Upending the Visit Paradigm: A Synopsis of our 2017 Spring Forum
“When you divorce providers from fee-for-service as a revenue stream, all kinds of exciting things can happen.” That blue-sky vision from Commonwealth Care Alliance Chief Medical Officer Toyin Ajayi, MD, MPhil, struck the keynote for this year’s WHCM “hot topic” Spring Forum panel presentation. Dr. Ajayi was speaking to this year’s panel topic, “Upending the Visit Paradigm: Bringing Care to the Patient.” Held at the end of March, the panel presentation also featured Alexis Bernstein, Wellframe’s Senior Director for Client Services, and Rebecca Bialecki, BSN, Ph.D., Vice President for Community Health and Chief Change Agent at Heywood Healthcare. Alexandra Schweitzer, a healthcare consultant with diverse experience building innovative care delivery models, moderated the discussion, which highlighted initiatives to expand care outside the traditional office setting.
The discussion kicked off with panelists identifying their motivation for innovating ways to deliver care to patients where they live. For Toyin and CCA, it’s about doing more for patients who need more frequent touches, while for Rebecca and Heywood Healthcare, it’s about bringing specialty care to patients in isolated rural communities. Alexis and Wellframe are looking to keep patients connected with care between visits. Heywood Health’s service area is about as rural as Massachusetts gets, so it’s hard to connect patients with care if it means getting each patient to where the care is. True to her title of Chief Change Agent, Rebecca found different route through telemedicine.
Heywood began by creating one of the first teleneurology services, providing access to a scarce but much needed specialty resource by building on their tele-stroke experience, which connected their care teams with physicians at Mayo Clinic via remote consultation. That success led to Heywood’s recent telepsych service for children. The service initially links behavioral health providers with families via a telehealth connection, and then sends out nurses to provide follow-up home visits. The model has enabled children with more acute mental health needs to get stabilized at home and avoid hospitalization. Heywood has seen gratifying results, with kids able to stay well with less psychiatric medication, and a decrease in hospital admissions. The resulting improvement in the hospital’s Leapfrog score will eventually mean better payment.
At Wellframe, care managers reach out to patients between visits, focusing on transitional or other vulnerable times. At each touch the care manager works on a small piece of the care plan with the patient, making the information more manageable for patients, many having multiple medical conditions. Through this highly efficient “mobile amplification” of care management, more patients are able to stay connected to care. Wellframe has demonstrated an ability to reduce no-shows for the critical post-hospital-discharge visit, as well as to boost medication and care plan adherence.
At CCA, Toyin and the team are developing ways to measure value when bringing care to highly vulnerable patients at home or in other new alternatives sites. When a provider organization leaves “transactional” care — and is no longer relying on the usual tallies of admissions, procedures, etc. – how will the providers know if they are getting the behaviors they want? Rather than measuring the absence of poor outcomes, CCA has been working on measuring the positive. Instead of counting hospital admissions, for example, measure days at home. Toyin and her team caution that it takes 18-24 months to see the benefits of increased investments in primary and behavioral health care through new models, but patience pays off, as costs are definitely reduced.
After our panelists had unpacked their organizations’ experiences, the question-and-answer session yielded a few gems for successful implementation of initiatives to expand care beyond traditional delivery settings:
- Make believers by sharing stories – providers engage peers in the excitement of patient successes.
- Expect glitches – technology is great at enabling care, but computers can go down!
- Better to go all in. Pilot projects can undermine adoption, because reluctant adopters think that if they wait long enough, the disruption to business as usual will go away. Instead, communicate that “this is now how we do our work.”
- Work with policy makers and payers to advocate for payment parity to support innovative delivery.
- Go to the patient to gain insight on what works – patients tend to show high engagement with these new “visit” paradigms.
- At the end of the day, we’re trying new things because we want to bring better care to people. Find common ground where it matters.
Blog post by WHCM Steering Committee Member Emily Brower