• Activating Patient Engagement for Population Health

    Karen Wagner Feb 10, 2016

    Effective patient engagement involves one-on-one personal care and high-tech tools that guide patients in changing their behavior and improving their health.

    As the healthcare industry transitions to value-based care, determining how to effectively engage patients in their care has become a growing challenge for hospitals and health systems. Just as care practices and technology have evolved over the years, so too has the concept of patient engagement, as several industry leaders who presented at HFMA’s Thought Leadership Retreat in October described in subsequent interviews.

    “Patient engagement in the past was really about educating patients,” says James Merlino, MD, president and chief medical officer of the strategic consulting division for Press Ganey, a patient-experience consulting firm. “It kind of evolved into this concept of empowerment. First, you’re getting patients a little more involved, then you’re giving them tools and asking them to do more. Now, it’s about activation and partnership.”

    William Appelgate, executive director of the Iowa Chronic Care Consortium, which designs and implements population health management and health coach training programs for healthcare organizations across the United States, agrees that activation is the key to successful patient engagement in today’s healthcare environment. “Just telling people what to do doesn’t engage them and doesn’t get the kind of desired results or changes in behaviors that we’d like,” Appelgate says. “We really need to build self-care skills and inspire patient accountability.”

    He adds: “If we can’t get to the 98 percent of health care that actually takes place in the bedrooms, bathrooms, and kitchens of people’s homes, we are not going to have the change in the outcomes that we want to have.”

    Guiding Principles of Engagement

    Strategies that incorporate technology and human expertise often are necessary to help patients understand the need to engage, and how they can become more active in monitoring their health conditions and making informed decisions about their care, Merlino says.

    Merlino describes four key principles that healthcare organizations should use when developing their patient engagement strategy.

    Identify key touchpoints. It may be impossible to engage with patients at every point along the continuum of care, but patient engagement is critical at certain touchpoints along the continuum. These are areas that can have a direct impact on outcomes, such as points at which conditions can worsen due to inaction or improper care—or improve because of appropriate care. These touchpoints should be similar across healthcare organizations, based on the disease being managed.

    Employing appropriate monitoring devices for various conditions at critical touchpoints will enable patients to be active in their care. For example, patients with hypertension should regularly monitor their blood pressure levels to prevent spikes that can send them to the emergency department (ED). Likewise, patients with congestive heart failure should regularly monitor their weight for signs of weight gain, which can indicate that the body is retaining fluid. “You have to ask: What are the critical touchpoints that are going to be high-value?” Merlino says.

    Recognize the psychological barriers. Providers often focus on giving patients care instructions and not on how or whether the patient is able to follow those instructions. Because many challenges with chronic disease management involve care practices in the home, providers should be more aware of what can go wrong outside the acute care setting and invest more time in addressing these barriers. For example, patients may not be able to afford brand-name medications and, therefore, may not fill their prescriptions. Merlino says providers should inform patients when low-cost generic alternatives might be available.

    Overall, Merlino says, the issue centers on, “How do we start to better understand the psychology and the social determinants of patients that are going to help us drive—or are going to be barriers to success in driving—patient engagement and patient activation? We don’t talk about that a lot.”

    Train providers to engage. Just as engagement is about preparing the patient, “it is also about preparing caregivers to better understand how to communicate,” Merlino says. Providers should be able to recognize when patients do not understand their directions or are not capable of fulfilling them. Providers must be trained, whether through internal expertise or outside programs, to probe for social determinants that will factor into the patient’s ability to seek appropriate care. Can the patient afford her medications? Does she need help to receive care? Is there a caregiver who will help administer medications or other kinds of care, as necessary? “It’s teaching providers how to use that information, when to use that information, and looking at leveraging the resources they have available to help try and fix the issue,” Merlino says.

    Employ technology when appropriate. It seems as if a new piece of technology for engaging patients is discovered every week. However, not all technology is effective, and technology is only part of the solution, Merlino says. Providers should determine the appropriate role of technology in their patient engagement strategies and ensure its effectiveness. Before implementing a new tool for engaging patients, providers should seek evidence from manufacturers and vendors to verify any claims about improving outcomes or changing behaviors.

    Web Extra: Clinical Health Coaching Model for Patient Engagement

    Innovative Patient Engagement

    The following three examples showcase how to put these guiding principles into practice by implementing innovative patient engagement strategies.

    AtlantiCare’s Special Care Centers. Bending the cost curve and forming patient relationships that improve care delivery are the goals behind the Special Care Center (SCC) program developed by Atlantic City-based AtlantiCare, an integrated health network owned by Geisinger Health System, Danville, Pa.

    The SCC program provides dedicated care counseling to patients with diabetes, congestive heart failure, and heart disease. Patients work with a health team, composed of a physician and a medical assistant who serves as a health coach, to develop individualized care plans.

