Patient Engagement Transformation

One example is Geisinger Health System, which already had a reputation for innovation, despite being a large organization with 11 hospitals across northern and central Pennsylvania. It also operates its own insurance plan with 550,000 covered individuals. Jaewon Ryu, M.D., Geisinger Health System’s CEO, said that as it reintroduces services post-COVID, it wants to learn from some of the agile and flexible rapid change that was required to respond to the pandemic and infuse it into its day-to-day activities. In an August online presentation, Ryu noted that Geisinger had already been working hard to get care into the home prior to COVID. “We were able to double down on that with telehealth and remote monitoring and mail-order pharmacy so people can get medications for chronic diseases without leaving their homes,” he explained. “Digital transformation must be a strategic priority and moving care closer to the patient is critical,” he said. The pandemic “has reinforced our belief in building clinical programs closer to communities and to make healthcare easier. It obviates the need for people coming in for in-person visits and allows us to still manage their care.”

Mount Sinai engages community health workers

As New York became the epicenter of the pandemic in March, Mount Sinai Health System’s traditional modes of patient engagement were turned upside down, and it sped up efforts already under way to deploy community health workers to reach patients.

“We realized that the normal way we serve patients with chronic conditions and our most vulnerable patients was no longer going to be in person, and had to be done remotely,” explained Robert Fields, M.D., senior vice president and chief medical officer of population health, Mount Sinai Health System, in a recent online meeting. “We couldn’t depend on typical passive models and wait for patients to call us. We had to do even more outreach than we typically do. Front-desk staff had to convert to calling our registry of the most vulnerable patients.”

Mount Sinai care managers were identifying very high rates of food insecurity and behavioral health issues, Fields said. “We needed to create a structure and enhance partnerships with community-based organizations to do the outreach we needed.” Mount Sinai’s population health group has some social workers to do outreach, but during the height of the COVID outbreak, they had to do outreach to many more people than they were staffed to do. “It required a fast-forward of evolving our strategy of using community health workers to help us do that outreach and identify people at high risk or newly in need. Because they lost jobs or had family members ill, we needed to find them quickly. Community health workers were key.”

Fields said Mount Sinai also realized that for these relationships with community health workers to be sustainable, they had to evolve from grant-based or community benefit-based because that undervalues the services and ultimately the value to patients. “We are creating a structure that brings community health worker nonprofits and other nonprofits into our network so we can share data more explicitly and cooperate operationally and financially, so they can participate in value-based dollars that the population health contracts bring. That is our ultimate goal.”

Rush University Medical Center extends patient outreach

Rush University Medical Center, on Chicago’s west side, had already begun deploying a data-driven patient engagement strategy before the pandemic hit. Using a platform from CipherHealth, Rush was working on more closely following patients after they leave the hospital to reduce readmissions and emergency department visits and to ensure smoother care transitions.

“During the COVID crisis, we have added things,” says Vanessa Roshell-Stacks, Rush’s former vice president of care coordination, clinical documentation and hospital operations. “We know we are in a pandemic and we had to get out in front of it. We didn’t want people showing up in the emergency department with some acute exacerbation because they were afraid to come in. We decided to be more proactive and created what we called our COVID longitudinal calls.” For any patients who are COVID-positive or discharged from the inpatient setting or ED, Rush initiates calls to them asking specific questions related to COVID. These calls continue for 14 days post-discharge from the hospital or ED. “We wanted to better understand what was happening to them after discharge and a little longer term,” she says.

Rush also enhanced its collaboration with community-based organizations to offer services such as food and prescription medication deliveries and home visits from volunteers. For patients living in neighborhoods without access to healthy food, or in areas where grocery stores and pharmacies were closed amid the George Floyd protests, staying in closer touch became increasingly important.

Another change, called the “Virtual Care Triad,” involves widespread distribution of communication devices such as iPads to admitted COVID patients’ family members to facilitate patient-to-family communication and alleviate some of the patients’ loneliness.

