LeadingReach News

Primary care facilities, often the first point of contact for many patients, may be hampered by outdated and inefficient processes, but data analytics can provide a potential solution.

Primary care is an essential facet of modern healthcare, serving as the conduit through which many patients access and engage with available medical care services. When a patient has a non-emergency health concern, a primary care physician (PCP) is charged with evaluating them and providing guidance on diagnoses, treatments, and next steps. If the patient’s concern requires additional testing or expertise that a PCP doesn’t have, a referral to a specialist is often necessary.

Referral processes look different at every healthcare facility, but all of them rely on data sharing. In the past, patient information was collected and stored on paper, and shared via mail or fax. Some facilities still rely on these more traditional methods, which can cause significant inefficiencies and burdens for clinicians.

Other primary care facilities, such as Central Ohio Primary Care (COPC), have chosen to alleviate these issues by going digital. Ed Helvig, patient access manager at COPC, spoke to HealthITAnalytics about how the organization is using data analytics to streamline referrals and improve the primary care experience.

DATA ANALYTICS AND DIGITAL TRANSFORMATION

Digital transformation is a term that comes up often in conversations with health systems that want to become more efficient in utilizing the data they collect and in better serving patients. COPC is no different, according to Helvig.

The organization, headquartered in Westerville, Ohio, includes 500 providers across 85 practices that serve 450,000 patients in the area. COPC has expanded beyond the primary care office, with teams at hospitals across the region and a growing offering of ancillary services, but the focus remains on providing high-quality preventative and chronic care.

Meeting those goals requires effective data collection, management, and analytics. With COPC’s large patient base, reliance on traditional methods created barriers and waste throughout these processes, Helvig noted. Thus, the health system partnered with analytics company LeadingReach to accelerate its digital transformation and streamline key processes, such as referral management.

STREAMLINING THE REFERRAL PROCESS

Referrals are crucial for patient care, as they are the main method PCPs use to connect patients with a specialist when needed. Prior to EHRs and digital data sharing methods, providers, including COPC, had to rely on paper-based methods.

According to Helvig, a typical referral at COPC contains patient identifiers and contact information, like their name, date of birth, and phone number, in addition to referral-specific information, such as the name of the specialist or organization the patient is being referred to, the location of the specialist or organization, and the reason for referral. Necessary medical documentation, including past laboratory or exam results, is also passed along with the patient’s insurance information.

“Prior to implementing LeadingReach, we relied on the old unreliable fax method,” Helvig stated. “A week or so after referral submission, we would contact the specialist to see if our patient has been scheduled for an appointment, and often times, be told that they don't have our fax referral on file. So, this obviously created increased delays in patient care and unnecessary and costly duplication of effort. LeadingReach allows us to submit referrals digitally. Sometimes within minutes after submission, we receive an updated status from the specialist of either 'received' or 'accepted.'”

Because all referral data is fed through the analytics platform, COPC’s referral coordinators spend significantly less time performing follow-up as the process has been streamlined and specialist receipt confirmations eliminate the need for follow-up, Helvig continued.

Previously, following up required referral coordinators to spend much of their time calling specialists’ offices, being on hold, navigating complicated phone tree systems, and leaving voicemails that often went unreturned. By utilizing digital messaging and data analytics, these barriers have been mostly removed and referral coordinators can quickly follow-up on only those referrals that require it, Helvig stated.

“In the first 10 months of implementation, we were able to digitize nearly 90 percent of all of our referrals going out our door, a volume that is averaging around 6,000 referrals a month,” Helvig said. “So, to be able to have that electronic capability, and [have] peace of mind that we're not worrying that the specialist doesn't have a referral, or it's lost in transmission… [is] just a huge, huge win for really any PCP office.”

GENERATING INSIGHTS AND IMPROVING PCP-SPECIALIST COMMUNICATION

Not only has the addition of the analytics platform streamlined the referral process for COPC, but it has also helped the organization generate key insights and improve communication.

“[Prior to implementing LeadingReach], we were unable to obtain really the big picture view with our networks data, with referrals, which would help us make sense of the large volume and identify inefficiencies and bottlenecks within our own workflows,” Helvig noted. “We now have insight [in]to key statistics available in real time, such as referral response rate, patient decline reasons, average length to schedule an appointment, and the ever-important referral-to-appointment ratio, which allows us to close loops after a patient sees a specialist.”

In addition to these insights, the analytics platform allows COPC specialists to see reports on their performance during the referral process. This reminder of operational efficiencies, or lack thereof, often leads to conversations between Helvig and specialists’ offices about process improvement.

These conversations have been extended to referral sources outside of COPC as well, according to Helvig. Various specialist groups have been reaching out for conversations about how they and COPC can better collaborate and improve processes, so that patients receive high-quality, timely care a lower cost.

This improvement in PCP-specialist communication is a major success for COPC since starting the digital transformation process, considering that communication in healthcare is fundamentally broken, Helvig noted.

Because this communication pathway has been opened, it is significantly easier to monitor a referral and close the referral loop once the patient has seen the specialist, he continued.