    “Our goal is to engage the patient in his care in such a way that we improve health while maintaining or reducing costs, especially costs of overutilization of the emergency department,” says Sandra Festa, administrative director of the SCC program.

    Patients can choose to use the center on their own or may be referred by their employers, who use predictive modeling to identify health plan members who are either high users of health services or at high risk for becoming high users, thereby increasing costs, Festa says.

    AtlantiCare’s two SCCs, one in Atlantic City and one in Galloway, N.J., serve as ambulatory practices. Patients switch from their regular primary care physicians to the SCC physicians.

    The SCCs serve about 2,000 patients under both fee-for-service and per-member-per-month payment models. Health coaches have between 175 and 200 patients in a panel, while each physician has 800 patients.

    Jayshree Patel, a medical assistant working as a health coach for AtlantiCare’s Special Care Centers.

    Jayshree Patel, a medical assistant working as a health coach for AtlantiCare’s Special Care Centers, gives a patient a checkup. (Photo: AtlantiCare)

    During a welcome session, the patient meets with the medical assistant/health coach and physician. The health coach educates the patient on his condition and discusses the patient’s expectations and role in his care. The coach coordinates various care services, including physician visits and any necessary screenings or diagnostic testing. The physician determines the appropriate visit frequency, which generally decreases as the patient’s condition improves.

    “Give us a good three months, and we can drop the A1C [level for diabetes] on average about 2.6 points,” Festa says. “As that patient becomes stable, and if that patient does really well, he doesn’t have to come as often. The care doesn’t have to be highly expensive.”

    With providers who are available 24/7 and elimination of copayments for physician visits and medications, Festa says, the program improves patient access and removes barriers to using unnecessary services.

    Festa says another important element of the program is determining personal barriers to appropriate health care. A physician may create a strong care plan, but a patient’s personal issues, such as marital or financial problems, may complicate or prevent his ability to seek care. The health coach works with the patient on such issues to try to remove or at least mitigate the barrier.

    Utilization and outcomes demonstrate the success of the program, Festa says. For the past eight years, readmission rates for SCC patients at AtlantiCare have averaged 5 percent annually, well below the 17.5 percent rate for all-cause, 30-day readmissions for Medicare fee-for-service beneficiaries reported in May 2014 by the U.S. Department of Health and Human Services. ED visits for high utilizers have been reduced by 50 percent, as have hospitalization rates, Festa says.

    When patients reach targeted care goals, they can choose to go back to their original primary care physician or stay in the SCC program and receive lower-intensity services. Leaving the choice to patients is all part of the patient engagement focus.

    “If you really believe in population health, you shouldn’t let patients sacrifice when they’re doing well,” Festa says. “You should continue to engage, but adjust the frequency and intensity of interventions, which will reduce costs.”

    Reduction in Utilization Measures
    Reduction in utilization achieved by AtlantiCare’s Special Care Centers.

    Ochsner Health System’s “O Bars.” The O Bars at Ochsner Health System (OHS) offer healthcare products and apps that help users monitor their chronic conditions and achieve healthier lifestyle habits (e.g., smoking cessation).

    Currently available at two OHS primary care clinics, the O Bars are similar to “genius bars” found at stores that sell computer technology. OHS includes 25 owned, managed, and affiliated hospitals and more than 50 health centers in Louisiana.

    “Technology has the capacity to help patients self-discover and the potential to be an enabler of patient engagement,” says Richard V. Milani, MD, chief clinical transformation officer for OHS.

    The first O Bar, located at the Ochsner Center for Primary Care and Wellness in New Orleans, opened in 2014; a second O Bar is housed at Ochsner Health Center-Covington, and a third is scheduled to open early next year.

    The apps are vetted and approved by Ochsner subject matter experts for ease of use and potential benefits to users. The vetting process is important because studies have shown that many healthcare apps on the market today offer no actual benefits to users, Milani says. The stores also offer interactive health technology, such as blood glucose monitors and scales and blood pressure cuffs, that work with either a smartphone or an online app, which can transmit results data from the technology to providers (e.g., via electronic health records).

    Richard Milani, chief clinical transformation officer, Ochsner Health System.

    Richard Milani, MD, chief clinical transformation officer of Ochsner Health System, sits at the O Bar, a retail store that offers healthcare apps for patients and other customers. (Photo: Ochsner Health System)

    The stores are staffed by technology experts who explain the types of apps that are available and how patients can download them to personal devices.

    The retail service also ties in with the health system’s focused programs in chronic disease management. A physician may recommend that a patient with hypertension wear a wireless blood pressure cuff for remote monitoring, for example. Rather than having the patient search for a device on his own, the physician can suggest the patient visit the O Bar to see what devices are available, Milani says. In a short period of time, the patient can also be shown how to set up and use the device with a smartphone.

    “There needs to be a customer-focused, user-friendly technology interface for individuals to be able to have appropriate access and understanding of how to use technology,” Milani says.

