I was recently reading a Bloomberg Opinion article that discussed cost savings for end-of-life care. The piece brought to light the numerous articles, blogs, and research studies that highlighted challenging ethical and economic considerations for end-stage patients. Some review utilization and cost associated with futile care, others mention social factors influencing care decisions, and some discuss ethical dilemmas faced by providers in caring for this population.
In my years of caring for chronically ill patients, I learned quickly that you can never predict how an individual’s symptoms will progress. I had many patients who hung on in intensive care for months – while others showed up in the ER with a vague complaint, quickly deteriorated, and passed away within hours.
Any clinician can tell you that every patient is different. No two disease trajectories are identical. Symptoms progress and differ based on countless variables, such as comorbidities, overall health, and social factors. And it is the patient’s right to choose the type and intensity of care he or she wishes to receive. That said, how can we help patients navigate their circumstances, especially when they are at their most vulnerable?
Guiding Patients Through Their Care by Asking the Right Questions
Our healthcare system is designed to treat patients and manage comorbid conditions. As the system evolves to be more focused on preventive health, how can we educate and guide patients to seek the best care at the most appropriate time?
Regardless of how sick or well a patient is at any given time, it is the patient’s choice to determine how aggressively he or she wishes to be treated. Providers need to ask specific questions, at very specific times, in order to effectively guide their patients and ensure they receive the care they desire.
Providers must be cognizant of the care they provide to ensure that it meets clinical, ethical, and reimbursement standards. However, there is a lot of gray area. For example, if a patient is diagnosed with cancer and asked if he or she would like to pursue treatment, most will respond affirmatively. It is up to the provider to treat the patient holistically and place this diagnosis into context with rest of the patient’s plan of care.
These questions guide patients and family members to make the most educated decisions possible regarding their care.
Actively Engaging Patients to Meet Their Individual Preferences and Needs
Meaningful patient engagement and care management efforts empower providers to better understand the needs and wants of their patients. Although these conversations are difficult and may be unproductive at first, it is critical to encourage patients to open up about their personal goals that will inform how clinicians can best meet them.
An especially challenging – yet important – task is working with patients to complete an advance directive and discuss this with their loved ones. This should outline the type of care welcomed, as well as scenarios in which the patient would not want additional treatment.
By leveraging the right data and technology, clinicians and care managers can be prompted to ask the right questions at the right time. Instead of asking for all the answers at once, engaging in ongoing conversations triggered by diagnosis, utilization, and time may prove more productive for both the patient and provider.
Ultimately, providers must solicit information on how patients want to be treated, especially in the event that they are not able to verbalize their wishes. This should not occur under stress, but rather when patients have the opportunity to consider how each scenario impacts their general wellbeing, as well as that of their loved ones.
Developing a deeper understanding of a patient’s wishes may reduce utilization and systemic spend for a patient at the end of life, but that should never be the driving force of these initiatives. More importantly, these conversations improve the quality and experience of a patient – ensuring that treatment is aligned with the goals of that individual.
This article was written by CipherHealth’s Vice President of Clinical Services, Lyndsey Lord, MBA, BSN, RN. Lyndsey brings over 15 years of experience in clinical practice, healthcare operations, case management, patient throughput, and healthcare IT strategy to her current role at CipherHealth. Prior to joining CipherHealth, Lyndsey worked with healthcare providers to implement alternative payment models, such as BPCI, and supported clinical care redesign efforts to promote success within value-based healthcare programs.
According to The American Cancer Society, nearly one out of three people will develop cancer in their lifetime. Although this statistic can be scary, patients can get regular cancer screenings that allow for early detection and prevention. In fact, five-year relative survival rates for breast, colon, and cervical cancers are 93 – 100% if they are discovered before spreading beyond the organ where the cancer began. By utilizing healthcare technology, providers can actively engage patients outside of the primary care visit to promote behaviors that support optimal health outcomes.
It is important for patients to follow recommendations for cancer screening tests, which vary depending on age and gender. When providers educate patients about healthy lifestyle choices and recommended cancer screenings, they empower patients to engage as full participants in their health.
