Using Patient Registries and Evidence-Based Guidelines to Overcome Declining Visit Trends
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Using Patient Registries and Evidence-Based Guidelines to Overcome Declining Visit Trends
- 1. Using Patient Registries and Evidence-Based Guidelines to Overcome Declining Visit Trends Steve Hatkin Chief Financial Officer Mankato Clinic
- 2. Presentation Objectives Understand the importance of effective care coordination in improving patient compliance and outcomes Identify gaps in patient care using registries and evidence-based guidelines Improve profitability while achieving key aspects of population health management
- 3. Agenda About Mankato Clinic Improving Quality Patients are not receiving recommended care Optimizing the physician-patient relationship Implementing Proactive Patient Outreach Engaging patients for recommended care Improved compliance to evidence-based guidelines Impact on Revenue / ROI Summary
- 4. OverviewAbout Mankato Clinic One of Minnesota's largest physician owned, multi-specialty regional group practices and represents the most comprehensive array of high-quality, professional health-care services in the area. 121 providers Multi-specialty 10 locations
- 6. OverviewMankato Clinic Excellence 2010 Minnesota Bridges to Excellence award winner by the Buyers Health Care Action Group (BHCAG) Three-year term of accreditation in Ultrasound as the result of a recent survey by the American College of Radiology (ACR). Mankato DIAMOND participant (Depression Improvement Across Minnesota), is a new model for treating patients with depression in primary care by taking a team approach. It was developed in 2008 by the Institute of Clinical Systems Improvement (ICSI)
- 7. Background:Patients Are Not Receiving Recommended Care New England Journal found only 45% of patients are compliant following their physician’s care guidelines RAND researchers found that patients received 55% of the recommended care. Patients with asthma received about 67% of the care recommended for routine management and only 48% when their condition worsened McGlynn et al “The Quality of Health Care Delivered to Adults in the United States” NEJM June 26, 2003 Health Study by the RAND Corporation (supported by the Robert Wood Johnson Foundation and the Veterans Affairs Health Administration);
- 8. McGlynn et al “The Quality of Health Care Delivered to Adults in the United States” NEJM June 26, 2003 Background:Patients Are Not Receiving Recommended Care
- 9. Research:Quality of Preventive Care for DiabetesEffects of Visit Frequency and Competing Demands Patients with low frequency office visits receive substandard preventive care for diabetes Patients with more frequent visits for low priority illnesses are also likely to receive substandard care because the doctors attention is being spent on that care rather than the quality care for their diabetes. Fenton et al “Quality of Preventive Care for Diabetes: Effects of visit Frequency and Competing Demands” Annals of Family Medicine, Jan/Feb 2006
- 10. Research:Missed Appointments and Poor Glycemic ControlAn Opportunity to Identify High-Risk Diabetic Patients Analyzed 84,040 patients that had specific criteria, one outpatient visit, continuous enrollment, medical drug plan, and at least 1 A1C test, using these for the study. Concluded that those patients who frequently miss appointments for diabetes care had substantially poorer glycemic control From the Division of Research, Kaiser Permanente, Oakland, California.2004 Andrew J. Karter, PhD, The Division of Research, Kaiser Permanente,
- 11. Research:The Effect of Advanced Access Implementation on Quality of Diabetes Care Just providing access to diabetics, any physician and convenient locations did not improve diabetes care. What did improve diabetes care was continuity of care, coming into the office for the visits and being seen by their physician. The study used a composite of measures for outcomes. The Effect of Advanced Access Implementation on Quality of Diabetes Care; Dr. JoAnnSperl-Hillen, MD, et all; January 2008
- 12. Solution:Improving Quality Through Automated Outreach Identify Patients that Need Recommended Care Motivate Patients to Reconnect with their Providers Improving Health and Outcomes
- 13. Implementing Automated Outreach Proactive Protocols Across Several Key Areas Asthma Diabetes High Cholesterol Hypertension Wellness
- 14. Primary Care Protocol Set* Appointment Reminders/Missed Appointment F/U Prevention/Screening: Annual Preventive Medicine Visits Breast Cancer Cervical Cancer Immunizations: Influenza Pneumonia HPV Mammography Osteoporosis Prostate Cancer Welcome to Medicare Visits Disease Management: Congestive Heart Failure: F/U Visit Frequency ACE/ARB/Beta Blocker Therapy † Coronary Artery Disease: F/U Visit Frequency Anti-platelet Therapy † ________________________________________ *Provided all data-points currently coded. † PQRI CPT II Coding Required ‡ Non-PMS data point(s) required. Diabetes: F/U Visit Frequency Hemoglobin A1c Frequency † Hemoglobin A1c Level Control ‡ Hyperlipidemia: F/U Visit Frequency LDL-C Frequency † LDL-C Level Control ‡ Hypertension: F/U Visit Frequency Systolic/Diastolic Frequency † Systolic/Diastolic Level Control ‡ Asthma: F/U Visit Frequency Appropriate Pharmacologic Therapy † Thyroid Disease F/U Visit Frequency COPD F/U Visit Frequency Practice Development Campaigns: Back to School Physical Examinations Travel Examinations Childhood Immunizations New Providers/Services
- 15. Methodology Overview Two Analyses Histograms of patient response to Outreach Calls Measured speed with which patients scheduled billed E&M visits following Phytel Outreach communications. Monthly trends of E&M visits for Outreach subscribers. January 2008 to August 2010.
