Having loyal and engaged patients may be one of the clearest hallmarks of a high-performing and successful healthcare provider. It may also be a critical financial success factor for organizations pursuing an accountable care strategy.
At a Glance
- Summa Health System, based in Akron, Ohio, implemented pre-visit multimedia engagement and post-visit centralized follow-up as a means to promote the more active engagement of its patients in managing their care.
- The initiative led to significant improvements in the patient experience, as measured by HCAHPS ratings.
- The initiative, among others, also helped ensure that Summa received 100 percent of its 2012 pay-for-performance incentive from the Centers for Medicare & Medicaid Services.
In the emerging new world of fee-for-value, providers can expect to receive financial rewards for improving the quality of care. But government and commercial payers are not the only parties interested in seeing improved quality; patients are paying attention to quality, as well.
Patients are becoming more savvy consumers of health care whose loyalties to their providers of choice are much harder-earned than in the past, particularly as advances in technology and access to data via the internet make it easier for patients to distinguish providers by the value they provide.
How will these new, better-informed patients change the way health care is delivered? The old, “paternalistic” approach to care—which assumes that patients will be passive participants in their care, refraining from asking questions or becoming actively engaged—will not work. The organizations most likely to thrive are those that embrace patient engagement as a business and growth strategy. Research has shown that communication is the key driver of patient satisfaction, as measured by HCAHPS. Patients who receive computer-based visualization tools instead of standard education practices retain information at a higher level and experience greater satisfaction with their medical procedure.a Hospitals have found that these tools enhance communication by creating a baseline of understanding and by providing a structured way for patients to ask questions and get feedback. By using audio-visual computer education tools, organizations improve communication and improve patient satisfaction without demanding significantly more time from their physicians or staff.
It stands to reason that, for healthcare providers, having a broad base of satisfied and proactive patients supports enhanced revenue and improved outcomes. Moreover, the success of any provider’s strategy to develop an accountable care organization (ACO) will depend in large part on the organization’s ability to build such a patient base.
After all, health care, at its core, is a service business. In other service industries, consumer satisfaction drives loyalty, and return customers drive profitability. Health care should be no different. Patient engagement is a sustainable growth strategy. To achieve a positive ROI, a health system must deliver a complete solution—one that is flexible and meets the needs of all constituents. Leveraging technology to connect with patients is only part of the answer. Changes to workflows, patient relations, and provider attitudes should be combined with health IT tools to engage patients cost-effectively and cost-efficiently.
Because of the important role patient engagement play in an organization’s success, healthcare finance leaders should be involved in setting plans for investments in patient engagement and in ensuring the ROI and success of these investments are effectively measured. Patient engagement leads to patient empowerment, without which an accountable care strategy cannot hope to succeed.
Removing Barriers to Patient Engagement
Summa Health System in Akron, Ohio, is nationally renowned for excellence in patient care and exceptional approaches to healthcare delivery. One of the largest integrated delivery systems in Ohio, serving more than 1 million patients annually in its seven hospitals and large ambulatory network, Summa’s commitment to the delivery of accountable care led to acceptance of its ACO in the Medicare Shared Savings Program in 2012. A few years ago, Summa recognized a need to build on work in enhancing the inpatient experience by finding ways to better engage patients before and after their stay.
Patient engagement had always been a foundational element of Summa’s approach to patient care, but as the health system grew, integrating a consistent approach to patient engagement proved increasingly challenging. Before 2009, it was up to each of Summa’s 1,200 physicians to develop a preferred, individualized method of preparing and educating patients for surgery, inpatient stays, procedures, and chronic disease management. The result: many different methods of engaging patients—with varied effectiveness. Traditional patient engagement tools, other than face-to-face physician communication, included providing patients with treatment-specific brochures, photocopied articles, and printed material from websites. Physicians were charged with selecting and updating the content, which added to their workloads. Furthermore, they had no way of tracking whether patients had reviewed the materials or understood the information until the day of procedure.
Summa’s leaders recognized these deficiencies in the health system’s approach to engaging patients and knew that the organization’s patient engagement efforts would need to expand and evolve, given industry trends related to care coordination and population health management. In 2009, Summa’s leaders formed a 15-member committee composed of patient education leaders to lead an organization-wide initiative to better engage and educate patients. Members included physicians from multiple specialties, senior finance and compliance executives, and patient relations staff.
