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FAQs: Connecting patients at crossroads in care

SCP Health logo with tagline Together, we heal.
SCP Clinician Portal
FAQs: Connecting patients at crossroads in care
FAQs: Connecting patients at crossroads in care

Q. How are patients engaging with their care providers, health care organizations, and their personal health care?

A. An increasing number of patients expect virtual access to nurses and clinicians – for care appointments, to ask questions about medications, or to seek medical advice. Patients need and want more information, support in navigating the system, and access to care. Without that support, patients often feel frustrated and disconnected from their care, which can have an impact on their overall health outcomes.

Q. What are some opportunities for more patient support?

A. Clinical encounters only account for a small percentage of a patient’s health care journey. There are factors impacting patient health that occur before, during, and after episodes of care – access to and reminders for preventative screenings, primary and specialty care access, prescription availability, and more. By providing support and touchpoints throughout the path, patients feel more connected to their care as a whole.

Q. What approach works best for providing more support with already stressed resources?

A. Multi-channel communication strategies and technology combined with clinical experts can make a significant impact with an optimal amount of resources. Using quantitative and verifiable data enables highly-targeted outreach and real-time intervention to reduce redundancy and increase engagement.

Q. What steps should health systems and hospitals take when they aren’t seeing patients engage with the outreach?

A. A program is only as good as the patients’ responsiveness. To improve the likelihood of patient response, consider using multiple channels – follow-up phone calls, text messages, etc – working in conjunction with one another. Programs should also routinely check their caller-id numbers to ensure that they are not being flagged as spam and vary the timing of calls to be targeted at more available windows.

Q. How can improved patient connection make a difference?

A. Providing targeted outreach, follow-up, and services, increases the value of care encounters, improves clinical outcomes, and reduces the total cost of care.

Q. How can you ensure the right level of intervention and when would it have the maximum impact for patients?

A. By using quantitative & verifiable data to determine what interventions may be needed, you can match risk factors with different types of outreach to get a “just right” level of care. We know from data analysis that if a patient is going to “bounce back” to the ED for a repeat visit after an initial discharge – more than 50% of those repeat visits happen within 7-10 days of the initial visit.  In this window, we know demographic information, the typical level of access to follow-up care in the community, and their past history with ED visits and we use all of that to segment discharges each day for outreach campaigns.

Q. When it comes to targeted post-discharge outreach, are physicians/care teams able to flag someone who may not meet the criteria specifically, but they think needs to be follow-up with?

A. An important aspect of a strong targeting strategy is incorporating recommendations from the hands on clinicians. To ensure this, clinicians and care teams must be aware of and understand any solution in order for it to be effective. There must be an easy way to flag patients within regular clinical workflows for simplicity. They are also a critical component of setting the expectations with the patients to look out for communications.

Q. How do you close the feedback loop when it comes to getting the information from the patients to the group that needs to take action?

A. In real-time, it is incredibly important to ensure patients who need more support get connected with it. This helps to reduce the YOYO effect and keeps clinicians connected to their patients and more confident in their care. Feedback from patients who don’t need support but are dissatisfied in some way must also be addressed and resolved as quickly as possible. It is equally important to pass along the positive feedback to appropriate groups so they know where their efforts are making an impact.

Q. What are you seeing across the country as the biggest challenges and reasons hospitals and health systems are not already doing this kind of outreach?

A. Many organizations are trying to do patient engagement effectively, but with the heavy lift of live phone calls, which gets very expensive, very fast. There’s no system to create closed feedback or reporting to get the information to the person who can take action. What’s needed most are clinically integrated technology solutions that connect back to EMR, allow the opportunity for closed loop reporting, and exist at the cost position you need to be able to make it work. These types of solutions are becoming available in the market now.

Q. Are there sustainable funding mechanisms for these types of programs?

A. Yes. Pay-for-performance models and gain-sharing agreements with health plans both have the potential to be sustainable sources of funding. There are also additional ROI opportunities from these investments, such as additional bonuses from reduced readmissions and improved HCAHPS, optimal clinician utilization and retention, downstream reimbursement opportunities, and improved patient acquisition and retention.

Q. How can using a program like Connected Care help solve strategic challenges a hospital might be having?

A. A program like our Connected Care solution integrates with and complements the hospital’s current strategies to expand the reach and impact of clinical and non-clinical patient support resources, increasing the rate of patient engagement, reducing avoidable readmissions, and improving HCAHPs. 

Research from multiple external sources, including Harvard Business Review and Deloitte) show that just a 5% increase in HCAHPS scores is correlated to a 1% increase in operating margin for hospitals.

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