Closing referral loops is just one component of effective care coordination and bridging care gaps, but it is critical for patients to move along the care continuum. Implementing data analytics is just one strategy to address these challenges, but experiences of organizations like COPC show that it can prove effective.

As one of the largest physician-owned primary care groups in the U.S., with more than 450 providers across 80 practices serving more than 400,000 patients, Central Ohio Primary Care was dealing with a lack of connectivity and usable data with its fax- and phone-based referral intake system.

THE PROBLEM

After referrals were created in the electronic health record system and sent off, staff often could lose sight of the patient and their follow-up care.

"We did not have the ability to quickly obtain simple status updates on referrals through the scheduling process or even determine if they had been received on the specialist's end," said Ed Helvig, patient access manager at Central Ohio Primary Care.

"It wasn't until the first follow-up, usually around seven days later, that we would gain a bit of insight, sometimes calling the specialist only to find out then that they hadn't even received the referral at all.

"Other times our staff would be on hold for 10-15 minutes, would have to deal with cumbersome phone systems, or would end up leaving a voicemail, sometimes in the wrong person's voice mailbox, in hopes that the message would be received and replied to soon," he added.

Relying on manually faxed notes also was problematic and created extra work. The organization was losing five to 90 minutes per referral by using a fax- and phone-based manual referral-management system, with no way of capturing and analyzing data to report or identify what was working well and what needed to change in processes.

Staff had tens of thousands of open referrals in the EHR with limited context on where patients were in their journey.

PROPOSAL

Vendor LeadingReach offered the network of physicians the ability to communicate efficiently and effectively, regardless of the native software of each provider office, Helvig said.

"We could create a LinkedIn-like community connecting our referral partners to us to allow for the passage of critical information among providers that our EHR wasn't able to manage," he explained. 

"By leveraging their referral management technology and analytics tools, our staff would have the ability to easily track referrals, follow up with them in a timely manner, and ultimately close the loop on patients whose care needs were now handled by a referred provider.

"We also would be able to track performance across our locations to identify process bottlenecks or similar care coordination challenges," he added.

MEETING THE CHALLENGE

Instead of using a one-size-fits-all approach, LeadingReach proposed a tech-based referral system that was customized to fit Central Ohio Primary Care's specific workflow.

"As our initial approach to managing referrals was challenging, it was clear that working with a partner with expertise in the referral space would be a great benefit to staff and patients," Helvig said. "We have been able to successfully connect the network of providers digitally and create a streamlined referral process that has increased efficiency, improved patient outcomes and lowered cost of care.

"With the new streamlined referral-management process and software, PCPs, nearly 1,500 specialists, and care coordination teams in the COPC network have gained more insight and understanding into each patient's unique care plan to help the patient navigate to the next care setting and gained more time in their day to allot to other patients," he added.

With the reporting that staff now is able to do, the organization has optimized its provider network by diverting patients away from less efficient specialty practices and toward the ones best equipped to provide care.

"We now have insight into key performance metrics in real time, such as referral response rate, patient decline reasons, average length to schedule a patient, and the all-important referral-to-appointment ratio, which allows our PCPs to close the loop of care after a patient has been seen by a specialist," Helvig noted.

"With the LeadingReach Analytics platform, we are able to have robust reporting and remind specialists and PCPs of the operational efficiency level their offices should regularly demonstrate to increase our operational efficiency, improve speed of care, and subsequently improve the quality of care for our patients," he continued.

This personalized data delivered on a regular basis allows for care coordination teams to have more meaningful, data-driven conversations with staff and provider networks. With this new referral process and its proven efficiency outcomes, the organization's central referral center has taken on increasing responsibility, and is a valued part of the organization.

RESULTS

Central Ohio Primary Care has shifted away from fax-based referrals and now is digital, allowing staff to see measurable and improved metrics across performance and patient outcomes.

"Follow-up calls were replaced with digital messages sent through the platform, saving referral managers multitudes of time," Helvig reported. "Initially, the organization's referrals were 59% fax-based and 41% digital, but after 10 months, we were able to digitize 89% of all referrals.

"We now are able to manage six times the number of referrals monthly at the central referral center – all without hiring more staff," he continued. "This also has allowed PCP care teams the time and resources to focus on assisting more patients, and has helped in achieving a 100% increase in appointments for referred patients."

ADVICE FOR OTHERS

Don't get stuck in ways of the past, Helvig advised.

"Just consider the basic hurdles of traditional, and what some may call antiquated, referral management, all the barriers of a provider office getting data from specialists such as the lost faxes, the search time, the long hold times, voicemails that aren't returned," he said.

"Provider organizations are doing a disservice to their staff, but most especially their patients, by dragging their feet and not getting referral management under control," he concluded. "The transition to digital isn't hard and the ROI is monumental."

A chronic disease management pilot program designed to digitally connect health care providers and community-based agencies reduced HF readmission rates and improved communication among care team members, according to a case study.

The South Texas Physician Alliance (STPA), an independent physician association serving the Lower Rio Grande Valley, worked with health care communication company LeadingReach to digitally coordinate care for its Heart Failure Reduction Program. The 30-day program is initiated when the hospital sends a collaborative referral for a HF patient. Care team members use a digital platform for confirming appointments, communicating issues via a team chat function and sharing documents.