Meet Patients Where They Are
Cancer screening guidelines vary depending on a host of genetic and environmental factors, including the individual patient’s age, gender, family history, and lifestyle choices. For example, the American Cancer Society recommends women aged 45 and older to get a mammogram every year. If an individual has a higher than average risk for breast cancer due to family history, discussing recommended screening guidelines with a provider is important since screening may be more frequent and/or start earlier. Since cancer screening guidelines differ and may prove challenging to navigate, patient education and partnership plays an important role in ensuring cancer is detected at its earliest, most treatable stages.
How Technology Improves Cancer Screening Rates
As technology is increasingly integrated into healthcare settings, providers can help patients manage their health proactively. By utilizing patient outreach technology, providers can send automated reminders informing eligible patients they are due for their preventive screenings. This technology should support flexible outreach, such that patients with different risk levels receive different outreach (i.e. earlier and more often) according to recommended evidence-based guidelines.
With automated outreach technology, providers can target patients with their preferred communication method, increasing the likelihood patients will engage in their health. Automation lessens the administrative burden on healthcare staff, allowing providers to reallocate their time and expertise to patient care.
Routine cancer screenings play a critical role in early cancer detection and prevention. By leveraging technology, providers can engage all patients in their plan of care and ongoing health. With automated outreach, clinicians can reach more patients, streamline staff workflows, and lower the total cost of care for their patients – achieving the Quadruple Aim.
To learn more about how leading healthcare organizations utilize automated outreach to increase cancer screenings, thereby achieving early detection and prevention, we invite you to check out these resources.
Consumer demand is shaking up traditional industries more than ever. From Lyft to Airbnb, expectations for fast, convenient, and affordable options are allowing industry newcomers to grow and obtain significant market share across various market segments.
Healthcare is no different and arguably has more at stake in meeting patient demand, as financial incentives are tied to patient satisfaction and outcomes. Patients want the same affordable, easily accessible, and personalized options they have come to enjoy in other facets of their lives. However, the healthcare industry is struggling to keep up with these growing demands. According to a recent study, nurses spend 73% of their day on documentation and administrative tasks. Instead of conducting repetitive tasks with little value for patients, nurses can drive better outcomes by dedicating their specialized expertise to patient care. Understanding this, how can healthcare leaders address this challenge head-on by empowering their nursing staff to work at the top of their licenses?
Why Front-Line Healthcare Providers Need Workflow Automation
With growing documentation requirements, the administrative burden on nurses has ballooned over the last decade. Today’s nursing school graduates abide by this rule: “If it wasn’t charted, it didn’t happen.” By performing repetitive, potentially duplicative work, nurses must allocate significant time to tasks removed from direct care, leading to higher burnout rates.
Since provider engagement is an important strategy to drive better patient outcomes, addressing these challenges means more than hiring additional staff – requiring leaders to find smart ways of scaling processes and maximizing the resources at hand. By bringing automation into everyday processes, nurses can focus their expertise and specialized skillsets on care delivery.
How Automation Optimizes Experiences
To identify where automation technology can be valuable, it is essential to first understand what it means to automate. According to the International Society of Automation, automation is the creation and application of technology to monitor and control the production and delivery of products. Automation has been used in various industries to meet changing consumer demands. For example, retail companies understood they needed to tailor online shopping experiences to an individual shopper’s preferences. Personal shoppers enhance the in-store experience by recommending clothing items according to the client’s taste and style – creating an experience tailored to the individual. To create a personalized shopping experience for online shoppers, retail companies leverage automated technology that recommends items based on past purchases and recent page views. The success of online shopping may be attributed to the personalized experiences and instant gratification consumers receive. Similarly, automated technology can accelerate innovation in healthcare delivery by streamlining repetitive processes such that interactions can be tailored to the individual.
By leveraging automation in clinical workflows, hospitals and health systems can more effectively engage with patients without adding additional administrative burdens for front-line providers. Clinical workflows can be automated with enhanced clinical decision support, care management task assignment, appointment reminders, and post-discharge follow up outreach.
In the example of post-discharge follow up, hospitals can automate the initial outreach call or text to assess recovery status for all patients within a target population. The automated outreach triages those individuals who indicate concerns, empowering clinicians to engage patients with targeted and meaningful information. This contrasts sharply with traditional outreach methods, in which nurses become increasingly frustrated with unsuccessful attempts to reach patients with manual outreach processes.
