The South Texas Physicians Alliance (STPA) in the lower Rio Grande Valley is working to improve communications between medical groups and social service agencies to better meet the needs of its patient population, which has among the highest rates of poverty and unemployment in the state.
One of the counties in its region, Willacy County, has the highest poverty rate in the state of Texas with 38 percent of the residents living in poverty. It also has the second highest child poverty rate at 45.9 percent. And its unemployment rate is at 13 percent.
The region’s high poverty rate contributes to a lack of financial resources for medication, food, reliable transportation and access to specialty care, said Sheila Magoon, M.D., director of STPA, which has approximately 100 physicians.
With a goal of eliminating the fax machine from its operations, last year STPA began working with a company called LeadingReach that offers a tech platform that helps organizations manage transitions of care, including referrals between primary care and specialist offices as well as referrals to social service agencies. Its web-based platform offers clinical workflow management tools, secure team-based chat, and clinical document exchange.
So far, STPA has connected to more than 50 organizations and done more than 5,000 transitions of care.
“As we began doing care coordination, we realized there are some significant inefficiencies in this whole referral process. And that's leading to these gaps in care that we've not been able to close,” Magoon said. “We identified LeadingReach as an opportunity for us to utilize this platform to connect our physicians, so we can track the patient through the referral process. This way, both sending providers as well as the receiving provider can get that full transparency and accountability.”
“We started with two practices, a primary care group and a cardiology group,” Magoon explained. “The cardiology group has 60 percent of their referrals from this large primary care group, so that was a way for us to learn how to use the program. It took a couple of months to work through those workflow processes. Once they got their workflows down, they were able to improve their efficiencies and reduce frustrations due to lost faxes. After that point, we really started pushing it out to the rest of our network, and have been working to connect other medical providers and social service agencies that are outside of our network. That way, we can maintain the referral patterns of our providers.”
Magoon said that sometime STPA’s care coordinators used to send somebody to a local social service agency, but the patient would come back and say no one had talked to them. “Now by connecting that social service agency, the agency lets us know when they set the appointment to contact the patient,” Magoon said. “Then they also follow up with us regarding the outcome. That has been tremendous, because now we're closing those loops. And now we know that they were able to get medication assistance, or able to get a provider in the home or whatever those particular needs are that we are looking to get addressed.”
Although they are beginning with linking to other physicians, hospitals, and pharmacists, Magoon said she thinks it's important to connect more than just traditional healthcare providers. “There are components of the community that touch and engage our patients’ lives that are going to be key stakeholders. These are the people that make up that community, which could include our fire departments, or EMS or social service agencies, grocery stores, or schools or faith-based organizations, nonprofits, daycares, so we're looking at being able to build a much broader network.”
Curtis Gattis, co-founder and CEO of Austin-based LeadingReach, said its mission is to provide accountability in healthcare, and particularly around the transition of care and improving communication and care coordination. “The mission for us here at LeadingReach is really to kill the fax machine. That's what ultimately, we believe it empowers folks like Dr. Magoon to fulfill their mission of geting patients the care that they need in a timely manner, in the appropriate setting.”
“When you start with the fax, it goes into that proverbial black hole, and very, very few times does that loop get closed appropriately, and you have very little visibility into the process,” Gattis said. “We have found that by really homing in on value-based care initiatives, we're able to hold the specialty networks accountable to a higher level of service to the primary care providers and their patients, and that really does lead to better outcomes, lower costs and higher quality of care. So we are very much focused on empowering value-based care providers across the country with a digital backbone to replace the fax machine and really put that accountability in that transition of care.”
STPA recently initiated a readmission reduction pilot project involving LeadingReach. “Upon hospital discharge a referral goes to our primary care physician or care transitions nurse and a local community paramedic program that we're working with. That way everybody can follow this patient for the next 30 days. We're anticipating the high-touch care coordination with transparent communications is going to be able to help us reduce our overall readmissions.”
STPA is looking at how it can use the communication platform to improve its value-based care arrangements. “We're having frustrations with the case management team at one of the payers,” Magoon said. “We’re thinking about how we could get their case management team on LeadingReach, so we don't have these communication gaps. I think there are huge opportunities to build out other kinds of programs. For instance, with the community paramedic program we work with, how can we improve this communication? How can we build other community-based models to use all those community resources in a more effective way for dealing with those social determinants of health? We're exploring a variety of different things, because it's time for us to truly think outside the box and no longer be held to the normal constraints that we are in.”
