2016 Quality Leaders Awards Winners

In 2015 UC Irvine Health was facing an expected growth of almost 30% in outpatient encounters, which would be layered on top of patient experience measures that were already in the bottom-third percentile. Add in declining staff satisfaction, and UC Irvine saw that a radical new approach was needed.

This new approach took the form of two innovative improvement initiatives: the Ambulatory Care Improvement Project (ACiP) and the Clinical Operations Management & Patient Analytics System (COMPAS).

ACiP is a 6-to-8 week clinic improvement project that uses lean, change management, and innovation methodologies to look at each individual practice and address specific challenges and opportunities. Structured as “events,” ACiP uses a team-based approach to spot challenges, identify solutions, and implement improvement practices tailored specifically to each clinic and the people who make it work. These improvement ideas range from changing the way MAs are scheduled, to the practice of texting reminders to patients, to redesigning the exam rooms themselves.

ACiP works hand-in-hand with COMPAS, an internally developed suite of clinical operation applications that provides real-time patient flow in a live map of the clinic. The COMPAS suite applications (Check-In, Clipboard, Patient Room, Live Map, and Analytics) allow clinic staff and leadership to accurately capture metrics that track clinic operational performance, including wait times, cycle time, and room utilization, and measure whether the improvement ideas generated through ACiP are working.

ACiP and COMPAS have been implemented in 90% of UC Irvine Health’s ambulatory care clinics based on patient volume, and will spread to all remaining clinics. These practices have led to increases in patient satisfaction, an improvement of more than 30% in both cycle time and room utilization, a drop of almost 20% in cost-per-visit, and a decrease in time to third next available appointment from more than 24 days to fewer than five days.

Historically, at San Mateo Medical Center (SMMC), new patients have had as many as 46 different ways to enter the system seeking care. This had led to a lack of coordination, delayed and/or siloed care, and a frustrating and confusing experience for patients and staff. With an influx of 20,000 adult patients in 2015, it became unsustainable. With the support of leadership and with consultation from its patient advisory council, San Mateo Medical Center used Lean management techniques to design and create the New Patient Connection Center (NPCC).

The New Patient Connection Center was planned using a Lean improvement event, at which staff considered how best to offer all new adult patients a single point of entry that welcomes the patient, connects the patient to a primary care medical home, provides onboarding assistance, helps patients navigate the system, provides insurance information, and improves overall patient experience. The event resulted in dozens of telephone lines being streamlined into eight.

The NPCC staff includes five Patient Services Assistants, one Patient Services Supervisor, two Registered Nurses, and is under the leadership of SMMC’s Patient Centered Medical Home Manager.

At launch, the NPCC conducted triage at one out of six sites, but has now been expanded to handling telephone triage, hospital discharge, and ED follow-up for all six sites, reconciling medications to prevent hospital readmission due to inadvertent drug misuse. NPCC RNs conduct telephone pre-visit intake for all urgent care patients who have never been seen in an SMMC primary care clinic, and are scheduled for an urgent visit within 48 hours.

From August 2015 to August 2016, the New Patient Connection Center received more than 30,000 calls, provided appointments for more than 2500 patients, empaneled more than 4600 patients into medical homes, and has decreased the “new patient abandoned call” rate from more than 30% to less than 10%. The Center has also given San Mateo Medical Center the ability to proactively reach out to new patients, as the system moves towards population health management, conducting welcome calls every month.

In 2017, the NPCC plans to be able to schedule all new patient appointments, and manage patient queues for all primary care clinics.

Being data-driven means doing more than collecting numbers. It means analyzing information, both quantitative and qualitative, then using that analysis to shape decisions, tracking whether those decisions had the desired impact, and sharing the results in order to correct course if needed. It also means going to great lengths to obtain reliable data, if it is not being collected accurately and consistently.

In Ventura County, like many communities across the United States, accidental prescription drug overdoses have hit record levels. Ventura County Health Care Agency (VCHCA) identified a lack of consistency among behavioral health providers in the use of evidence-based practices when prescribing alprazolam (Xanax) and other benzodiazepines – a powerful class of medication primarily used for treating anxiety, and one of the most commonly misused. The agency also found that monitoring tools, which have been shown to reduce the risk of overdose, were being underutilized.

VCHCA’s safe alprazolam prescribing initiative uses a multi-level approach, beginning with the establishment of practice guidelines. The initiative also accesses reports from the CURES prescription drug monitoring program, uses a medication treatment agreement (MTA) between prescriber and patient, utilizes urine drug screens, and ensures that patients have access to non-pharmacologic treatment options, which has included training therapists in cognitive-behavioral therapy.

VCHCA faced a data challenge, since some data – including average daily dose of medication, unclear indications for treatment, and certain diagnoses – is not available in the EHR. The safe alprazolam prescribing initiative also has to rely on hard copy chart review.

The program includes the routine tracking of prescriptions and the distribution of a quarterly prescriber report card. Prescribers were surprised to learn that 62% of urine specimens were positive for a substance of abuse, and only a third were consistent with the known medications that a patient was supposed to be taking and free of other drugs.

Through the initiative, VCHCA has cut its number of patients prescribed alprazolam to less than a third of what it was in 2014, it has doubled its rate of medication treatment agreements, and increased the percentage of CURES reports run from 18.7% to 97.7%.

Like most health care systems, the resources at Arrowhead Regional Medical Center (ARMC) are disproportionately utilized by a very small percentage of patients with multiple comorbidities. The High Utilization Patient Care Outreach Program (HUPCO) is an aggressive nurse care management program designed to improve underlying conditions that have historically led to hospitalization. The program also identifies patients at risk for becoming high utilizers, and provides education and team support aimed at keeping these patients healthy.

RN Care Managers, embedded in the health centers, are introduced in-person to patients by their primary care providers, with the initial goal of establishing trusting relationships with the program’s patients. RN Care Managers then work with patients and their families and caregivers to assess their individual needs and priorities, coordinate appropriate care, improve health literacy, and to help patients overcome their fears around being seriously ill with limited resources.

In building the program, ARMC reclassified the RN position to create an entirely new outpatient nurse care manager position, identified the target population for the program, located community resources to leverage, built all its policies and procedures from scratch, and began working on how to integrate patient assessments and care plans into its EHR system.

A three-tier classification system was also established to identify those at risk of becoming high utilizers and to determine the appropriate level of intervention. The top tier consists of patients with between three and five comorbidities, the simultaneous use of ten or more medications, and who have had three or more inpatient or emergency department visits in a calendar year; these are the patients cared for in HUPCO.

This aggressive approach to high-utilizing patients resulted in a 56% increase in care manager visits – which in turn has led to a 27% decrease in length of stay, a 35% decrease in inpatient visits, and a 64% drop in ED visits. The program has spread from Family Medicine to the Internal Medicine and Pediatric Clinics.