Automated workflows ensure that staff not only have more meaningful conversations, but patients are connected to the resources they need more quickly. This reduces the likelihood of adverse events, such as avoidable readmissions.
How Workflow Automation is Accelerating the Healthcare of Tomorrow
By implementing the right technology that reduces repetitive work, hospitals and health systems will experience healthcare’s Quadruple Aim of improved patient outcomes, enhanced patient experiences, increased staff satisfaction, and lowered cost of care. To maximize labor efficiency ROI, leading healthcare organizations are leveraging automated technology to reallocate valuable nursing resources to direct patient care. When providers work at the top of their licenses, healthcare organizations are better equipped to face the growing challenges presented by the ongoing evolution of the industry.
To learn more about how automation is changing the healthcare industry, we invite you to check out these resources:
In today’s evolving healthcare landscape, finding the intersection between clinical workflows and information technology (IT) plays a key role in driving long-term success. In hospitals and health systems, the Chief Nursing Informatics Officer (CNIO) ensures clinicians have the tools they need to deliver high-quality care.
In a recent interview with Health System CIO, Nancy Yates, MSN, RN, RN-BC, CNIO of Providence St. Joseph Health, shares how to create and scale enterprise-wide processes that lead to better patient and staff experiences.
Identifying System-Wide Opportunities
Yates shares key challenges that CNIOs frequently face in developing technology-enhanced workflows, such as creating efficient and standardized systems that empower staff to deliver the highest quality and experience of patient-centered care. Driving towards a system standard is important to scale best practices across a 50-hospital system spanning six states.
In leading the informatics team at Providence St. Joseph Health, Yates helps front-line clinicians articulate their pain points by identifying the deeper issue: “What is the problem you’re trying to solve? Tell us what problem you’re trying to solve, and we’ll help you figure out the best way to do it and the tool for it.” For example, one of Yates’ key stakeholders is nursing leadership. After assuming her role as CNIO of Providence St. Joseph Health, Yates learned that nurses across service lines experienced challenges in developing optimal rounding workflows at the bedside, leading to inconsistencies in delivering high-quality patient experiences. Since everything was paper-based and difficult to track over time, it was difficult to establish accountability across teams.
In response to this challenge, different hospitals went “off in their own direction” to assess digital rounding solutions. These alternative options proved unsuccessful due to poor connectivity, complex reporting, and insufficient account management. Yates soon paused these disparate processes because “in an organization as large as ours you have to have standard platforms, and you can’t scale best practice tools when you’re doing it ten different ways.”
Selecting the Right Technology to Address Problems
To standardize and scale a system-wide solution, Providence St. Joseph Health embraced the opportunity to work with AVIA, the nation’s leading network for health systems seeking to innovate and transform care delivery. AVIA convened a group of health systems to evaluate, select, and implement the best digital rounding solution to improve the patient experience. After applying rigorous diligence to evaluate options with objective scoring criteria, AVIA conducted a “shark-tank” style event where top digital rounding companies conducted demos and fielded questions. Nursing, Information Systems, and Innovation teams reached a unified decision at the end of AVIA’s comprehensive evaluation process, aligning on CipherHealth’s digital rounding solution. After conducting their own due diligence and undergoing a 30-45 day discernment process in which each vendor demoed their product, Providence St. Joseph Health selected and approved CipherHealth as the sole rounding solution to drive enterprise-wide standardization and scale across the organization.
By removing typical biases that exist during the technology evaluation process, Yates and her team focused on features and ROI for system-wide deployment. Yates shares, “CipherHealth landed on top. It was efficient, easy to implement, and very intuitive from an end user perspective, meaning it takes less than 10 minutes to train someone on how to use the tool.” CipherHealth’s intuitive user interface enhances the rounder experience, making it easy to proactively resolve issues and conduct service recovery. With a longitudinal view of historic patient experience data and strong reporting and dashboards, Providence St. Joseph Health standardizes care delivery processes across the health system by comparing activity across individuals, departments, and hospitals. By leveraging real-time data to identify rounding best practices, Providence St. Joseph Health improves the quality of patient care and the overall experience for its entire patient population.
Yates and her team empower providers to drive accountability, consistency, and best-practice processes at the point of care by scaling CipherHealth’s digital rounding solution across the health system. As a result of moving from a manual to a digital rounding process, Providence St. Joseph Health enhances the patient experience, proactively identifies quality and safety process improvement opportunities, and streamlines staff workflows.