The initiative was motivated not only by the goal of improving patient care and outcomes, but also by financial incentives linked to patient satisfaction. For example, under the Centers for Medicare & Medicaid Services (CMS) pay-for-performance guidelines, hospitals that do not deliver a patient experience on par with the regulatory requirements can be penalized 1 percent of their Medicare payments (up to 2 percent over the next four years) for each Medicare patient they treat. For Summa, that risk amounted to about $1.4 million.
Two Approaches for Engaging Patients
Summa’s patient engagement committee considered numerous methods for more actively engaging patients, weighing the financial and quality impacts of each. On the committee’s recommendation, the health system undertook two targeted approaches to reach patients outside the four walls of the hospital.
Pre-visit multimedia engagement. With this approach, Summa implemented a web-based, multimedia, interactive platform using voice and visuals to engage patients and their families in preparing for surgery and subsequent care needs. This multimedia tool guides patients and their families through the requirements for anesthesia and the surgical procedure, and it provides them with information on what to expect during their surgical stay, including issues related to pain management and patient safety. The hospital recently expanded this initiative to include automated interactive calls to manage population health and drive healthy behaviors.
Post-visit, centralized follow-up. This approach involved creation of a centralized platform for handling discharge phone calls, information collection, and reporting to reinforce healthy behaviors and help patients be more compliant and achieve better outcomes.
Ultimately, for pre-visit multimedia engagement, the committee determined that a third-party, customizable, web-based, interactive tool would be the most cost-effective and least technologically disruptive solution. This solution required minimal workflow changes in the hospitals or practices, and offered Summa control over content selection and quality. Moreover, the vast majority of Summa’s patients had internet access and were comfortable using the internet to obtain healthcare information.
For the post-visit follow-up, Summa formed a discharge call center where designated clinical support staff team members would contact patients to ensure they understood their discharge instructions and medication changes and that they had scheduled appropriate follow-up visits. Centralizing this process helped smooth patients’ transition back to their homes and ensure their compliance with follow-up physician appointments. As a result, patients became more actively involved and better informed about their treatments—qualities that are often linked to reduced readmissions and improved outcomes. Summa also evaluates feedback from these calls along with other patient data gathered from the multimedia program to measure the ROI of the overall patient engagement initiative.
Overcoming Early Skepticism with Results
Summa first implemented its multimedia engagement platform at its surgical practices and hospitals, where it was “prescribed” to help patients prepare for anesthesia administration, their surgeries, and their inpatient stays. Initially, the individual practice sites were charged with emailing to patients the links that connected the patients to the web-based educational programs, but it was later determined that this step could be managed more efficiently by Summa’s preadmission staff. Providers in the practices, however, are required to “prescribe” the program and inform the patient to expect an email containing the designated link. This program also requires hospital and practices always to remember to collect patients’ email addresses upon registration, which they hadn’t had to do prior to the patient engagement initiative.
Any type of technological or process change at a healthcare organization is likely to encounter some resistance. Summa was no exception. A few physicians were skeptical about the new educational methods, expressing concern that the new programs would supersede their direct contact with patients, instead of serving as a supplement to their direct contact, as intended.
To overcome the early resistance, Summa relied on the enthusiastic endorsement of the platform by physician leaders at the practice and hospital level. Senior executives also met with physicians, listened to concerns, and explained how the multimedia platform would inform and empower patients and likely reduce the number of patient question phone calls and procedure cancellations. Sharing user data from comparable organizations showing increased patient satisfaction also made an impact on physicians. For example, Summa’s leaders pointed to an analysis of 3,300 inpatient medical records in six DRGs at the University of Pittsburgh Medical Center, which found that patients who had viewed interactive web-based programs that provided information about their upcoming procedure had an average length of stay 0.7 days shorter than did patients who had not viewed the programs.b
Engaged Patients More Satisfied
A few months after implementation, physicians began to notice the positive impact the multi-media programs and post-visit follow-up calls had on patient outcomes and compliance and, most significant, satisfaction.
Summa identified one area in which this positive impact might be evident: HCAHPS patient perception-of-care scores. Some Summa providers assess this measure directly via patient surveys completed after viewing a multimedia program.A more rigorous approach, obtaining possibly a more meaningful measure, is evaluating the impact on HCAHPS ratings for the hospital.
