Providers Meet Patient-Centered Goals by Transforming Access to Care

Added on Feb 21, 2019

Providers Meet Patient-Centered Goals by Transforming Access to Care
By Andrea Fitzgerald

Once narrowly defined as the time between a patient’s request for an appointment and the next available spot on a provider’s schedule, the concept of patient access has broadened in scope in the era of patient-centered care delivery to encompass a wide range of operational considerations, from provider availability to hours of operation to care coordination.

This more expansive characterization has far-reaching implications. Today patient access influences consumer loyalty, patient experience, provider satisfaction, organizational productivity, revenue, market share, and more. For this reason, many organizations’ efforts to transform the patient experience include innovative strategies and programs to expand and enhance access to care.

Three such efforts—one by a medical practice group, another by a large integrated health system, and a third by a small rural hospital—were presented during the 2018 Press Ganey National Client Conference in November. Pennsylvania-based Lehigh Valley Physician Group (LVPG), California-based Kaiser Permanente of the Northwest (KPNW), and Iowa-based Sanford Sheldon Medical Center each described the unique ways in which their teams have risen to the challenge of improving access to timely, high-quality, coordinated, and, when possible, in-network care.

For each of these organizations, the access improvement journey began during a period of extreme growth. In 2016, patient volumes in Sanford Sheldon’s emergency department more than doubled, jumping from four or five patients per day to 12. Since experiencing a spike in membership of 20,000 in 2014, KPNW has been challenged with meeting the needs of a dental patient population that continues to increase upward of 10,000 members per year. And at LVPG, the number of providers has nearly tripled in the past decade and the number of patient visits has risen to approximately 2 million per year in locations throughout Pennsylvania.

To ensure continued delivery of exceptional care in the face of such growth, each organization aligned resources, leaders, providers, and patients around a strategic approach to empower the latter to take control of when, where, and from whom they get care. As a result, each organization was able to achieve substantial improvement across a range of access-related questions on patient experience surveys, and by so doing improve their percentile ranking in their respective peer categories. 
 
Lehigh Valley Physician Group

LVPG is a not-for-profit subsidiary of Lehigh Valley Health Network (LVHN) and one of the largest medical groups in the country. Committed to making Lehigh Valley a healthier and better place to live, in 2015 the physician-led organization launched access improvement efforts with a strategic focus on patient acquisition and the patient experience.

“These components are obviously important for financial reasons, but they are also important for assessing our commitment to our mission and to our patients. If we truly believe that our system delivers excellent care, then we should strive to be the destination where patients come—and stay—to receive care,” said James Demopoulos, senior vice president of operations and chief operating officer, during his presentation at the 2018 National Client Conference.

Seeking to incorporate the voice of the patient in its efforts to improve access at every touch point of the patient journey, LVPG correlated feedback on CGCAHPS patient access and experience survey questions with its own 12 unique solution bundles. Using a Lean tool, LVPG assessed the difficulty level of each bundle as well as its impact on the survey questions to identify the top three priorities for every specialty practice. “Rather than have our practices try to implement all 12 solution bundles, we wanted them to prioritize the three that had the greatest correlation to the questions they were struggling with most,” Demopoulos said.

For the internal medicine physician practice, the three bundles with the highest impact rating on the majority of survey questions were leveraging advanced practitioners as dyadic partners of physicians; optimizing the EMR to enable and standardize procedures for e-visits, patient self-scheduling, and more; and gathering clinical intelligence through the patient portal, MyLVHN, in advance of the patient visit.

A team of project managers, Lean consultants, practice coaches, and organizational development leaders was created to help practices implement their top bundles. In addition to completing cause and effect analyses and failure mode and effects analyses, the team created job aides to answer the What, How, Why, and Who of each bundle. For example, a job aide for the Advanced Clinical Intelligence solution bundle lists promoting the use of MyLVHN as a logical step for advancing the work. It suggests that patients be encouraged to enroll at every stage of the visit, from front-desk registration to check-out, and mentions increasing patient satisfaction, improving practice efficiencies, and patient engagement as reasons for implementing this best practice. Finally, all colleagues are listed as responsible for this component of the bundle to reinforce shared accountability.

As a result of these robust efforts, LVPG raised its patient experience ranking from the 37th percentile to the 64th percentile in the first 12 months. Its in-network referral capture rate (instances of keeping patients within network) increased to 84% in that first year as well, and to 93% the following year. LVPG also raised its top-box scores for “Routine appointment/check-up as soon as needed” and “Right away appointment as soon as needed” from 74.0 and 70.1, respectively, in October 2015 to 97.1 and 95.1, respectively, in April 2018. In addition, it increased the number of “Yes” responses to the “See provider within 15 min. this visit” question on the CGCAHPS survey from 54.0% to 90.5% in that same period. LVPG’s financial performance is equally impressive: The organization was $42 million under budget and 130,000 visits above budget in fiscal year 2018.