Many of the changes Rush made to cope with the pandemic are likely to continue going forward, Roshell-Stacks says, “particularly our Triad model reaching families who aren’t able to come into the hospital. Our visitor restrictions are still in place. Even though we are not at the height of COVID as we were, families have loved ones in the hospital and can’t visit. It is heart-breaking. We had a wife parked on the street all day because she just wanted to be close to her husband of 40 years who was in the hospital. That struck a chord. We have to ensure they stay connected and are getting the information they need. We know that drives patient and family satisfaction.”

“Our longitudinal calls will continue as well,” Roshell-Stacks says. “The concept of doing more outreach to patients will continue, whether we are in the midst of a pandemic or not.”

Mass General Brigham puts health equity at the forefront

Health equity has been a topic of increasing importance to health systems for several years, and the disparity in impact of COVID-19 on African-American, Latinx and Native American communities may be the thing that catalyzes meaningful change. In March, Boston-based Mass General Brigham (the new name for Partners HealthCare) launched an Equity and Community Health COVID Response Team, with changes to outreach that will likely last long past the pandemic.

In May, Joseph Betancourt, M.D., vice president and chief equity and inclusion officer of Massachusetts General Hospital, led a team of Mass General Brigham (MGB) leaders in describing multiple aspects of the health system’s response. Initiatives ranged from redeploying doctors and researchers and building a registry of multilingual clinicians to enhancing clinical communications to patients and employees, and ensuring community access to updated information. “We anticipated that the social determinants of health crisis would be exacerbated and began to focus on how we might mitigate those,” Betancourt said. “We pivoted to a community-based public health equity COVID strategy in hot spots.”

Aswita Tan-McGrory, the deputy director of the Disparities Solutions Center at Mass General, stressed that it is important to stratify data by race, ethnicity and language and make sure clinicians understand who the patients are and where they are coming from. “This is how we were able to identify that on our COVID floors, over 50 percent of our patients were Spanish-speaking,” Tan-McGrory said. “In terms of thinking about discharging patients to a recovery location, how do we integrate interpreter services there and what technology do we need to use? Thinking about remote monitoring programs — we have set these up for patients, but they do need to be pretty savvy, so how do you address the language component and technology barriers? We spent a considerable amount of time translating educational materials both for patients and employees.”

Elena Olson, J.D., executive director of the Mass General Center for Diversity and Inclusion, described how MGB worked to leverage their multilingual work force for COVID needs. “So many of our patients and employees impacted by COVID are limited English proficient (LEP),” she said. “We decided that we wanted to create a multilingual staff directory that would include both clinicians and non-clinicians. We had research staff that had not been able to do their regular research, so there were a lot who were multilingual and available to help out. How could we collect this data and provide help with employee education as well as patient-facing operations?”

The equity effort extended to how MGB conducted telehealth visits. “COVID really challenged us to make sure that our virtual health solutions could have the same kind of equitable reach as our in-person care, so that meant connecting with folks who focus on medical interpretation to make sure we could provide medical interpreters to them through the same channel,” said Lee Schwamm, M.D., MGB’s vice president of virtual care. “It also meant making sure that we thought about systems to engage our patients both into our electronic health record as the primary gateway to doing virtual visits, but also to think about the patients who for whatever reason were unable or reluctant to use that channel and provide alternative channels to connect those patients to their physicians.”

All of these changes made in the short-term to address the COVID emergency can inform long-term strategy about patient engagement in the region. Schwamm said it is important that “leaders of organizations trying to find the path forward in this new world order of ambulatory care in the era of COVID ensure that there are guardrails in place to make sure we have equitable access for all our patients.”

