Ambulatory Care

How to Optimize Ambulatory Care

September 20, 2017 12:10 pm

In the Healthcare Challenge Roundtable, leaders with a health system, medical group, and health plan discuss ways to collaborate on solutions to some of the industry’s biggest issues. This month’s topic: ambulatory care.

As healthcare organizations wrestle with how best to improve the health of their patient populations, they increasingly appreciate the need for ambulatory care that is more effective, integrated, collaborative, and convenient. Making strategic improvements to an ambulatory platform can bring long-term financial and operational benefits to an organization.

In this edition of the Healthcare Challenge Roundtable, senior provider and health plan leaders describe components of a successful ambulatory care strategy, including how such a strategy enhances value-based care and ways in which stakeholders can work together on mutually beneficial ambulatory arrangements.

Participating are Luanne Thomas Ewald, CEO of DMC Children’s Hospital of Michigan, Detroit; Mary Johnson, COO with University of Minnesota Physicians, Minneapolis; Eric Jenkins, vice president of integrated care delivery, Care Delivery Organization, Humana; and Yogi Hernandez Suarez, MD, vice president and chief medical officer, Care Delivery Organization, Humana.




What are some of the steps your organization has taken to enhance its ambulatory care offerings?

Luanne Thomas Ewald: About eight years ago, Children’s Hospital of Michigan began looking at its ambulatory footprint and started shifting care out into the community, closer to families. We’re a large pediatric hospital in downtown Detroit, and we used to have both our inpatient and ambulatory services located in the city. Our patients found this setup to be challenging, and we wanted to improve access as well as the care experience.

Since embarking on this new strategy, we have opened five ambulatory centers in the surrounding suburban areas, ranging from 2,000 to nearly 70,000 square feet. With each one, we have listened and responded to what the families and primary care pediatricians want in their neighborhoods.

For our Troy [Mich.] facility, for example, we constructed a life-sized model out of cardboard and had physicians, nurses, patients, and families walk through it. This allowed us to gather and react to feedback. For instance, the nurses could say, “Why is this wall here? This doesn’t make sense. I’m going to have to take 25 extra steps in this configuration.” We could then pull the cardboard down, and the architects could redesign as we went along.

Similarly, we received feedback from the children about the check-in desk. The children were usually smaller than the desk, and they told us that they were scared when they couldn’t see what was going on and whom their parents were talking to. As a result, we included cut-outs in the registration areas so kids could see behind the scenes. Overall, we took patient, doctor, and nurse preference into account when designing our buildings, with the administrators and architects taking a backseat.

Mary Johnson: University of Minnesota Health views ambulatory care from both a cost and patient experience perspective. Regarding costs, we have moved a majority of our clinics away from a provider-based model to a freestanding one. In a provider-based model, a facility fee and a professional fee are billed, which results in higher costs for payers and patients. A freestanding model, however, has one global bill that covers physician, facility, supply, and support staff costs.

Making this transition was a big step for us. To account for the change to reimbursement, we had to do a substantial amount of planning for how we would work differently in the ambulatory setting to ensure we could contain costs while providing value.

On the patient experience side, we do a number of things to increase convenience and meet the needs of our market. For one, we engage in significant pre-visit planning to make the ambulatory visit as meaningful and efficient as possible. When a patient schedules an appointment, we coordinate the other services or appointments that go along with that visit. If there are required labs, those are drawn prior to the encounter. If the patient needs to see multiple specialists, we aim to schedule those clinic appointments for the same day, as well as any other diagnostic tests that are required.

To make appointments more efficient, we ask patients to complete questionnaires and forms online ahead of their visits. The questionnaires are tied to the specialists the patient is seeing—for instance, there is a specific questionnaire for a gynecological visit versus an orthopedic visit. By receiving the information in advance, the care team can better prepare for the patient’s visits and won’t use valuable time during appointments to gather information. When patients use the online forms, we can even check to see how much of the information is complete and give them gentle reminders through email or phone calls to finish the task. We also give patients an incentive to complete the forms ahead of the visit—if they send their information in advance, they can arrive 15 minutes later for their appointments.

We also expanded our hours of operation, offering appointments from 7 a.m. to 7 p.m. during the week and 7 a.m. to 5 p.m. on Saturdays. Although extended hours are common in primary care, they are less common in specialty care. We felt it was important for our patients to have access to all of our specialties across the expanded time frame. This is especially relevant for working adults, whether for their own healthcare needs or to accompany family members during more convenient hours.

Yogi Hernandez Suarez: To meet the needs of our patients, we consider the disease burden along with relevant social determinants of health. In the United States, people 65 and older often have at least one or two chronic conditions, such as diabetes or hypertension, or maybe they are cancer survivors. Our job is to help them manage those conditions and keep them from acquiring new ones. In other words, we assist them with healthy aging.

