etc., ), patients do show up for their appointments causing a sudden overload in the back of the clinic. This causes some staff to interpret this as “an unsolvable problem” in the world of public health, which is simply not accurate. The following best practices must be implemented concurrently with No Show reduction to provide the necessary cushion for the opening of the “floodgates.”
Huddles: A huddle at the beginning of each clinic session means that the members of the patient care team gather together in an exam room with the EMR (Electronic Medical Record) and the schedule in order to talk through each patient before they get here. The goal is to bring each patient to life momentarily so that the team can mentally engage and can—as a group—anticipate and strategize as much as possible to help the visit run efficiently. (See “The Patient Care Team Huddle“)
Quick Start: Quick Start is a Coleman Technique of ensuring a crisp start to the clinic session. If patient and provider are in the exam room at the time of the first appointment, it means everyone has a much better chance of going to lunch on time and finishing the day on time. (See our “Quickstart Tool“)
Team Dance: Patient care team members—which can include: the MA, RN, provider, front office clerk, call center representative, social worker, biller, etc. —communicate directly and urgently, focusing on the patients who are in the clinic. With a deliberate set of team dance “steps” they can work together in a beautifully choreographed clinic session: staff work synchronously and not linearly, checking in with each other throughout the patient visit to streamline workflow. (See “Do the Team Dance”)
Robust Patient Care Teams: Once you have begun honing enhanced teamwork and communication, the next step is to concretize a consistent patient care team. A team-based care delivery model is ideal when it comes to care management and coordination. As patients begin to feel connected to their patient care teams and feel like a member of their care team, they are more apt to follow up and be compliant (a common complaint of providers of public health patients). Patients who are part of their own patient care team are also more likely to seek out their healthcare provider team first with any problems or concerns rather than opt for the ED.
Use the RN Tactically: RNs can be the ultimate team players. Integrating Tactical Nurses strategically into teams can enhance patient care as RNs are trained to be holistic, highly skilled health care providers—not just an extra set of hands for a physician (or other provider) to offload tasks—and are therefore catalysts for preventative care. (See “Are You a Tactical Nurse?”)
Improving the Patient Experience
Due to competing priorities of protocols, policies and day-to-day tasks, the patient can sometimes get lost in the shuffle of paperwork and rules. It has been said that the first impression is the most important—unless a drastically different secondary experience says otherwise. As Community Health Care (CHC) professionals, we must admit that patients don’t often have the best experience when they come to our clinics. While we don’t have control over the un-pleasantries of a required procedure or a diagnosis, we can positively affect the patient experience even before they walk through the clinic doors.
Positive and Streamlined Registration Process: Patients are sometimes told to come in 15 or 30 minutes before their actual appointment time to fill out paperwork, yet the provider is not ready to see them until 15 to 30 minutes after their actual appointment time. This is a patient dis-satisfier, a time waste for everyone. Office staff can make the registration process less tedious by checking eligibility and/or calling patients a day or two before their appointment to complete most of the registration over the phone at the patient’s convenience. This can be done in conjunction with Robust Confirmation Calls. If most of the eligibility is done prior to the appointment time, then patients can be “expressed” through the line and checked in as soon as they arrive resulting in less time wasted and providing patients with the feeling that we are organized and prepared for them.
Enhancing Patient Experience with Staff by Creating a Customer-Service Friendly Environment: As clinics go through a Coleman Rapid DPI, the intense focus on the patient means an improved patient experience which indirectly leads to improved staff morale and job satisfaction. The culture shift that ensures more specific customer service (such as Red Carpeting the patient: walking up to patients in the lobby rather than announcing their name loudly in the waiting room) makes a distinct difference for the patient.
Don’t Move the Patient: We recommend that the staff move towards the patient versus moving the patient for staff convenience. Essentially, the exam room then becomes the patient “home” for the entirety of the visit. While there are a few exceptions to the rule (like a patient who needs a stat X-ray) ideally, the only time the patient leaves the room is after they are checked out.
Empowering Staff: Research suggests that increased productivity and a healthier work environment are largely dependent on empowering employees and boosting morale. By implementing a clear set of protocols/best practice guidelines based on your new model, by engineering open communication with frequent check-ins and by developing a culture of trust between management and staff, you can ensure that staff understand their roles and the new model clearly. Staff who are satisfied in their work roles and are functioning at the top of their license tend to be more productive and positive at work and less likely to use up their sick time for “mental health days”. (Source “The High Cost of Low Morale”)
Reducing Wait Times as Part of the Patient Experience
No one likes to wait a long time. Human beings become impatient easily…think of the last time you had to wait a couple of seconds for the car in front of you to go after the traffic light turned green. Part of improving the patient experience is confronting our expectation that it’s ok for patients to wait a long time (possibly more than an hour) before they see their provider. The following best practices are recommended to affect cycle times and patient wait times by streamlining patient flow:
Prepare for the Expected: This Coleman principle involves a very deliberate look ahead at the schedule and preparing for the visit (See Chart Prep Tool—with the intent of anticipating by reviewing labs, imaging results, looking through health maintenance needs, etc. Robust preparation for the visit also means Robust Confirmation Calls the day before the visit and huddling at the beginning of each clinic session with the patient care team, reviewing the schedule for the day, and exchanging information between all members of the team about each patient.