For instance, he says, telehealth for cancer care may persist. (See sidebar, p.8.) “We will have to do patient satisfaction surveys, but the patients we have been dealing with are not unhappy with this,” Reddy says. “They understand that there are limitations because of the pandemic. This is a good way for people who don’t need to be seen in the office setting to engage with a practitioner. It allows us to expand our reach and check in more frequently, and I think that improves the quality of care. The only reason it wasn’t adopted earlier is that there was zero reimbursement support. Because of reimbursement changes during the pandemic, it has been universally adopted, and I think you have seen for the most part, effective use. Patients are happy, and doctors are happy. If you need to tell somebody about their laboratory test or symptoms that don’t require a face-to-face visit, why not do that? It’s less costly and better for everyone. That is something I hope we can learn from.”

In addition, Reddy says, both patient-reported outcomes and remote monitoring of vital signs through something like an Apple Watch are becoming much more attractive concepts, “and remote monitoring is so easy because the patients don’t have to enter data into a journal.” The pandemic brought out very quickly the need to evaluate temperatures remotely, he adds. “It doesn’t require much added effort but provides really important information about the health of a person. We know whether patients are sitting in bed for 12 hours after chemotherapy or are up and moving around. Without a doubt, that type of technology is here to stay. It is ubiquitous and cheap and now we know it is effective.”

To accompany the main story, our editorial team put together a collection of other case studies that looks at new modes of engagement, including patient monitoring, that might survive beyond the end of the COVID era because clinicians and patients find them valuable. Below are those respective stories.

“Yes, we are ahead of a lot of people in patient engagement virtually,” says Gina Altieri, executive vice president and chief communications officer for Nemours Children’s Health System. “We always had our KidsHealth.org information available online for parents, teens and kids for 20-something years. We invested in the EHR [electronic health record] 20 years ago. So wherever you were, it was the same record. We also had a pretty robust patient portal, so clinicians could retrieve the information they needed virtually, and in addition, we had our telehealth program, enterprise-wide, for all providers. And then we created the technical logistics center at our Orlando facility, beginning in 2012. So because we had made those investments, when it was time to actually start using them at a scale way above anything we had done before, we were able to do it quickly and effectively,” with Nemours going from fewer than 100 virtual visits a day to over 1,500 a day within just a couple of weeks—a 2,400 percent increase.

“One of the key things that we had been working on prior to COVID was an integrated telehealth platform with our Epic EHR, and we had to simplify scheduling for telehealth in order to fully integrate the systems,” says Carey Officer, operational vice president of the Nemours Center for Health Delivery Innovation. The workflows between the Amwell platform [from the Boston-based Amwell] that the Nemours clinicians were using for telehealth, and the Epic EHR, “tend to be different,” she adds; so integration work had to be done, but was accomplished successfully.

“And what we learned during this time was that families were confused: if I’m looking up information on the web, and then have to download an app, and then go into a patient portal, that is confusing to families,” Altieri says. “And the thing we had been working on for years was creating a seamless digital experience. We realized that was really necessary. We actually launched that app this month; it was a fun launch, 35,000 people are using it, and it’s been going well.”

Have there been any specific challenges? “We did have some challenges around regulations, laws, and licensure; all of that existed,” Altieri says, though she also notes that the public health emergency rules created by the Centers for Medicare & Medicaid Services (CMS) lifted some of the more onerous burdens. “Reimbursement was and still is a challenge,” she adds. “Also, not everybody has a good connection at home,” so there remain connection challenges.

But, by and large, Officer says, “Private payers came along, which is great. Some even reimbursed copays,” she notes. “And the same thing happened with Medicaid. That allowed us to go from 1,000 to 28,000 visits a month, so that was critical.” That said, she adds, “There was a lot of confusion on the payer side; we had to resend the claims so that they could process the claims in their systems. That’s caused a lot of back-end work. And that digital equity is not the same in all populations. So, connectivity and digital literacy remain problems.” Still, all in all, the shift into virtual, with a comprehensive digital platform accessed by families via Kidshealth.org, has been a resounding success.