Over a 19-month period beginning in January 2011, the web-based engagement programs were “prescribed” to 10,983 Summa ambulatory and admitted patients. Of those who were admitted, 425 completed HCAHPS surveys, which represented approximately 33 percent of those eligible for the engagement program. Those who viewed one or more of the programs rated their care significantly higher than did those who were “prescribed” but did not view a multimedia program. Across all nine HCAHPS dimensions, viewers answered with a higher percentage of top box answers than did nonviewers.
In five dimensions, multimedia viewers rated their care significantly higher than did those who had not viewed the multimedia programs. Based on national Press Ganey benchmarks from the fourth quarter of 2011, patients who viewed the engagement programs reported:
- A 36 percentage point increase in the overall hospital rating over nonviewers
- A 57 percentage point increase in the rating of communication with nurses over nonviewers
- A 57 percentage point improvement in the rating of pain management over nonviewers
- A 47 percentage point improvement in the rating of hospital staff responsiveness over nonviewers
- A 57 percentage point improvement in the rating of communication with physicians over nonviewers
The statistical validation of these improvements was performed using the odds ratio test. This ratio and the sample size can be used to determine a confidence level that the difference was in fact more likely due to actual differences as opposed to random variations. The dimensions listed above all had a confidence level of 95 percent or higher.
Similarly, on measuring the impact of its centralized discharge follow-ups, Summa observed
dramatic improvements in many of the HCAHPS patient experience dimensions, specifically including the overall rating, patient willingness to recommend the hospital, communication with nurses, and responsiveness of staff.
In each of these dimensions, Summa moved from below to above the national 50th percentile. Moreover, those who received follow-up calls rated their care significantly higher than did those who had not received such calls. The following differences were noted in HCAHPS comparing the called and non-called groups during the fourth quarter of 2011:
- A 9.1 percent difference in hospital rating
- A 5.5 percent difference in the likelihood the patient would recommend the hospital
- A 4.3 percent difference in the rating of communication with nurses
- A 6.8 percent difference in the rating of hospital staff responsiveness
Patients who were contacted at home had lower 30-day readmission rates than did those not contacted, indicating the potential for a significant reduction in annual readmissions.
The programs helped Summa capture 100 percent of its 2012 CMS pay-for-performance incentive, and the health system is actively expanding the multimedia platform across the organization to manage patient populations. For example, Summa launched a program using automatic, interactive voice response phone calls to diabetic patients with the goal of having patients either contact their optometrists to send the patient’s eye exam records to their affiliated physician or schedule eye exams.
The automated system successfully contacted 105 of 289 diabetic patients in only three weeks in October 2012. Nearly a quarter of those patients complied with the request in one way or the other. The improved compliance increased Summa’s HEDIS score on this measure by 13 percent after six weeks and improved the accuracy of the organization’s database with updated patient phone number and current physician information. Future call campaigns have been conducted or are under way on preventive measures such as the HbA1C tests, mammograms, colorectal cancer screening, and hypertension screening.
Tips for Implementing Patient Engagement Technology
For organizations not yet employing patient engagement technologies, a good place to start is with the low-hanging fruit: the transition from the hospital to home. In light of the scrutiny of readmissions by CMS and the corresponding potential impact on payments, ensuring a successful transition home has become imperative. Providers also may want to consider how technology can help patients better prepare for visits or admissions to the facility. And as hospitals move to new models of care delivery, they require technology that can address gaps in care by motivating patients to take preventive actions, such as scheduling screenings, getting vaccinations, or talking with their physicians.
Whichever IT solutions a hospital or health system chooses, there are key lessons to keep in mind.
Make it a C-level and physician-led imperative. Support and involvement in patient engagement should start with the CEO and medical director and extend through all levels of the organization.
Define success. Different technologies will all have their own impacts, so it is important to choose those that will be most significant for the organization. For example, is the goal to improve patient satisfaction scores or reduce operating room cancellations? Leaders should be able to describe what success looks like.
Be prepared with evidence. Physicians are end users and ultimately the ones who will experience the value of patient engagement initiatives, so leaders should be prepared to demonstrate the patient care benefits these programs have produced for comparable organizations.
Have a solid plan to measure ROI. It is important to establish a plan for measuring the impact of patient engagement technology so adjustments can be made, if necessary, to achieve the desired ROI.
A Reward in Itself
Hospitals and health systems will require loyal and engaged patients to achieve financial success in the emerging world of value-based payment—especially in view of the importance of maintaining a large and healthy patient base to be able to take on the risks inherent in accountable care and population health management. An organization’s ability to engage patients effectively will depend largely on two factors: technology and physician buy-in and support of the organization’s approach to engaging and empowering patients. And measuring results will be of critical concern.