How CNIOs Can Achieve Success
Yates believes that a “partner who was willing to help us drive that process and be very open and flexible” was the key to successfully scaling technology for meaningful impact at Providence St. Joseph Health. In their search for a digital rounding solution, Yates and her team gathered feedback from stakeholders across the organization in order to understand the scope of the problem they were trying to address, determine the best solution to meet the needs of their patient population and staff workflows, and implement quickly at scale.
Ultimately, this journey provided Providence St. Joseph Health with a clear path towards developing a unified rounding standard across dozens of hospitals. By scaling a digital solution that optimized rounding processes, Yates and her team executed and maintained rounding best practices to increase patient satisfaction and better support nursing staff.
To learn more about how leading healthcare organizations leverage CipherHealth’s digital rounding solution to improve patient outcomes at scale, check out the following resources:
Engaging patients has become a key strategy for healthcare organizations to drive outcomes and satisfaction improvements. Although previously seen as a buzzword, patient engagement is a cornerstone to successful programs that drive towards home health agency KPIs.
Patient engagement is a set of tools, processes, and actions that allow providers and patients to communicate effectively make informed decisions to improve the odds of success. A common misconception is that patient engagement only happens in the home during home health visits; however, there are many opportunities for agencies and their staff to remain engaged with patients during the entirety of the episode of care.
As other industries have worked towards perfecting customer engagement, home health agencies must follow their lead and capitalize on the benefits of engaging their consumers, or in this case, patients.
3 benefits of enhancing home health episode engagement are:
Patient engagement is at the forefront of healthcare policy and is a critical component of providing high-quality care. Effective patient engagement helps to improve health outcomes, drive better patient care, and achieve lower costs. Patients want to be engaged in their healthcare decision-making process, and those who are engaged in their care tend to be healthier.
If you are interested in learning more about how your home health agency can implement patient engagement programs, check out these resources:
1. 5 Steps to Creating a Successful Home Health Outreach Program
2. 5 Keys to Becoming a Preferred Home Health Referral Partner
3. Engaging Home Health Patients Throughout Their Episodes of Care
At CipherHealth’s June User Forum Webinar, John Dodd, Program Manager in the Office of Patient Experience and Engagement at University of Alabama at Birmingham (UAB) Hospital, and Jeff Richard, Clinical Informatics Director at Baylor Scott & White Health – The Heart Hospital Plano/Denton, discussed how they are achieving the Quadruple Aim with patient engagement technology.
During this peer-to-peer learning session, both Dodd and Richard shared how they are implementing and evaluating patient-centered initiatives designed to improve clinical outcomes.
Key Success Factors for Any Patient Engagement Initiative
As Dodd and Richard shared, any new initiative will require multiple stakeholders to drive success. Richard elaborated by providing three best practices to other healthcare leaders:
By following these steps, organizations are more likely to create meaningful and lasting programs that achieve desired results.
Putting these ideas into practice, Dodd highlighted how UAB Hospital leverages their digital rounding program to achieve Quadruple Aim goals – especially as it relates to their Transitions of Care (ToC) Rounds. Although UAB Hospital is currently performing dozens of rounding initiatives, the ToC rounds in particular leverage a multidisciplinary approach.
During the daily discharge planning meetings on inpatient units, leaders use their CipherHealth program to audit the quality of the ToC rounds and ensure that all necessary components of discharge planning are addressed. By partnering with CipherHealth to increase rounding compliance and improve rounding quality, UAB ensures that patient needs are met prior to discharge and length of stay is reduced.
Connecting Team Members to Coordinate Care
Both UAB Hospital and the Heart Hospital Plano/Denton are large organizations committed to transforming the patient experience. To achieve their respective goals, their leaders emphasize the need for strong communication and collaboration inside and outside of the hospital – both with patients and other team members.
Creating meaningful connections with patients inside the facility is the first step in creating a positive environment. Dodd shared three tips that staff should keep in mind during their interactions, especially during rounds.