The program is designed to improve overall patient well-being; however, the STPA also observed an overall reduction in HF readmission rates as well as improved care coordination across agencies, according to Sheila Magoon, MD, executive director of STPA.

Healio spoke with Magoon and Curtis Gattis, CEO and co-founder of LeadingReach, about the importance of collaborative care in HF, getting ahead of patient challenges and plans to expand the program beyond HF.

Healio: Why was there a need for this type of program, specifically for HF?

Magoon: We have had readmission issues and high admission rates in our region for many years. This issue has always been on our radar, and we have been approaching it from a variety of different standpoints. When we looked at Medicare data for HF in particular, our readmission rates ran 22% to 23% in our region. This is something we need to figure out how to fix. We chose to focus on HF for several reasons. First, it is an outpatient treatable condition most of the time. Second, HF, unlike sepsis, which also has high readmission rates, is a condition that could be more amenable to a pilot program.

Gattis: Communication has been broken in health care. We are in the business of connecting communities digitally. If you look at a typical HF patient, this work has really opened our eyes to the team-based approach that is required for it. HF requires not just the primary care physicians and the cardiologists, but subspecialists — a HF specialist, HF nurse, imaging centers, case managers, pharmacists, physical therapists and home health agencies. It is a challenge in the urban areas, but once you get down into the Lower Rio Grande Valley and overlay the social determinants of health and other unique challenges, a program like this provides a great opportunity to move the needle in a big way. If we get ahead of these challenges, we can keep these patients healthier.

Healio: How did this program come together and how does it work?

Magoon: One of our larger hospitals came to us and said, ‘We have a readmission problem.’ We said, ‘So do we.’ They are all our same patients. So, how can we fix this? We were already working with LeadingReach in the classic physician-to-physician referrals. I have seen what it can do.

At the same time, local emergency medical services initiated a community paramedic program. The hospital administrator and I started building this program out. We created a plan where the hospital case manager would identify the patients with HF while they were still in-house, and then we designed what we call a collaborative referral. That referral goes to the community paramedic. It goes to our care transitions nurse. It goes to the PCP. Then, anyone else we need to tag in who is already known to the care of that patient could be added to this referral that goes out electronically. Now, we are all held responsible to each other. We have the greater level of accountability.

We met with the other stakeholders — PCPs, community paramedics — everyone agreed this was a great opportunity. We put together tracking tools and education programs. Then we went live.

The community paramedic goes into the home twice a week. Our care transitions nurse calls patients in between. We have a weekly huddle and we ask the PCP to see the patient post-discharge within 7 days. Our increased ask was to follow up with the patients just before 30 days after discharge. The community paramedic is who is responsible for closing out that discharge.

Healio: What are the results so far?

Magoon: It is a small number of patients, but we have been able to get our readmission rate down to 13.3%. We are excited. Additionally, the local social service agency is also connected to LeadingReach. That has been a huge benefit. If the team identifies a person who cannot afford medications, we can refer them to the agency. It is all built into the platform. We have been able to address patient needs in a way we have not been before. That has been a wonderful piece to be able to pull together in a new way.

Healio: You mentioned readmission rates falling and addressing patient needs. Any other lessons learned since implementing this program?

Magoon: For the patients readmitted, we found there was often no support in the home. When there is good support in place, and we support that home support, patients tend to do better. We recognize that is a challenge.

Another challenge is end-of-life care. We want to help the patient and family better recognize that is where they are and help them through. It’s one thing to complete your advanced directive counseling, but patients need emotional and spiritual support. We recognize that we need to add that into the program, as well as behavioral health support.

Gattis: What Dr. Magoon just illustrated is the definition of the team-based approach to health care. You cannot build on programs like this one unless there is a good foundation in place to make sure the patients get what they need. We can say we have gone from 23% to 13%. Now, how do we tackle the more challenging pieces? Some patients have no support network. Some patients cannot or will not take ownership of their health. Then there are those who do want help but do not have the resources. This program gives the PCP the opportunity to hold that network accountable. Our technology allows us to monitor and see what is going on. We can see who is having staffing issues. We can monitor what is going on across the network and identify gaps in personnel and other challenges.

Healio: Are there plans to expand on this program?

Magoon: We do plan to expand and take on additional diagnoses. In addition to HF, we would like to take on sepsis follow-up. That is our other big primary diagnosis that ends up with a readmission. We want to add a broader profile of patients and then look to continue to add additional community-based organizations, see if we can identify someone to help us with behavioral health support, as well as the additional pieces of the medical community at large that can benefit our patients. It’s all about right care, right time, right resources.

Gattis: This is exciting for us to empower these thought leaders and physician leaders in the communities we work in. We are big believers in value-based care. We want the PCPs to have the ability to be actively managing their patients’ health. If we can stop some of these problems at the PCP level and reduce specialist burden, we will have healthier communities. I love bringing our technology to the table and listening. Software never sleeps; we are always doing new things. We look at what the Dr. Magoons of the world see as the next-level challenges and we go and support efforts to make these communities thrive.