But perhaps the most exciting and rewarding benefit of an investment in patient engagement is in the reduced anxiety and improved satisfaction of patients. In a service industry, exceeding expectations is critical to increasing loyalty and profitability.
Carmen V. Natale, MS is system director of service excellence, Summa Health System, Akron, Ohio.
Devin Gross is CEO, Emmi Solutions, Chicago.
a. Enznehofer, M., et al., “Improvement of the Educational Process by Computer-Based Visualization of Procedures: Randomized Controlled Trial.” Journal of Medical Internet Research, April-June 2004; and O’Conner-Von, S., “Preparation of Adolescents for Outpatient Surgery: Using an Internet Program,” AORN Journal, February 2008.
b. “UPMC Study Finds Emmi Reduces Average Length of Stay,” UPMC Nursing: Pathways to Excellence, August 2010.
What Is Patient Empowerment?
Although definitions vary, the concept of patient empowerment generally involves helping patients to become informed, active, collaborative participants in their care. Achieving this result depends as much on providers’ and patients’ attitudes as it does on their actions. No one can directly empower a patient, but all health professionals can help patients become empowered.
The concept is defined perhaps most aptly in a seminal article published in Clinical Diabetes by the researchers Martha M. Funnell and Robert M. Anderson:a
Patient empowerment is defined as helping patients discover and develop the inherent capacity to be responsible for one's own life ... [T]here has been a growing recognition that, although health professionals are experts ..., patients are the experts on their own lives. This approach recognizes that knowing about an illness is not the same as knowing about a person's life and that, by default, patients are the primary decision-makers in control of the daily self-management. Empowerment is not a technique or strategy, but rather a vision that guides each encounter with our patients and requires that both professionals and patients adopt new roles. The role of patients is to be well-informed active partners or collaborators in their own care. The role of health professionals is to help patients make informed decisions to achieve their goals and overcome barriers through education, appropriate care recommendations, expert advice, and support. Professionals need to give up feeling responsible for their patients and become responsible to them.
In short, patients should be informed, active, and collaborative participants in their care, and providers should support patients in their efforts to overcome barriers and meet their goals. Providers can best achieve these objectives using a five-step process.
Identify which patients can benefit most from empowerment. The patient engagement initiative should focus on those patients who are in greatest need of support. These patients can be identified by evaluating each patient’s level of health and determining whether the patient is at risk of an acute event or has a chronic condition.
Connect with those patients on their terms, with targeted, timely, and coordinated messages. For example, patients preparing for surgery can receive access to a web-based program about their procedure that they can view in any convenient location with the device they choose, such as a smartphone, tablet, laptop or desktop computer. Other ways to connect with patients include opt-in text message reminders to fill prescriptions, maintain appointments, and follow up with providers after the procedure.
Inspire patients to care more about their health and to be more proactive in the management of their care. A provider can encourage patients to take a greater interest in health-related issues by offering web-based educational programs and other materials that help them understand their conditions, why it is important to follow their providers’ instructions, and how to ask questions and talk with their caregivers about improving their care management. Patients are also inspired and engaged by follow-up phone calls from the provider after a hospital discharge and reminders to complete follow-up appointments and fill prescriptions.
Help patients maintain their health, stay on course, and avoid relapse. Patients can receive reminders, either by text, email, or phone, to stay adherent to their treatment plan. For example, diabetic patients may receive reminders to weigh themselves, check HbA1c levels, maintain their diet, and schedule routine screenings related to their condition, such as tests for their vision or feet. Internally, organizations can create reports for patients with chronic conditions who have not visited their provider for their required checkups or screenings and start outreach campaigns to engage those patients.
Measure outcomes. Measurement should look at results for physicians, both individually and across the system as an aggregate, because healthcare providers cannot improve what they cannot measure. Specific systemwide measures might include readmission rates, length of stay, and overall spending related to conditions. At the individual physician level, organizations should analyze metrics such as patients’ adherence to annual checkups or screenings within prescribed timeframes, compliance with medication refill, and satisfaction with their providers’ communication level.
a. Funnell, M., and Anderson, R., “Empowerment and Self-Management of Diabetes,” Clinical Diabetes, July 2004.
Publication Date: Thursday, August 01, 2013