To do this, we must not only address their needs in the clinic or ambulatory setting but also look at the entire continuum of care with wraparound services that help doctors in the outpatient space understand what’s truly happening with their patients no matter where they are.

How does an ambulatory care strategy fit into the larger effort to optimize the value of health care?

Johnson: First and foremost, access to care for chronic conditions in the ambulatory setting is an important factor in preventing hospitalizations. You want patients to come to the clinic, where care is less expensive and more proactive. They are only going to do that if it’s convenient, cost-effective, and efficient. That’s why we focused on making the clinic experience as meaningful as it can be. The hospital is the highest-cost environment we have, and effective outpatient care can reduce unnecessary hospital visits—it’s better for patients and providers.

If a patient is hospitalized, then the role of the care team in the ambulatory setting is to avoid unnecessary readmissions. This may involve checking in with patients 24 to 48 hours after discharge to see if they are doing OK. If there are signs that a patient isn’t doing well, they may need to come to the clinic, and we must have the right access protocols in place to fit them in.

To further cut down on unnecessary hospital visits, we have a mechanism in place where the emergency department [ED] physician notifies us if an individual was seen in the ED but was sent home and should be seen in the clinic the next day. Since we have protocols for following up in a timely fashion, there is no need to hospitalize the patient “just in case” he or she has a problem.

Eric Jenkins: The role of ambulatory care is to ensure patients get exactly the care they require when they require it, and in the safest possible place for their conditions.

From a finance standpoint, the money flows with this concept as well. By pursuing a holistic approach to care, you can prevent patients from going to the hospital unless that is where they need to be, which is both clinically and financially beneficial.

Suarez: There are multiple studies now showing how older people lose function when they’re taken out of their home environment. The more we can do to help people age well and in place—using the acute setting only when necessary—the more we can help the individual sustain positive outcomes. One of the extraordinary benefits of the Medicare Advantage program is that the compensation allows for the dollars to flow in areas of care that keep patients at home.

What approaches in the ambulatory setting can help reduce the unit cost of care while maintaining or improving quality?

Ewald: Last year, we launched the state’s first pediatric-only clinically integrated network. We have about 480 pediatricians and pediatric subspecialists who deliver primary and specialty care. Our goal was to improve outcomes, quality, and access. The network is attractive to pediatricians because we use metrics that are meaningful to them, and we help them keep care in their offices while reducing costs.

For instance, if a pediatric neurologist can educate a pediatrician on how to handle migraines, then a child with a routine case may not have to be sent to the specialist, which is obviously a higher-cost setting and may require multiple tests. The beauty of the clinically integrated network is that we have the pediatricians and the specialists working together to make sure care episodes occur in the most appropriate place.

Johnson: One way we’ve tried to reduce costs is to look at our skill mix and check that it is appropriate—that we have nurses doing the work of nurses, and medical assistants and other staff handling the issues that do not require nursing expertise. Basically, we try to design our processes so that everybody is working to the top of their licenses and we are optimizing our resources.

Another factor that drives up cost is the overreliance on ancillary labs, imaging studies, and so on. We employ evidence-based protocols to make sure we order only the appropriate tests, with the goal of decreasing the total cost of care.

Suarez: Humana physicians use a single electronic health record that is integrated with our claims database, so our physicians have a deep understanding of the drugs that our patients are taking and the prescriptions they are filling—a perspective many doctors in the outpatient space don’t have.

This has been a tremendous advantage, especially with our patients, who often have cognitive dysfunction and are in and out of various facilities. Through our system, we can verify that patients are on the right medications—and the least amount of medications—for their conditions. It’s a win-win from a patient safety viewpoint and also from a dollar perspective.

Jenkins: Our clinical teams also serve as trusted advisers to our patients, steering them to a facility or specialist.

In South Florida, where we have numerous clinics, we are able to create partnerships with nearby health systems, such as HCA or Tenet, offering to refer and recommend our patients who need a certain service—like knee or hip replacement—to their facilities in exchange for a preferred rate. Since there’s such competition in this area, the health systems are willing to work with us on a unit cost if we can deliver volume, which we’ve proven that we can do. They are also willing to tailor the way they take care of our patients to ensure that there is appropriate stewardship of the payments from our patients and Humana.

How can collaboration among clinical partners set the stage for enhanced ambulatory care?

Johnson: As I mentioned, we coordinate visits so that patients have the convenience of seeing all their providers on the same day. In some cases, a physician may see a new patient and want to quickly check in with a specialist colleague, such as a pulmonologist, cardiologist, or endocrinologist. We’ve organized the clinical areas in our new facility so that our specialties are connected through what we call collaboration spaces. A provider can step out of an appointment, walk down the hall, and get a colleague’s opinion.

