Front-Office Integration Improves AdvantageCare Physicians' Patient Experience

Added on Mar 21, 2019

Front-Office Integration Improves AdvantageCare Physicians' Patient Experience, Workforce Engagement
By Whitney Fishburn

By investing in the professional development of front-line staff and integrating front- and back-office tasks using value-based principles, one of New York’s largest health systems transformed its front-office staffing model. One year later, the system’s patient experience scores are trending upward, and anecdotal evidence of workforce satisfaction and engagement also indicates positive change.

AdvantageCare Physicians (ACPNY), with 36 locations across New York City and Long Island, is responsible for treating half a million patients annually. Daily primary care physician visits at ACPNY collectively average around 10,000, and approximately 850 front-office employees currently support more than 600 primary, specialty, and advanced practice medical personnel.

In 2017, ACPNY was already accredited by the National Committee for Quality Assurance (NCQA) as a Level 3 patient-centered medical home and was in the 90th percentile across most Healthcare Effectiveness Data and Information Set (HEDIS) measures to address gaps in care. However, its patient experience measures showed room for improvement in care coordination and patient–staff interactions.

Input from provider, operational, and nursing departments revealed inconsistent staff performance, likely driven in part by unscheduled callouts and attrition over 10%. These factors likely were contributing to an inconsistent patient experience and, as a result, fluctuating service levels.

Based on this insight, ACPNY leaders realized that the traditional primary care team model of two providers, one nurse, two medical assistants, and two patient service representatives, with coordinators and patient advocates filling in the gaps, was not meeting their needs. “We needed a model that could provide our support staff with the collaboration, agility, and team approach needed to effectively deliver high-quality, value-based care,” ACPNY’s senior vice president and chief operating officer, Anne Dunne, said during a recent webinar.

To ensure that front-line staff had knowledge of all office functions and to help address cross-coverage, Dunne created a new two-tiered care team associate role. Working with ACPNY’s vice president of human resources, Jessica Chiclacos, new job descriptions were created, and these changes were negotiated with union leadership. A level one care team associate would have the skills of a patient service representative, a patient advocate, a surgical coordinator, and a cardiac procedural coordinator. A level two care team associate would have all of these skills, plus the clinical know-how of a medical assistant. Pay raises would be given to those who successfully completed the necessary training to earn care team associate designation. As an added incentive, any care team vacancies would be filled only by level two care team associates.

Customizing Training Development

To achieve their staffing training targets and increase their competitive standing, Dunne and her regional operations and clinical directors collaborated with Press Ganey Strategic Consultants to create a customized professional development training program designed to standardize procedures and improve staff performance. The modular training curriculum combined best practices in service behaviors with the cross-training didactic content. The goal was to promote workforce flexibility and maximize efficiency by ensuring that the care team associates could perform any necessary function on any given day.

To develop the training program, the ​Strategic Consulting team and managers visited care locations that they determined would offer the most useful data for building a snapshot of a typical day-in-the-life of front-line ACPNY staff. Through these visits, they were able to identify gaps between organizational expectations for operating procedures and service behaviors, and staff expectations and behaviors.

The development team also canvassed human resources and seasoned staff members who had witnessed the high attrition rates and could describe what the correct expectations should be for new hires, and how the hiring process could be improved. During this stage, the team also sought ways to minimize performance variability by asking high performers about their best practices so that they might be implemented systemwide. They also involved key stakeholders such as the clinical staff, call centers, and finance departments to ensure that the cross-training modules reflected the needs of all who would be influenced once workflows were integrated.

After their fact-finding mission, the team assessed which portions of the training modules would best be conducted in the training environment, which ones needed to be didactic, and what could not be addressed fully by the training modules alone.

“Some things we can definitely tackle by the broad resetting of the organization and the training of all the associates, but some things still have to happen locally,” Adam Higman, Press Ganey ​Strategic Consulting partner, said during the webinar.

To achieve this, the ​Strategic Consulting team developed a plan adopted by ACPNY leadership to carry the culture change into the future, including through continuous learning programs.

From Planning to Action

The change management was no small undertaking. Twenty members of the ​Strategic Consulting team worked with ACPNY management to train more than 1,000 employees. Training sessions were conducted only on weekends over the summer so as to cause minimal disruption to patients and providers. Additional personnel were called in to support Epic electronic medical records software training, and to provide overall IT support.

Employees were engaged in the process and eager to learn. Employees reported that they felt valued and appreciated the investment in their training and professional development. They were also happy to share what they knew with others. As a result, learning partnerships arose, which contributed to greater levels of teamwork during office hours.

The ultimate program included five modules. The first module on patient service excellence was viewed by front-line staff as well as clinical staff to set baseline expectations systemwide, according to Higman.

The second and third modules focused on traditional front-office functions, such as pre-appointment services, patient intake and discharge, and referral coordination. The fourth module brought in the medical assistant skills such as phlebotomy and rooming functions. The fifth module focused on leadership and included important skills to keep up the change momentum, including how to provide effective employee feedback, how to set appropriate expectations, and how to tie goals to outcomes and important metrics.

At all times, the modules were taught from the patient’s perspective to balance the technical and behavioral considerations, according to Higman. The modules also were designed to address real-time, unexpected situations that required care associates to respond, while maintaining their patient-centered focus.

Once the baseline was established, the ​Strategic Consulting team worked with ACPNY leadership to identify champions internally who could drive this culture of integration forward and trained them on how to be trainers themselves.

“They were already the subject matter experts. What they needed help with were the facilitation skills,” Higman said.

Front-Line Engagement Drives Performance Gains

Anecdotal evidence collected by Dunne indicates that front-line staff members are more engaged in their work, and ACPNY leadership expects the changes will equal a downward attrition rate that will reduce hiring costs. Metrics already indicate that since implementing the professional development program and creating the new care team associate roles, ACPNY’s overall and month-to-month patient experience scores have improved across the board.

From the March 2018 baseline overall mean score of 85.8, ACPNY saw more than a 2% rise, up to 87.2 in September 2018. During that period, ACPNY also saw a nearly two-point rise in the “Likelihood to recommend” score, and a similar gain in the “Response to concerns and complaints during the visit” score. ACPNY’s mean overall rating increased from 84.7 to 87.2 between September 2017 and September 2018.

The lesson in ACPNY’s journey for other organizations, according to Higman, is not to underestimate the impact of focusing on front-line staff when seeking to improve the patient experience and the overall bottom line.

“Because patients have greater choice, anything you can do to help either minimize turnover or improve the flexibility of the organization really applies to most medical practices across the country,” Higman said.