Summary: Digital technologies—ranging from mobile apps and interactive voice response systems to video recording and conferencing software tools—are finding their way to safety-net settings, helping to increase access to care and convenience for patients. Finding money to support their use is still a challenge though emerging payment models may help.
By Martha Hostetter and Sarah Klein
Under pressure to control costs and improve health outcomes, many health systems are exploring new models of care delivery, including those that focus on better meeting consumers’ needs and leveraging digital health tools to make care more accessible, efficient, and affordable. This latest wave of innovation has been lagging in the safety net, where public hospitals and community health centers have had fewer resources to invest in new care models though they are arguably more important there. “Their patients are often high utilizers of care, and stand to benefit from greater engagement and care coordination,” says Anuj Desai, vice president for market development of the New York eHealth Collaborative and director of its New York Digital Health Accelerator. “The safety-net population is right in the center of the need for innovation.”
This may be changing, however, as technology entrepreneurs become more familiar with the large and relatively untapped market safety-net patients represent and design products and services to better meet their needs. The fact that more safety-net patients are likely to be insured, either through Medicaid or private plans, is helping as well, as is the fact that growing numbers of low-income Americans now own smartphones and have access to the Internet.1 The expansion of Medicaid programs in some states also is pushing safety-net hospitals and clinics to innovate by creating competition for patients who previously had few options for care.
"The safety-net population is right in the center of the need for innovation. Their patients are often high utilizers of care, and stand to benefit from greater engagement and care coordination."
—Anuj Desai, vice president for market development of the New York eHealth Collaborative
Of course, leading safety-net systems have long been innovative in their efforts to coordinate care and link people to the support services they need to get and stay healthy. Minnesota’s Hennepin Health, an integrated delivery network, has improved care and lowered costs for Hennepin County’s Medicaid beneficiaries by linking physical, mental, and dental health providers with social service agencies and community-based organizations. And Denver Health has put lean engineering principles to work to support a sustainable, high-performance public health system.
As a group, federally qualified health centers are ahead of office-based physician practices in their adoption and use of electronic medical records.2 This positions them well to take advantage of new care models that leverage digital health to enhance the efficiency of the health care workforce and provide consumers convenience and value, while also empowering them to take charge of their own health.
Building Relationships Beyond Office Walls
Many initial efforts focus on expanding access for vulnerable patients. At West County Health Centers in California’s rural Sonoma County, clinicians in its four community health centers are experimenting with a HIPAA-compliant video conferencing platform that enables nurses visiting elderly patients in their homes to confer with other providers. The same platform allows clinicians to check up on patients in their homes or include an out-of-town family member in an end-of-life discussion, and is being used within the clinics to enable primary care providers to make “warm handoffs” between patients and care managers, social workers, behavioral health staff, and others—using $50 desktop video cameras.
Technology for West County serves as a tool to build connections with patients over time, says Jason Cunningham, D.O., medical director at West County. “Our most important product in primary care is relationships,” he says. “Developing trusted relationships with patients is the only way we’re going to promote behavior change and drive better health.”
Many health systems, including West County and Columbus Regional, a community hospital in southern Indiana, also are experimenting with social media to engage patients in their care. For example, Columbus Regional created a private website for diabetics to network with their peers and interact with their physicians and diabetes coaches. West County is piloting Well Fx, a HIPAA-compliant social networking platform, to help patients lose weight or quit smoking.
Similarly, University Behavioral Associates (a behavioral health management association that is part of the Bronx-based Montefiore Medical Center) has piloted the Sense Health tool, a care management platform, as a way to build stronger relationships with patients while using technology to automate some parts of care. The tool helps care managers create customized care plans, delivered via text message, and then lets them choose from a variety of scripts offering educational and motivational content, as well as automated appointment and medication reminders and check-ins. The trial, involving 15 providers and 67 behavioral health patients, found the text-based communication between care managers and patients improved patients’ knowledge of their conditions and increased their motivation to improve health; patients were also more likely to say they remembered the goals of their care plans and followed them.
Envisioning Care from Patients’ Eyes
As part of its efforts to better serve patients, the Los Angeles County Department of Health Services is using creative approaches to learn about patients' experiences and design care from their point of view, taking a page from the “design thinking” approach to problem-solving. “We want to position ourselves as a desirable provider, one that patients choose to come to,” says Mark Richman, M.D., of the County's Olive View–UCLA Medical Center.
In February 2012, Los Angeles County began using the dscout app to enable providers and care managers to share experiences and submit real-time feedback via photographs and text. This research led the health system to a guiding metaphor of seeing patients discharged from the emergency department (ED) or hospital as “lost travelers,” often confused by their diagnoses and unsure of next steps.
