We at Healthcare Innovation were once again thrilled with the outstanding quality of submissions we received from innovating patient care organizations across the U.S. In addition to the four winning teams this year, our editorial staff also selected six organizations as semifinalists. Below are descriptions of these teams’ initiatives, written by the project leaders themselves.
University of Colorado, School of Medicine’s Project CORE
The use of subspecialty medical services has risen rapidly, with referrals to specialists more than doubling. Along with increasing referral rates, the quality of communication and coordination between primary care providers and specialists has decreased over time. As such, patients are faced with poor access to specialists, high costs, and fragmented care.
To combat this challenge, the University of Colorado, School of Medicine, implemented Project CORE, which aims to enhance communication and coordination between primary care physicians (PCPs) and specialty physicians.
The CORE model uses tools embedded in the electronic medical record (EMR) system, known as enhanced referrals and eConsults, that provide point-of-care decision support. The first part of the intervention is the enhancement of the traditional referral process.
An enhanced referral provides point-of-care decision support for the referring provider through the use of condition- and specialty-specific templates within the EMR. These templates convey pre-consultation guidance from specialists at the point of referral, which streamlines the transmission of the clinical question and key diagnostic data. This process maximizes the effectiveness of the first specialty visit, thus preventing unnecessary follow-up visits for reviewing diagnostic tests.
eConsults are asynchronous exchanges initiated by a PCP between that provider and a specialist colleague. In lieu of an in-person visit, a specialist responds through the EMR to a PCP’s inquiry. eConsults are responded to within 72 hours, and these exchanges use structured templates within the EMR to create a point-of-care pathway that facilitates high-quality coordination and communication between providers.
Since the organization went live with Project CORE in April 2018, with two specialties, it has added four to six specialties to the project every quarter, with a goal of having more than 30 specialties live with the project by the summer of 2020. Through October 2019, more than 2,000 eConsults have been sent, with 76 percent of them having been answered by the specialist. Sixteen percent have been converted to an in-person visit, and 8 percent have been declined due to the question being unclear or other logistical issues. And, more than 20,000 referrals have been placed using the enhanced referral workflow.
Kaiser Permanente Southern California’s Home-Based Cardiac Rehab Program
Cardiac rehab includes a prescribed exercise regimen, counseling, health education, and behavioral and lifestyle risk reduction techniques. Historically, there are two types of cardiac rehabilitation programs: paper-based, in-home cardiac rehab, where patients are required to use paper and pen to track exercise regimens; and in-person, site-based cardiac rehab. These traditional programs are inconvenient and a bit archaic, so the goal at Kaiser Permanente (KP) Southern California was to develop a solution that would make cardiac rehabilitation fit more seamlessly into patients’ lives, while improving clinical outcomes.
As such, the KP Southern California team implemented a technology-assisted, home-based cardiac rehab program that allows patients to complete the program at home and track exercise using a wearable from Samsung. Patients with a clinical indication for cardiac rehabilitation are referred via the provider’s electronic health record (EHR), and a case manager provides coaching and support to help members navigate through the 36-session, eight-week program.
The first appointment is made face-to-face to begin establishing a bond, and in the subsequent seven weeks, the same case manager, who has access to all the wearable data, conducts weekly phone calls to further deepen the bond of trust with that patient. All data input through the wearable is also transmitted to a compatible clinician dashboard. The clinician uses the dashboard to set exercise goals for the member and to monitor adherence, compliance, and overall progress. The members are further provided with educational materials and referred for additional local patient education classes based on specific co-morbidities.
The program has accepted over 3,800 patients with an 85 percent graduation rate. When compared to site-based cardiac rehab programs, completion rates have improved by 74 percent. What’s more, less than 1 percent of patients were re-hospitalized for any cause within 30 days, 18 of which were cardiac-related.
Houston Methodist Coordinated Care’s Plunge Into Downside Risk
In 2019, Houston Methodist Coordinated Care’s (HMCC) Medicare Shared Savings Program (MSSP) accountable care organization (ACO) had 212 primary care providers with 30,000 Medicare fee-for-service beneficiaries utilizing nine different EHRs. The challenge was to engage PCPs and their staff to achieve the 90th percentile nationally on defined CMS quality metrics for the MSSP.
The innovation involved was the CMS quality metric dashboard embedded in Epic to provide real-time feedback to PCPs. The other eight EHRs were utilized to build reports and to provide the same feedback designed within Epic. The innovation was not only the IT tool, but also the innovation in how HMCC worked with primary care practices to design new workflows to address gaps in quality of care by training staff to be competent in fall risk screening and depression screening at visits.
They also trained all outreach teams to include nursing, care coordinators, care coaches, and pharmacists, to utilize the provider quality metric dashboard to close gaps of care telephonically during their patient outreach. The health system’s IT team was integral in designing and piloting the quality dashboard and including PCP feedback to accommodate their needs. In 2018, the ACO had the second highest score nationally for MSSP Track 3 programs.
Avera Health’s Avera eCARE Virtual Care Delivery Program
Twenty-five years ago, Avera Health, based in Sioux Falls, S.D., recognized the disparity between its urban tertiary center in Sioux Falls and the numerous rural communities across its footprint, which now spans 72,000 square miles.