What about the technology and equipment involved? “We had to provide more equipment, and adjust it as needed,” Officer says. “And we had different types of technology and equipment to connect them. We had the infrastructure set up and were ready to go. The vendors experienced such a load. They stepped in and purchased the additional bandwidth necessary to accommodate the services; but that was a shock to the nation,” she says, speaking of the sudden need for a massive increase in bandwidth needed overall across the U.S. healthcare system and beyond, at the outset of the pandemic.

What have been the biggest lessons learned? “From my perspective, it’s access: the consumer wants access,” Altieri says. “They want it to be convenient for them, and they want it when they want it. And in order to achieve a win-win, we needed to provide data to the providers. So this is great; a provider is thinking: I have access to information about you even though you’re not coming into the office. That made it a win-win, so that they wanted to use as much technology as they could. And they care, of course. It gave them more access to the patients as well.”

What would their advice be for the leaders of patient care organizations not as advanced as theirs is? “Start now,” Altieri says. “It takes planning, it takes a lot of effort to be able to have that smooth experience. And there will be some other crisis in the future. Plan now, and give it the consideration that it needs.” And always remember, Officer says, “It’s not just about the technology, it’s about the people and the process—the people, the workflows, the change management, and the engagement.”

Chronic Care Management: Reimaging Engagement Through Remote Patient Monitoring

By Rajiv Leventhal

Putting their brains together, Regis and his team launched a virtual office right by its corporate headquarters, inclusive of a 12-person staff which had an initial task of calling all attributed members to get them in for annual wellness visits. Indeed, given that the traditional in-person visit was going to be extremely limited throughout the pandemic, the group’s leaders realized they needed to shift their priorities from episodic care to care management. They knew that the Centers for Medicare & Medicaid Services (CMS) had recently come out with new reimbursement rules for remote patient monitoring codes, so the organization, with its IT partner CareminDr, developed a remote patient monitoring app designed to connect with patients in between provider visits.

Via this app, says Regis, the Reliance team began to monitor its hypertension and diabetic patients, checking in with them intermittently. If patients ever fell off protocols—such forgetting to take blood pressure or medications, for instance—the app would alert a connected Reliance staff member, which would then lead to a physician-patient phone call and possibly a follow-up telehealth visit. For the medical group on the back end, all of this could be coded and sent to CMS for reimbursement.

To this end, Reliance simultaneously launched its “red bag” initiative where it handed out actual red bags with the organization’s logo to patients, putting home monitoring devices such as blood pressure cuffs and glucometers in them relative to the patient’s needs, along with important educational material, free of charge to each person, says Regis. The red bag program, originally for hypertension and diabetes patients—of which 6,000 were pulled from the group’s EHR—has been expanded to include patients dealing with COVID-19. “That red bag actually became famous in the community. People have been walking around with it and going shopping with it. This red bag is just as important as your prescription,” says Regis.

Regis’ ambitious goal is to get each one of the organization’s 70,000 patients live on the app. In some cases when individuals don’t have smartphones, Reliance has provided one for them. “We want to put everyone on this journey,” he says, noting that about 1,000 patients are on right now.

Regis says the program is more successful than what his team originally expected, both in terms of patient engagement and revenue. For the latter, Reliance is generating close to 98 percent of its pre-pandemic revenue, and while reopening for in-person visits has contributed to that, he strongly credits using the remote patient monitoring codes as well. “The beauty of it is that these codes and opportunities are already there. We’re not asking Congress to go to the taxpayer with some special stimulus package,” he says.

On the engagement front, the Reliance team has found that most patients quickly take to the program. Between the check-up alerts and the ability to have a phone call with a provider by the end of the day, if requested, “Our patients [like] that we’re monitoring them and they know that we have listened to the issues they were having. They are fascinated by this system,” Regis contends.

He asserts that the program is ideal for serious patients who aren’t reluctant to go on this engagement journey with the practice. “And if they are, it may be that it’s best you switch providers,” Regis acknowledges. “This pandemic is going to change healthcare forever and some of those changes will be positive,” he adds, pointing to the prevention of ER visits and hospitalizations through Reliance’s home monitoring program. “The days of coming into the office to get your prescription and have your blood pressure checked are gone. We’re going to find new ways to engage our patients—wherever they are.”