    More than 2,000 customers have visited the stores since they opened, Milani says. Some of the apps purchased most often track nutrition, fitness, diabetes, medication, and smoking.

    Because the stores are open to the general public, OHS does not measure the results of app usage on its chronic care populations. Milani says anecdotal feedback from app buyers has been positive, with users reporting benefits such as improved quality of life after losing weight. Users can fill out an emailed survey that asks questions about their experience with the apps.

    ”We have those stories in abundance,” Milani says. “Survey data have been very, very positive in terms of how the O Bar has been an enabler; it’s improved their engagement.”

    Gundersen Health’s “Respecting Choices.” Patient engagement generally is associated with helping patients who have chronic conditions. However, helping patients make plans for potential future healthcare decisions should they become incapable is equally important for the patients and for their family and friends, says Bernard “Bud” Hammes, PhD, director of medical humanities and of bereavement and advance care planning services for Gundersen Health System, La Crosse, Wis.

    Gundersen Health’s Respecting Choices program, formally started in 1991, is designed to get patients thinking about their end-of-life care so they can make more thoughtful, informed decisions about accepting and refusing treatment.

    “We can engage our patients and those close to them in planning well for healthcare decisions,” Hammes says. “We want to be in a position where when any of our patients get really sick and are unable to tell us what’s important to them, we have a good idea of what they want out of health care—and we’ve made the commitment to honor that. We want to know and honor the informed thoughts and values of our patients even when they cannot tell us themselves.”

    The program uses trained facilitators—many of whom are nurses, social workers, or chaplains—to help patients consider their options and plan their care by getting patients to express their views, values, preferences, and goals regarding end-of-life care. These choices are then documented and stored in the patient’s electronic health record for easy access by caregivers when the time comes to make decisions, including life-or-death decisions, Hammes says.

    Facilitators, who are trained internally, elicit patients’ perspectives by asking them about their experiences with medical treatment decisions when they or a loved one previously faced a critical situation. “It’s out of those personal experiences then that we start to examine the values that they have,” he says. “It is this person-centered approach that makes the planning engaging and helpful to both the family and the providers.”

    Facilitators are trained via an online course encompassing about six hours combined with classroom sessions totaling eight hours that focus mainly on communication skills and how to facilitate discussions with patients, Hammes says. The training also covers how to document the patient encounter and enter the information into the patient’s electronic chart.

    In addition to creating the role of facilitator, Gundersen adjusted its electronic health record system by creating a link to patients’ advance directives so physicians and other care providers can easily enter and retrieve the information at any time across care settings. Physicians are trained on how to access the information and how to use the patient directives in making treatment decisions. For example, if a patient has appointed another person to make treatment decisions, the physician must understand when the directive should be consulted in the decision-making process and when to discuss care with the appointed person as opposed to the patient, Hammes says.

    Gundersen disseminates information about the Respecting Choices program through presentations to church groups, service groups, and elder groups, among other audiences. The health system also works in conjunction with Mayo Clinic Health System-Franciscan Healthcare, a competing health system in the La Crosse market, to train facilitators, market the program, and present it to the public, Hammes says.

    To gauge the effectiveness of the program, Gundersen periodically measures the prevalence and use of advance directives at the time of death across care settings in La Crosse County, the immediate geographic area served by the health system. In Gundersen’s last measurement, covering a seven-month period from 2007 to 2008, 96 percent of adults who died had a written care plan, and 99 percent of the time that plan was in the medical record of the healthcare organization providing services at the time of death, Hammes says.

    In surveys, patients and family members have indicated a high level of satisfaction with the quality of communication they have experienced in the Respecting Choices program, Hammes adds.

    The ROI of Engagement

    The ROI of implementing practices that help patients monitor their own health and reduce the need for more costly interventions is only beginning to become evident, Merlino says. Currently, the evidence comes from the success of individual initiatives. Merlino says it is up to financial leaders of healthcare organizations to measure the ROI and inform colleagues of the results, letting others know the value of investing in patient engagement strategies to improve clinical and financial outcomes.

    “It’s a growing field with evolving metrics. But it passes the sniff test,” he says. “It’s the right thing to do, it’s going to make care better, and it’s going to save money.”


    Karen Wagner is a freelance healthcare writer based in Forest Lake, Ill., and a member of HFMA’s First Illinois chapter.

    Interviewed for this article: James Merlino, MD, president and chief medical officer, Press Ganey Strategic Consulting Division, Chicago.

    William Appelgate, PhD, executive director, Iowa Chronic Care Consortium, Des Moines, Iowa.

    Sandra Festa, administrative director, AtlantiCare Special Care Center, Atlantic City, N.J.

    Richard V. Milani, MD, chief clinical transformation officer, Ochsner Health System, New Orleans.

    Bernard “Bud” Hammes, PhD, director, medical humanities and bereavement and advance care planning services, Gundersen Health System, La Crosse, Wis.

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