To demonstrate the importance of identifying and acting upon patient issues and concerns, Richard shared how his team is engaging patients after undergoing CABG surgery. With post-op phone calls provided by CipherHealth, the hospital identifies common challenges that patients experienced upon discharge. After uncovering trends, providers at the Heart Hospital Plano/Denton developed tailored interventions to improve long-term recovery and reduce barriers to care among the CABG patient population – including the implementation of the Patient Advisory Nurse Line, an after-hours initiative that resulted in readmissions reduction.
Dodd showcases the importance of communication among team members in order to act upon patient feedback. During UAB Hospital’s Healing Environment Rounds, Arts in Medicine staff utilize CipherHealth’s alerts to streamline communication with Chaplains, Music Therapy, Pet Therapy, and other services. During the webinar, Dodd shared a touching story about a patient who loved creating artwork, but she didn’t have her glasses so she couldn’t see anything. After the patient shared this, the Arts in Medicine team were automatically alerted by alerts via the rounding technology and immediately delivered glasses, along with coloring supplies, to the patient. This demonstrating the role of real-time alerts in providing the highest quality and experience of care to patients.
As these leaders illustrate, patient engagement is an ongoing organizational priority that requires commitment from all stakeholders involved in how healthcare is delivered, experienced, and perceived. Empowered by technology, providers truly can meet patients where they are – across the entire continuum of care, foster effective communication, and deliver exceptional experiences for patients and their families.
To learn more about how leading healthcare organizations leverage CipherHealth’s patient engagement platform to transform the future of care delivery, check out the following articles:
During CipherHealth’s quarterly User Forum Webinars, clients share best practices in enhancing patient engagement across the care continuum with the CipherHealth user community. Contact us here if you are interested in learning more about the benefits of joining our community.
Since the passing of the Affordable Care Act, the United States healthcare system has undergone major shifts. Specifically, the ACA has paved the way for healthcare providers and payers to focus more on delivering value over volume in care. Although there are challenges in achieving a truly value-based system, there is one constant that help drive success – collaboration.
The last decade has shown that collaboration, both amongst providers and between providers and patients, will yield the greatest results. Even now, government agencies are working towards proposals that will require collaboration in data sharing and move the country closer to interoperability.
I recently had the pleasure of attending the National Association of ACOs (NAACOS) Spring conference. Over the course of a few days, I learned much about some of the challenges and successes ACOs are experiencing across the country and it was apparent how important collaboration is proving to be.
The event proved to be a safe place for Accountable Care Organizations to come together and candidly express challenges and how they have been successfully addressing them. What I found most inspiring was how willing the different organizations were to share their stories and knowledge with their colleagues across the country. The success and challenges often stemmed from the ability or inability to collaborate across their networks with data sharing, proactive engagement, and ongoing care management.
As the organizations continue to ask the difficult questions, deal with regulatory uncertainty, and address the looming timeline to take on more risk, collaborating with their provider networks and patients will be critical to both long and short-term success. While the U.S. continues to push for innovation in healthcare, it is the collaborative spirit within and across these organizations that will inject more value into the system.
This article was written by CipherHealth’s VP of Government Programs, Liz Lagone
Accountable Care Organizations (ACOs) have been at the forefront of driving value in healthcare. Through provider collaboration and information sharing, ACOs are positioned to manage the care of patients throughout their entire care journeys. With more than 500 ACOs across the United States, there are many opportunities to advance quality care and provide much-needed value into the American healthcare ecosystem.
While ACOs have immense potential, they still face major obstacles in making lasting achievements. Similar to many providers and managed care organizations, ACOs struggle to incorporate data from disparate sources. However, as new regulations encourage data sharing, ACOs will have access to a wealth of patient information that can be leveraged to target patients for quality improvement initiatives. Even as accountable care organizations move towards more unified systems, there are many ways that patient engagement technology can be used to meet quality metrics.
Addressing the Data Lag
The first challenge in meeting ACO quality metrics is often knowing which patients to engage in their care to close gaps in care and meet benchmarks. With lagging claims data and disparate data sources, simply knowing what quality metrics should be prioritized is a hurdle many ACOs face.
Instead of waiting for retroactive claims data, patient engagement technology can be used to combine information from multiple data sources. This can help proactively identify where resources will be best utilized to help maximize potential savings and reimbursements. By integrating with multiple systems that span the patient’s journey, ACOs can leverage the information to deploy programs that close gaps in care before a quality benchmark is missed.