Communicate Directly: Lack of urgency and unclear communication often result in a disorganized day for staff which leads to frustration and re-work. Engineer into the work processes more direct communication between the Front Office and the Back Office, and between all members of the patient care team.
Get All the Tools You Need: If staff members do not have what they need to do their jobs effectively (enough BP cuffs, thermometers, pap lights, etc.) then it’s likely that they will spend precious time hunting for it, and that is not the best use of staff time which is already so tight.
Advocating for the Patient
In the primary care world, a patient’s visit is valuable time for healthcare providers to make sure that patients are well educated about their medications, their disease process, and what referrals or follow ups they may need. However, advocating for the patient not only means teaching/sharing with the patient but also entails discerning appropriate timing on addressing what is the highest priority for the patient and what is necessary to discuss during the visit versus focus on covering what’s on our agenda. It’s a fine line to walk.
According to a New York Times blog post (See “Avoiding Emergency Rooms”), a study of emergency department use done by the California Healthcare Foundation found that 46% of problems reported by patients who had insurance coverage could have been addressed by their primary care physicians. So then, why do patients check in to the ED most of the time? It’s quick and easy. There are long wait times, yes, but less “jumping through hoops.” They can be seen for the exact thing that brought them into the ED. So if a patient comes into the clinic and simply wants an inhaler because they are experiencing shortness of breath, then it might not be the time to lecture them about medication compliance. Members of the patient care teams should primarily focus on building relationships with the patients and from that foundation gauge when to divulge into in-depth conversations about health and wellness.
Bridging the Gaps
Connecting patients to primary care is not simply about referring them to a clinic and available services—it’s also about meeting them where they are in their own health improvement and determining their needs. This is what Value Based Payment has been created to reward. It’s a pursuit of a different kind of relationship. It’s about a focused investment in the patient. With this approach, the patient is empowered, well informed and more likely to participate in managing their health.
Providing More Robust Patient Education That Involves the Patient Care Team and the Patient: When new patients call the clinic or walk-in, utilize the MA/RN to educate patients about services offered at the clinic specific to their diagnosis or chief complaint. Develop scripting aimed to assess and educate patients about relevant issues regarding their healthcare. In our culture, where trust often needs to be earned before individuals decide to accept any new information, a good rule of thumb for staff is to always gauge the readiness of the patient.
Community Outreach: Patient Care Teams (PCTs) no longer have to be confined within the clinic walls. Alternative Payment Models reward clinics for providing care in ways that meet the patients needs abandoning the dependence on clinic visits and the fee for service model. Clinics can partner with local community centers—like churches and schools—with the intent to connect or reconnect their immediate patient population to primary medical providers (See “The Hot Spotters: Can we lower medical costs by giving the neediest patients better care?”) These are effective ways to (a) encounter patients who aren’t connected to a clinic and would otherwise visit the local ED and (b) a way to build up patient panels and increase overall visit numbers. PCTs can offer classes and health screenings specific to what the community needs.
Inreach: Inreach (often used interchangeably with outreach) is an active promotion of services available to patients who already have access to health care. It is an effective strategy to discover and bridge gaps in care with patients that are in the current provider panel. Partnered with Coleman Scrubbing the Schedule and Chart Prep Techniques (See Tools Section) before the visit, inreach can enhance efforts in cancer screening, health improvement initiatives and other preventative measures to improve clinical outcomes.
Connecting to the Local ED: Patients usually do not follow up with their provider post ED visits in a timely manner for various reasons. Maybe they don’t know where to go for a follow up, their immediate need is now passed, or they simply forget. Sometimes, if they do call to schedule a follow up visit, they are unable to get an appointment within the recommended few days so they choose not to spend their time and resources to follow up.
Developing relationships with local hospitals and emergency departments can help clinics get information quicker about patients and can serve as an added safety net for those who may otherwise slip through the cracks. This active and personal connection when partnered with a more established means of communication between the clinic and the ED can be effective. In some clinics this is done electronically, with a rounding point person.
Under the tenants of the Affordable Care Act, the Health Insurance Marketplaces that have opened up and Medicaid expansion in many states—millions of people who were previously uninsured will gain coverage to care. This is an unprecedented opportunity for Community Health Centers (CHCs) to become medical homes for millions of patients who may for the first time have reimbursement attached to those visits (Source www.hhs.gov/healthcare). With this impending reality—and in the name of preventative care and continuity—CHC’s must assess how they are able to accommodate a potential influx of patients while seeking to attract patients to the clinic instead of the more costly ED for their medical needs.
Similar to newly diagnosed diabetic patients who are faced with the advice to submit to rigorous exercise, diet and medication regimen to control their blood sugar, it takes acceptance, commitment, and diligence on the part of a clinic to institute change that will make the difference in improved results. Winston Churchill once said, “To improve is to change; to be perfect is to change often.”
Redesigning a clinic system is similar to remodeling a house; producing results requires getting it down to the bare structure, then rebuilding it. It’s a process that takes an investment of time and energy (and often outside advice and support), and acceptance of a little bit of chaos in the pursuit of something much better. It’s why it’s called home improvement. An essential aspect of an effective Coleman DPI™ initiative (See “Dramatic Performance Improvement”) is that each recommendation is made with the intention of building upon the last in order to create a seamless, thoughtfully coordinated new model of seeing patients. The Coleman model of redesigning clinic systems comes from our ethos that we partner one clinic at a time for the benefit of improving health care for everyone.