- 16. Patients Respond Fast to Outreach In the 90-day Histogram, 27% of patients responded within 5 days of the call and 50% within 15 days. Trend line indicates patients respond quickly to Phytel Outreach by scheduling and then having E&M visits directly related to the call reason.
- 17. Outreach Motivates Patients to Reconnect With Their Providers Patients additionally respond by scheduling visits where the billing reason is different than the call reason. Trend lines also indicate a fast response for these visits, indicating that Phytel is motivating patients to re-engage with their providers.
- 18. Outpatient Visits and Primary Care Physicians In August 2009, Mankato transitioned to a hospitalist model. Formerly, Mankato PCPs spent an hour each day seeing patients in the hospital. Following the change, PCPs had an additional hour each day available for outpatient visits.
- 19. Outreach Response Improves E&M Trends Green bar is start of Phytel Outreach. E&M visits increase by 22% afterward. Red bar is start of the initiative to add an extra hour of office visit time. E&M trends increase significantly after the implementation of Phytel Outreach.
- 20. Summary Outreach is in alignment with our quality initiatives Relatively effortless implementation Immediate impact on patients in need of care Very quick win with a near term ROI
- 21. Questions?
Notas del editor
- There is solid and convincing evidence in numerous well received studies that quantify the occurrence of patients not receiving recommended care between 45% and 55%! Even at the low end of the range it represents a potentially enormous problem in terms of outcomes based health improvement initiatives and evaluation of such based on population health methodology, or looked at another way – an enormous opportunity to reach out and engage patients to book appointments to get the care that has been recommended to them.
- In the next four slides, we’ll be reviewing outcomes generated by the Outreach program.There are really two fundamental questions we’re concerned with:Is Outreach driving a patient response?If so, does that response affect our visit volumes for our providers who utilize the Outreach product.To better understand the patient response to Outreach, we used histograms.We analyzed monthly E&M visit volumes to get at the second question.
- This is the first of two histogram slides. It measures how quickly patients respond to Outreach calls by scheduling visits that are billed with codes that are directly related to the call reason. For example, if a patient is called because he or she is in need of treatment related to diabetes, the patient has a visit billed with an ICD-9 code for diabetes. If there were no response to the Outreach calls, patients would be as likely to have a visit 90 days after the call than they are at 5 days. Their response would look something like the dotted red line, which is flat over the entire time period. Instead, there’s a large volume of appointments booked right after the Outreach call. This histogram measures patient response over a 90-day period. Within 5 days of the call, 27% of the patients book an appointment. That number jumps to almost 50% at 15 days. This means that of all the patients who scheduled an appointment directly related to the call reason within 90 days of the call, 50% of them did so within 15 days. When you turn on the Outreach product, patients will start calling your office to schedule appointments.
- This second histogram measures patient response where the visit is ultimately billed for a code that is different than the call reason. For example, the patient was called for hypertension, but instead had a visit related to some other reason. While the patient response is not as pronounced as it is for visits that are directly related to the call reason, there’s still a downward slope. The act of generating a targeted phone call to a patient population drives a residual response as well as a direct response. The main point of the histogram slides is that Outreach is going to both bring patients back into the office for reasons directly related to the call, and drive a residual effect in which patients are motivated to simply reconnect with their physician.
- [Good place for Steve to add insights into how Mankato operationalized the extra hour of office visit time for PCPs]
- This slide trends monthly E&M visits between January of 2008 and August of 2010 for Mankato providers who subscribe to Phytel Outreach.The red bar indicates the time when the initiative to add an extra hour of office visit time for Mankato PCPs went live. There is an uptick in office visits from August to September, but the most significant change happens after Outreach went live. The average monthly visits in the period from January to August 2010 is 22% higher than the average from August to December 2009. Notice the big increase in office visits in the spring of 2009. That was the result of the H1N1 pandemic. We actually had to call patients to tell them to stay home. Even with that spike, the average monthly E&M visits in the January to August 2010 time period – the time after Outreach went live – are still 14% higher than the same time period in 2009. And they’re 22% higher than the same time period in 2008. This is to say that from our experience there are two pieces to increasing visit capacity. First, operational processes need to support the goal of seeing more patients – Mankato addressed this through the initiative to add an extra hour of office visit time for PCPs. And next, a program to proactively bring patients in need of care into the office is important to filling that capacity.