Closing Gaps in Care
One of the most effective uses of patient engagement technology is to close gaps in care. With many quality metrics relying on improving outcomes, targeting patients with tailored education and surveys will help drive desired outcomes.
One example of a care gap patient engagement program would be ensuring patients with cardiovascular disease are being monitored and are under control. By reaching out to patients with reminders of why, when, and where they can get relevant care, ACOs are more likely to get patients to take control of their disease and avoid adverse events. With automated outreach, resources can be leveraged efficiently with the initial outreach being performed by the technology and relying on manual resources only once a patient has engaged with the program. This drives resources efficiency and helps ensure all eligible patients receive important reminders and education.
Reporting on Progress
Once patients have been identified for engagement and the gaps in care have been closed, leveraging reports can be used to ensure quality benchmarks are met and that savings are maximized. Over time, the aggregate data can be used to understand where resources are most needed and the engagement programs that produce the greatest results.
As ACOs are increasingly held accountable for driving value and reducing the overall cost of care, patient engagement technology will play a large role in achieving results in a cost-effective way. Implementing patient engagement solutions that help to address multiple quality metrics will help ensure both short and long-term success even amidst regulatory uncertainty. The biggest gains will first come from addressing the data lag, engaging key patient populations, and identifying actionable trends for improvement.
To learn more about how patient engagement is playing a role in the future of healthcare, we invite you to access these resources:
When providers and payers discuss value, it is with the goal of achieving a patient-centered model that supports better collaboration across care settings. It is understanding patients’ needs – both psychosocial and clinical – and acting upon them.
Historically, each care setting and provider billed uniquely, with little regard for utilization of services up- or down-stream. The primary goal of these alternative payment models (APMs), such as BPCI (Bundled Payments for Care Improvement Initiative) or MSSP (Medicare Shared Savings Program), is to create visibility and transparency across providers and care settings. CMS aims to reinforce the principle that more care does not equate to better care.
Consider these scenarios: A patient has knee replacement surgery and is in the hospital for 3 days and then transitions back to their home with the support of their family and home health services; or, the same patient has knee replacement surgery and remains in the hospital for 17 days and then transitions to a skilled nursing facility for another 46 days. Which one would you prefer? Which appears to be a higher quality patient experience? Personally, I would prefer to be in and out of the hospital, and back home with my family, as soon as possible!
With continued innovation around value-based care, providers can expect to see both mandatory and voluntary programs that enforce the dimensions of the Quadruple Aim, designed to improve the health outcomes of patient populations without incurring higher costs. The key will be creating the right processes to empower the team, as well as technology to implement and sustain value-based programs.
Empower Value-Driven People
As proven processes are implemented, it is important to empower the right people with the right responsibilities. It is not enough to ask a nurse or case manager to take on more responsibility in addition to their day-to-day tasks, as this often results in fragmented processes and unclear cause-and-effect impact of their efforts. By improving processes, organizations can better leverage current resources to accomplish better results – and in many cases, more satisfying work.
Leveraging Value-Driven Technology
Technology can serve as a great asset to those looking to provide value-based care. In many cases, technology creates the workflows and processes that reduce duplication by leveraging resources to the fullest extent. When leveraging the right tools, care teams should codify workflows, track activities, and assign tasks with uniform timeframes. This allows the team to better understand the impact of each individual intervention and can create best practices that drive towards the desired results.
The right processes, people, and technology are critical aspects of delivering value in healthcare. Instead of waiting for patients to get sick and reactively treating their acute needs, value-based care means focusing and incentivizing efforts on prevention and person-centered care. Ultimately, value-based care will become the biggest asset in reducing the overall costs of care by improving patient outcomes and experiences across the care continuum.
As the Vice President of Clinical Services, Lyndsey Lord, MBA, BSN, RN brings over 15 years of experience in clinical practice, healthcare operations, case management, patient throughput, and healthcare IT strategy to her current role at CipherHealth. Prior to joining CipherHealth, Lyndsey worked with healthcare providers to implement alternative payment models, such as BPCI, and supported clinical care redesign efforts to promote success within value-based healthcare programs. Lyndsey is passionate about leveraging technology and data to assist providers in delivering high-quality, low-cost care.