This prompted creation of an automated email notification to medical home care managers when their patients visit the ED or inpatient setting, so they can follow up and offer help in managing whatever issues led them there. "We want the medical home to be the patients' concierge travel agency," says Richman. In a pilot, this effort resulted in a 6 percent absolute and 25 percent relative risk reduction for repeat ED visits. The system has also begun offering telephone-based visits with providers to offer convenient, timely advice to patients.
Starting Small and Leveraging Existing Resources
Unlike large health systems like Mayo and Geisinger that have resources to dedicate to developing new delivery models, safety-net providers engaged in innovation tend to focus on solutions that attack discrete problems and have an immediate impact. Indeed, a series of interviews with safety-net organizations in California found that their leaders tend to view innovation as an iterative, incremental process—not one that requires whole-scale disruption. Many focus their efforts on leveraging their workforce and forging impactful relationships with hard-to-reach patients.
“As the futurist Ian Morrison says, ‘We don’t need to apply the principles of the T.V. show Pimp My Ride to health care and technology products,’” says Veenu Aulakh, executive director of the Center for Care Innovations, a California-based nonprofit that provides technical assistance, training, and grants to safety-net providers working to transform care delivery. “There are not of lot of tools in different languages or for those with low health literacy, and many of the tools out there are unaffordable for safety-net patients and providers.”
For some organizations, innovation does not involve technology at all, but instead is about redesigning care delivery. Clinica Family Health Services, which operates five community health centers north of Denver, Colorado, developed a new approach to appointment scheduling and team care to tackle related problems: growing demand for care, coupled with provider burnout and low job satisfaction among nurses. To offer same-day appointments to patients with minor acute illnesses, such as ear infections or sore throats, Clinica nurses share visits with physicians, nurse practitioners, or physician assistants (only the latter providers are able to prescribe medications or bill for visits). Nurses take patient histories and intake information, work up tests, then present the patient to the provider and document the physical exam. After the provider diagnoses the problem and prescribes medication, if needed, nurses explain the care plan to patients.
In two pilots, these “co-visits” increased the number of appointments per day by 17 percent in one site and 12 percent in another. Patients were pleased to be offered timely appointments, and in many cases to have a chance to meet in person with the nurses who act as their coaches and help with triage over the telephone. Nurses found the work rewarding, while physicians and other care team members said it gave them some breathing room to take a lunch break, or leave on time at the end of the day.
Supporting Innovative Efforts the Safety Net
Clearly, limited resources constrain safety nets’ efforts to innovate care delivery. Many current efforts are supported by philanthropies such as the California Healthcare Foundation and the Nicholson Foundation. (The latter recently sponsored a challenge to come up with ways to improve care for underserved communities.) And nonprofits like the Center for Care Innovation and the New York Digital Health Accelerator serve as technical advisers to safety nets as well as matchmakers between safety-net providers and companies interested in partnering with them to pilot their products.
Some tech companies are willing to partner with safety nets in exchange for access to their clinical test beds and providers’ feedback (see Q&A). The startup 22otters, which among other things creates interactive apps to help patients prepare for medical procedures and adhere to treatment plans, offers its tools to some safety-net providers with no upfront charges—asking instead for a share of any increased revenues that come from reducing no-show rates or filling freed-up appointment times. “That model resonates,” says Robert Quinn, the company’s CEO. “They don’t have a lot of leeway in their budgets to pay for these things.” (The Center for Care Innovations’ Innovator Database includes more than 12 companies with products that meet a critical need of safety-net populations, and that are interested in partnering with providers to pilot them.)
Still, new payment models will be needed to encourage safety-net organizations to move beyond their early innovation efforts to more broad-based efforts to proactively manage the care of high-need patients, improve population health, and control costs. “The current fee-for-service environment does not allow safety-net systems to take risks and implement innovations that can save costs and improve care,” says Aulakh. “We need more flexibility in our payment systems to allow safety nets to deliver care that better meets the needs of vulnerable patients.”
The Centers for Medicare and Medicaid Services has allocated $100 million over the next five years to help states develop and test new payment and delivery models. A portion of the funding will be devoted to help states develop new models of care that target high-need populations.
1. According to the Pew Research Center’s Internet and American Life Project, 84 percent of U.S. adults with income below $30,000 had cell phon es and 47 percent owned smartphones as of August 2014. See http://www.pewinternet.org/.
2. The Commonwealth Fund’s national surveys of federally qualified health centers (FQHCs) in 2009 and 2013 show that adoption of health information technology has grown substantially for these important providers of care in poor and underserved communities. In 2013, 93 percent of FQHCs had an EHR system—a 133 percent increase from 2009, the year federal “meaningful use” incentives for use of health IT were first authorized. In contrast, a Health Affairs study found that in 2013, almost eight of 10 (78 percent) office-based physicians reported they had some type of EHR system. Another survey published by Health Affairs found that in 2013 EHR adoption rates were approximately equivalent among hospitals that care for poor patients and those caring for more affluent patients.