We also use a radio-frequency system with sensors throughout the building. Our team members wear badges, so if a provider wants to find a colleague, he or she can access the online application, type in the colleague’s name, and know whether the colleague is in the building and in what location.

Suarez: Another way in which we collaborate with our partners involves a scheduling solution that allows us to book patients’ appointments with our specialty partners. Since our patients are older, frailer, and often have cognitive issues, telling them not to forget to make an appointment with the specialist is frequently ineffective. Through this technology, our patients leave our ambulatory facility with an appointment and a trusted endorsement from their primary care doctor.

We have found that the combination of the primary care endorsement and the scheduled appointment has improved patient adherence and reduced the specialty provider’s no-show rates. Although getting an appointment quickly might not be an issue in some markets, in many of the markets we serve, it is a big deal for Medicare Advantage patients to get an appointment within a brief amount of time. The longer patients wait for specialty care, the more likely they will be to go to the emergency room if there is a problem because they may not fully understand whether there is a serious issue or not.

Ewald: We are also considering how to employ telemedicine. There’s a national shortage in some pediatric subspecialties, so we’re trying to better utilize the specialists we have. For instance, we are looking at how to use telemedicine for social work and emergency room consults. We’re exploring whether we can get our specialists up on a screen while there is a child in the emergency room to talk to the ED physician, parents, and child.

What sort of collaboration between providers and health plans can enhance ambulatory care?

Ewald: Our clinically integrated network seeks health plans that are willing to partner with our nearly 500 physicians who are focused on achieving defined quality metrics and eliminating waste within healthcare delivery. By working together, we can reward the participating physicians for top-notch quality outcomes and drive down costs. We’ve partnered with a couple insurance plans so far and seen some encouraging results. This clinically integrated structure benefits the patient, the hospital, the pediatricians, and the health plans. I believe health plans are becoming more open to this line of thinking.

Johnson: Delivering value in the ambulatory setting and keeping patients out of the hospital creates a higher-cost ambulatory model. For example, having dietitians, social workers, and behavioral health providers embedded into our clinics has been a huge help in proactively identifying potential issues that could result in an acute care visit or negative health outcome. However, this is a more expensive model.

The good news is that even though it’s a higher-cost model in the ambulatory setting, it is a lower-cost model overall if you’re preventing hospitalization, overutilization, and duplication. As an industry, we must change to a more holistic reimbursement methodology or we will be limited in how much we can shift the care model. We are starting to think this way, but we have more work to do.

Jenkins: Interoperability between providers and the health plan is essential. In our case, having the health plan give data that lets our providers understand what has happened to our members beyond just what’s inside of our clinic and our medical record is key. We can share that information with the specialists to whom we are referring our patients so the physicians don’t duplicate services.

How do you foresee ambulatory care changing in the future?

Jenkins: From a finance standpoint, our medical costs are unsustainable. In general, hospitals are expensive. Technology is advancing every day, and I believe we’ll see more procedures being done in the home or in an ambulatory setting to reduce the financial outlay and to increase patient safety and positive outcomes. It’s only going to get bigger and bigger as the years go on.

Johnson: Ambulatory care is poised to change dramatically through the use of virtual care applications. We will be able to communicate with and assess patients in many more ways, such as via technology that enables virtual physiological monitoring. Within the next five to 10 years, we expect 40 percent of our patient appointments to be virtual, especially for returning patients because it is often unnecessary to see them in person. We do so today due to reimbursement methodology and limitations.

Suarez: As the Baby Boomers age into Medicare, there will be more pressure for health care to be even less clinic-centric. This generation of seniors will want to be on a mobile platform so that they will have access to services outside the traditional doctor’s visit—although there will always be a need for that kind of visit.

I also believe there will be more consumer pressure to broaden what ambulatory care means. It’s going to be more telephonic, involve video applications, happen via email, and so on. Because there haven’t been payment models that support these new modalities, we haven’t explored what those vehicles can safely offer in the Medicare space. I think that’s going to change.

Kathleen Vega is an HFMA contributing writer and editor.

Quoted in this article: Luanne Thomas Ewald, CEO,  DMC Children’s Hospital of Michigan, Detroit; Eric Jenkins, vice president of integrated care delivery,  Humana, Miami; Mary Johnson, COO,  University of Minnesota Physicians, Minneapolis; Yogi Hernandez Suarez, vice president and chief medical officer, Care Delivery Organization, Humana, Miami.

Check out previous installments of the Healthcare Challenge Roundtable: 

Integrating Behavioral Health Care and Primary Care

Assessing the Value of Care

Optimizing the Preauthorization Process 

Working Together to Make APMs Succeed

Coming soon: The Healthcare Challenge Roundtable will look at how different stakeholder groups can collaborate to promote interoperability in a way that enhances care redesign and population health management. Watch for this feature on in November.


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