Over that span, Avera eCARE has developed an innovative virtual care network to meet its own needs as a health system, and has expanded beyond its traditional geographical borders to serve more than 400 sites in 30 states. Today, Avera eCARE offers specialized services that include emergency, pharmacy, ICU, senior care, specialty clinic/consults, hospitalist, behavioral health, correctional health, school health and more. Beyond rural health care, eCARE serves many urban sites, too. Via secure, interactive and real-time audio-visual technology, participating sites can access specialty support and face-to-face consultations, 24/7, at the touch of a button.
eCARE offers 24/7 access to specialty care through innovative ways, such as using critical care specialists who are based on the other side of the world, in Israel, to cover nights. What’s more, one key example of how eCARE works to provide solutions to some of today’s most daunting challenges is through ambulatory telemedicine. The hardship of taking time off work or school, or requiring an escort to travel across the state for one or multiple appointments, is more than many patients can absorb. But eCARE allows patients to see physicians in many medical specialties—including infectious disease, pulmonology, cardiology, nephrology and others—without having to leave their community.
Up to 30 percent of eCARE Consult patients indicate that without telemedicine, they would have forgone specialty care. On the post-acute side, Avera has implemented telehealth access to geriatric services to prevent avoidable escalation of illness for residents, resulting in better quality, better patient experience and lower costs. eCARE data suggests geriatric telemedicine can improve unplanned transfers by 62 percent and saved an estimated $342 per beneficiary per month on Medicare costs.
Main Line Health’s “Project Road Trip” Analytics Transformation
Healthcare analytics at Main Line Health, in Pennsylvania, just like in every health system, is in a continuous state of transformation. Main Line Health’s Quality and Patient Safety (QPS) analytical team was challenged with providing better analytics and creating an interim bridging strategy to provide more timely, accurate and consistent report and analytical solutions. This required a transformation on how the department worked, allowing a new focus on integrating previously disparate data into a central repository.
The team’s primary focus is strategic and initiatives reporting, providing long-term trends, and tracking against benchmarks. Previously, different analysts supported various business units and independently performed most aspects of generating QPS Dashboard and Clinical Environment Workgroup (CEW) reports, which follow the Institute for Healthcare Improvement (IHI) measure categories of Safe, Timely, Efficient, Effective, Equitable, and Patient Centered care (STEEEP).
The QPS Dashboard and CEW STEEEP reports are sent to system and campus leaders within the organization; STEEEP reports are sent to system leadership. As clinical and operational leaders depend on the Dashboard and STEEEP reports to monitor and prioritize work for organizational strategic initiatives, the analytics team had to effectively address core challenges such as becoming more effective and efficient in creating dashboards, reports and analysis, and reducing work redundancy and lag.
The project initiative, dubbed “Project Road Trip,” was the creation of a data warehouse, a measure repository, and visual analytics tools.
Prior to “Project Road Trip”, it took six analysts, one data administrator and one analytics project manager 1,000 hours to develop the Q&S monthly dashboard and 11 quarterly STEEEP reports. With the development of the above three solutions, and by leveraging existing tools and resources, within two years the team has reduced development and data managements hours by 75 percent; eliminated 100 percent of duplicative work; increased security with centralized data into a more secure data warehouse; eliminated 100 percent of production lag time for all measures; increased analytical support via visual analytics and multi-level reporting across multiple data sources; and built and standardized metadata for every metric reported from the department. This initiative become the foundation for the organization’s next generation of analytic solutions.
St. Joseph’s Health’s Physician\Revenue Cycle Collaborative
St. Joseph’s Health (SJH), based in Paterson, N.J., provides care to a largely underserved population with significant challenges in the area of social determinants of health (SDOH). In 2018, SJH created a physician\revenue cycle collaborative to defragment the organization’s efforts across the system and develop a true clinically-integrated revenue cycle.
The initial aim was to reduce lost revenue and expenses related to concurrent inpatient denials; at the time most concurrent denials were handled on appeal by expensive outside consultants who were often time delayed and frequently unsuccessful. This group of about 20 system leaders began meeting weekly, and by the end of 2018 had recovered $5.8 million in net receivables, using only internal resources and focused on a single payer.
In 2019, the group expanded their efforts to include all inpatient denials; increase the use of appropriate observation and outpatient designations; maximize CMI (case-mix index) using the compliant documentation team for all payer classes (not just Medicare) and a post discharge review process; and focus on the professional fee billing of employed physicians both in the ambulatory and acute settings.
The ability to focus on professional fee billing stemmed from a conversion to Cerner Millennium as the organization’s single enterprise EMR. SJH used this conversion in early 2019 to streamline and change the revenue cycle processes, including considerable education for physicians and other providers.
Through the end of 2019, SJH reports the following results, attributed to $20 million in increased revenue: recoveries from concurrent denials of nearly $14.5 million (net receivables) in 2019; a nearly 40 percent increase in observation discharges (driving a decrease in denials) in 2019, compared with 2018; and a 6 percent increase in system-wide CMI from 2017 to 2019.