Rehabilitation: The Centre for Neuro Skills Adapts to a COVID-Influenced World

By Mark Hagland

At the Bakersfield, Calif.-based Centre for Neuro Skills (CNS), clinician and administrative leaders moved quickly to adapt to the new COVID-19 pandemic, in a patient care area not historically seen as easily adaptable to telehealth-based care delivery—the area of rehabilitative care for brain injury.

Understandably, converting this normally “high-touch” form of care to a virtual format presents special challenges. Yet one organization has successfully made the leap.

Indeed, at the end of March, the Centre for Neuro Skills, which provides rehabilitation services for patients living with traumatic and acquired brain injury in Bakersfield, San Francisco, Los Angeles, Dallas, Ft. Worth, and Houston, announced that it had converted all patient therapy sessions to remote care, using existing telehealth technology. The shift was not as challenging as might have been feared. “Things are going pretty well for the most part,” reports David Harrington, the organization’s president and COO. Initially, he says, “We flexed 100 percent to telehealth. And we were trying to keep the inpatient and outpatient separate. We were really most concerned about the inpatient care, where they’re in one of our facilities.” Over time, he says, Centre for Neuro Skills clinicians were able to refashion care delivery into a careful mix of safe in-person care delivery and virtual care, assisted by family member caregivers who are physically in the presence of the patients.

“What we’ve done is that we’ve slowly migrated patients who weren’t as successful with the telehealth approach back to the clinic,” Harrington explains. “So we have patients at the residential site, and in those cases, the clinicians are going out to treat them. We’ve studied what we’ve done; there are patients who didn’t do as well with the telehealth approach. We also have patients who’ve done very well with the telehealth approach. Some patients are hybrid: a subset of day treatment patients will come in in person for all the disciplines. Others are only telehealth. A third subset will be successful with speech therapy, educational therapy and counseling, but really need to come in for the physical and occupational therapy.”

And what does patient engagement look like in the neurological rehab world? “It involves really trying to understand the specific needs of a particular patient, and to build that program around that patient,” Harrington says. “And it does involve the whole family ecosystem that we have to manage,” including with the full participation of family members who are family caregivers. In terms of the durability of the solution, we’re relying on the patient to go the longer distance, and in many cases, that involves family member caregivers.”

Brain injury rehabilitation remains a challenging area when it comes to delivering virtual care. “Looked at through the patient lens, the social distancing” involved in telehealth-based care delivery remains a challenge, Harrington says. “When a person has a brain injury, they often feel isolated and alone, and that can create a lot of anxiety and depression. Now you layer on the pandemic, and the patients are further isolated. Patients would come to the clinic and find validation with people sharing the same struggles. And also, seeing your friend make progress, and using their progress as a guidepost—that’s kind of lost. So maintaining some kind of group process remains critical.”

Meanwhile, Harrington and his colleagues have left nothing to chance; in particular, they’ve leveraged data analytics to help them sort through what’s working optimally and what might not be. “We measured adoption from staff, patients, family members,” he reports. “And ultimately, what are the outcomes? We had our data scientists and researchers, and looked at the outcomes; there were 58 patients who received in-person, versus four who received telehealth. And the conclusion was that patients with telehealth had the same level of progress as those with in-person care—even among inpatients. For years, we had been trying to better integrate our residential and clinical staff. So all of a sudden, we had clinicians more present with the residential staff. That gave our direct-care staff the opportunity to connect with the clinicians. The residential acumen among clinicians improved; the clinical acumen among the residential staff improved. It’s what it did to us in terms of the culture, and how we blended those two treatment modes to become one. And so they become more integrated, for better outcomes.”