Demopoulos encouraged attendees to continue on their own access improvement journeys, cautioning those who may be pursuing a quick fix. “Improving access is a complex issue and, as such, requires complex solutions that take time and resources,” he said. As LVPG’s performance improvement attests, the rewards—in terms of patient experience, growth, and revenue—are worth the effort. 

Kaiser Permanente of the Northwest

Kaiser Permanente is the largest not-for-profit, integrated health care system in the United States. Dedicated to improving the total health of its members and the communities it serves, the system provides both high-quality care and high-quality coverage. As the only region that offers dental services, KPNW extends this commitment to 290,000 dental patients.

One of the organization’s greatest challenges is providing timely hygiene access to these members, according to Kari Engholm, senior director of Dental Care Delivery for Kaiser Foundation Health Plan of the Northwest. In the spring of 2017, KPNW Call Center audio clips highlighting the frustration and emotional distress of both medical and dental members struggling to receive care were shared with senior leaders. Galvanized by these patient voices, senior leadership set out to develop and implement a rapid improvement strategy across five departments, including Dental.

A key element of the strategy was embedding patient partners on cross-functional teams to share their preferences, challenges, and experiences in scheduling appointments. On the Dental team, these patients worked with dentists, dental assistants, hygienists, call center representatives, local operation managers, and other stakeholders to co-design initiatives and standardize processes to improve hygiene access. One such initiative is Hygiene Cleaning Anywhere, which allows patients at low risk for dental disease to see any hygienist. This idea came directly from patient partners, who explained that while some patients want personalized care from the same hygienist year after year, others would rather see any hygienist as soon as possible.

“This is just one way our patient partners helped us think differently about the ways we could restore choice to our members and best meet their needs,” Engholm stressed. “For this reason, they were more than partners in this work. They were core team members.”

Among other impressive outcomes, Dental increased the number of “Very good” responses to the “Ease of scheduling appointments” question on the Press Ganey survey from 48.3% in January 2017 to 61.5% in July 2018, leading to a substantial increase of 4.6% in its mean top-box score.

Engholm credits Dental’s sustained success to the cultural shift that took place at the onset of the rapid improvement strategy. “We treated it not as another initiative, but as a new way of doing business. That’s exactly what improving access is,” she said. 

Sanford Sheldon Medical Center

Comprising a 25-bed critical access hospital, four clinics, home health and hospice services, and a long-term care facility, Sanford Sheldon serves patients across four counties in northwest Iowa. Its mission is rooted in improving access for rural communities that historically have been underserved.

Four years ago, when the hospital began offering 24-7 emergency care, the staff realized that many patients were coming in for non-acute issues. Puzzled, senior leaders turned to Sanford Sheldon’s patient and family consumer council for insights. From their explanation of the consumer preference for nontraditional hours, senior leadership deduced that many patients were coming to the ED not because they required specialized or urgent care, but because it was the only location with hours that could accommodate their schedules. To reduce ED utilization and the costs incurred by patients and the hospital, Sanford Sheldon introduced extended primary care hours at its on-site clinic in 2016. The Sanford Sheldon Clinic is now open from 8 a.m. to 8 p.m. Monday through Thursday, from 8 a.m. to 5 p.m. on Friday, and from 8 a.m. to noon on Saturday to better meet the community’s needs.

To avoid infringing on the needs of its providers, Sanford Sheldon implemented staffing best practices to protect their work–life balance. While advanced practice providers (APPs) are on staff in the ED 24-7, physicians are on staff in the clinic and are only on call in the ED. When needed, nurses and APPs from the ED can move over to the clinic to meet patients’ non-acute needs, and vice versa. “This is a major advantage of an integrated system: We can allocate resources—meaning both providers and dollars—where the consumer needs them most,” said CEO Richard Nordahl during his presentation.

According to Nordahl, more patients are now able to receive care in both settings, as reflected in Sanford Sheldon’s access survey scores. Within a year of extending the clinic’s hours, the organization achieved top-box scores in the 99th percentile for “Routine appointment/check-up as soon as needed” and “Right away appointment as soon as needed.” Additionally, the top-box score for “Recommend the provider office” rose to the 90th percentile, bumping Sanford Sheldon’s ranking from the 25th to the 58th percentile.

Nordahl stressed that improving access is also important to an organization’s financial performance. “As the Centers for Medicare & Medicaid Services and insurance companies continue to elevate and reward quality over quantity, we need to look for more ways to care for patients in the clinic, and ultimately the home, rather than the ED,” he said. 

Conclusion

By consulting patient and family advisory committees, partnering with patients in the co-design process, and gathering patient experience data and feedback, integrated health care delivery systems are launching change efforts that align their workforces and patients around the mission of improving patients’ access to and experience of care. Their efforts, successes, and lessons learned can be applied to many care settings to transform the way care is accessed by and delivered to patients across the country.