Three key lessons have emerged from the experience of this so far, Harrington says. “It really has been a case study on three fronts: one, in terms of healthcare delivery. Two, in terms of organizational behavior, how do you manage change and pull people along? And three, sustainability: how do we make sure we sustain our organization? It means dropping your preconceived notions about what can or cannot be done. A lot of people in our space felt that this could not be done, because of artificial constraints they were putting on themselves. Sometimes, we limit ourselves. One of our mottoes is to find a way; this is a perfect example of living that out.”

Post-Acute Care: Hospital at Home Model Gains Momentum During Pandemic

By David Raths

COVID-19 hit South Carolina later than some regions, but when it did, Prisma Health, the largest nonprofit health organization in the state, was ready to pivot to an innovative “hospital at home” model to help cope with the surge and to meet patients’ needs. That approach is likely to outlive the pandemic.

Angela Orsky, R.N., vice president for post-acute services, says that Prisma had been working for a year on setting up a joint venture with a company called Contessa Health to offer acute-care services to patients in the home using both on-site and hospital-based nurses, telehealth and remote monitoring overseen by a Prisma hospitalist.

“When South Carolina started seeing a surge in COVID cases, we began brainstorming with Contessa about our options for patients to receive care in their homes. Our work with payers allows us to offer a solution where once patients are stabilized in the hospital after a day or two of hospitalization, we could transition them home to complete their acute care services — and it could be a COVID or non-COVID patient,” she explains.

Prisma contracts with Contessa for a team of nurses called recovery care coordinators who are embedded in the hospital and are very familiar with the model of care and the clinical pathways. They do remote monitoring of the patients and communicate with the other care team members.

The issues around hospital capacity and patients’ anxiety about COVID and hospital stays — and the fact that visitors were not allowed in hospitals — all reinforced the use of a solution that redesigned how Prisma delivers care, Orsky says. “We already had this relationship with Contessa and we already had infrastructure in place. The timing was perfect to implement a program like this and do it rapidly,” she adds. “Our patients have fallen in love with this opportunity to be back at home and are seeing the benefits of recovery in their own home setting. When we looked at what was happening around us in South Carolina, it just made perfect sense for us to be able to pivot and offer a different solution.”

Orsky notes that older patients are stressed and at increased risk of falls and delirium when removed from their home environment. “A lot of that is eliminated when you are able to bring care to them,” she says. “We have full intentions of continuing to leverage this program wherever there are opportunities in value-based care models.”

Contessa has been working on the hospital at home model with Mount Sinai Health System in New York for several years. “New York was experiencing a massive surge, with hospitals at full capacity and running out of PPE,” he says. “We were able to get some of the patients out of the hospital and yet provide hospital-equivalent services to free up capacity.” He notes that within 10 days of Mount Sinai’s initial outreach about the COVID emergency, Contessa was moving Mount Sinai patients out of the hospital and into their homes. These patients saw their risk of infection decrease, while comfort and satisfaction increased, he adds. Clinicians also identified patients with COVID symptoms they were comfortable treating in the home, so Contessa began accepting patients who tested positive for the virus into the Mount Sinai at Home program. The biggest challenge was making sure there was enough PPE available, he says.

When the virus started proliferating across the country, Messina says, a number of health systems called the company because they needed something to help with the surge and create as many beds as possible — physical or virtual. “One cohort of health systems is only thinking about the near-term problem, but another group contacted us because they had an epiphany of sorts and realized they needed to think about this for the long-term,” Messina says. “I applaud them, because while they had a team doing disaster planning, they also had another team planning for the future and being methodical in terms of how they build this out to be a critical component of their delivery system.”

Is such a program scalable absent a pandemic? It isn’t yet covered under Medicare fee-for service. “I would say the increase in health plans covering this demonstrates that it has a sustainable and scalable dynamic to it,” Messina says. “The biggest problem has always been a lack of reimbursement. Now Contessa has demonstrated with the dozens of health plans we have reimbursing for it that this is a model that patients and payers want, and it can be scalable now that there is broader adoption.”