Help patients make sense of complicated health information when the stakes are high

Health literacy had a star-studded moment when Saturday Night Live (SNL) recently covered the topic.

Of course, SNL didn’t say “health literacy” a person’s ability to find, understand and use health information — but one character squirted hand sanitizer into his mouth and slapped it on his neck like aftershave. Another sipped a martini declaring she already had her vaccine.

Unfortunately, these jokes weren’t wild fabrications. Due to people perilously ingesting disinfectants like Lysol, the CDC issued warnings in April about how to use them safely. The following month, tackling another unfounded rumor that was gaining traction, the National Institute of Health announced that “drinking alcohol does not prevent coronavirus.”

Health care systems have also played a leading role in curbing the spread of misinformation about COVID-19. They also have developed a library of evidence-based advice to address patient concerns and keep them safe.

Indeed, an unheard of number of patients are seeking clarity in uncharted medical territory. In the first two months of COVID-19, as well as swamping health care systems’ call centers, patients sent 285 percent more text messages with questions and inquiries to WELL’s customer base.

Many organizations have provided patients with everything from texts about what symptoms might signal COVID-19 and how to get tested to doctor-authored blog articles about how to prevent the coronavirus to Facebook Live events and emails about the safety of coming in for a colonoscopy or a child’s vaccination.

But do patients understand this information? The numbers don’t bode well. When health literacy was last measured nationally, nearly 90 percent of respondents were identified as having low health literacy, as detailed in the 2003 National Assessment of Adult Literacy study.

Who has low health literacy? Hint: it might be you

According to Dr. Danielle Ofri, an internist at Bellevue Hospital and Clinical Professor of Medicine at New York University School of Medicine, limited health literacy is “especially common in those who have the most diseases and the fewest resources.”

It’s also common in older adults and those who have low education levels and low general literacy skills, such as written language and basic math.

But they are far from the only ones. As a college-educated, native English speaker (who is a health care writer!), I could not make sense of a chemotherapy brochure that stated, “Fatigue is not relieved by rest.”

Confused by this stand-alone statement – doesn’t rest recharge you? – I was unable to use this information to take a specific action to feel better. By definition, I was a textbook case of demonstrating low health literacy.

Less understanding = more unwell patients (and unhappy staff)

Many patients’ inability to comprehend or flat-out misunderstand health information can have much graver consequences. A 2020 Journal of the American College of Cardiology literature review of 15 health literacy studies, which included heart failure patients, discovered just that.

“Our findings showed that an inadequate level of health literacy is associated with increased risks in mortality and hospitalization among patients with heart failure,” said Lila J. Finney Rutten, PhD, an author of the study and Professor of Health Services Research in the Department of Health Sciences at Mayo Clinic.

Limited health literacy is also associated with more ER visits and fewer mammograms and flu vaccines, according to a 2011 Agency for Healthcare Research and Quality report, as well as higher health care costs.

Call volumes and inbound text messages can also increase when patients have unanswered questions, as hospitals and systems experienced when COVID-19 hit. When patients are muddled about medicine, health care staff feels the brunt.

While it’s easy to put the burden of understanding health information on patients’ shoulders, Dr. Rima Rudd, a health literacy researcher at Harvard University, believes health systems need to do a better job explaining all things health related.

“Are our forms readable? Are the directions after surgery written coherently? If it’s written in jargon, with confusing words and numbers, you won’t get the gist of it and you won’t get important information,” Dr. Rudd told the New York Times.

Cognizant of the problem, some health systems have been moving away from dense, medicalese copy that can be hard to digest. Instead, they are embracing everyday words, short sentences, more white space and visuals.

For example, WELL customers have been able to deliver to their patients evidence-based, bite-sized videos and straightforward written materials on COVID-19 through WELL’s partnership with Wolters Kluwer. The partnership helps allay patient fears, provides clear direction on when to seek care and reduces the number of calls patients place to their providers.

And instead of sending this easy-to-understand information to a patient’s sometimes infrequently checked email address, physical mailbox or patient portal, WELL sends it by many patients’ preferred method: text.

“A communications emergency”

As COVID-19 flares across the country and misinformation continues to catch fire online, the stakes for people understanding health information and accepting a coronavirus vaccine could not be higher.

“A pandemic is as much a communications emergency as it is a medical crisis,” wrote members of the CONVINCE initiative, a global business coalition to advance vaccine literacy, in Harvard Business Review (HBR).

As more and more people say they will definitely or probably would not get vaccinated at this time (49 percent), according to a September 2020 Pew Research Center survey, governments, corporations and health care systems face a daunting communications challenge ahead.

Given the complex nature of vaccines, “literacy for COVID-19 vaccines will require more extensive efforts than many other health literacy campaigns,” according to the HBR article.

To build confidence in the coronavirus vaccine, health systems must tackle patients’ fears and concerns – from safety to “big pharma” – by creating the type of scientifically sound content (e.g., blogs, Facebook posts) that’s most popular with their patients.

Placing doctors front and center in YouTube videos and on podcasts might make most sense. In a recent October 2020 AP-NORC poll, the family doctor ranked highest when it comes to whom Americans trust for information about the coronavirus.

Health systems’ proactive communication measures could turn vaccine hesitant or hostile patients to vaccine accepting ones, decreasing their chance of contracting COVID-19. This outreach will also better buffer administrative staff from the crush of calls expected to roll in once the first vaccine is released. ♥

Calculating the true cost of missed medical appointments

It’s 7:45 a.m. on Tuesday morning. You expect 211 appointments at your busiest practice location.

After careful forecasting of patient-to-staff ratios, you know you have the right amount of staff to deliver great care while containing costs. 

But then Mr. Fagan, who staff have just completed the prep work for, doesn’t show for his 8:15 appointment. Staff call to see if he just pulled into the parking lot. But no answer. They leave a voice mail and  tell the physician that he may not show up. 

An hour later, they call out, “Ms. Garibaldi?” to a full waiting room. Silence. Patients are visibly disappointed not to hear their name called. “Ms. Garibaldi?” staff call again. She missed her appointment.

Later in the afternoon, Mr. Ramos, Mr. Ballard, and a dozen other patients don’t show either. For each of these patients, staff go through the same time-wasting prep and abort rigmarole. All of this adds up to the cost of no-shows. 

The cost of overstaffing doctors and staff

Nothing shatters health care systems’ financial spreadsheets like patients who miss appointments. 

Instead of having the optimal number of clinicians and staff to serve that day’s patients, there are too many. 

With labor representing between 50 to 60 percent of operating revenue, excess capacity contributes to lower margins. An ongoing shortage of doctors and nurses and ever-increasing clinicians salaries compound the problem. 

Missed appointments, which result in overstaffing, can also take a toll on employee engagement and turnover, both which hit the bottom line. 

The emotional cost of missed medical appointments

Physicians are likely to become frustrated at the futility of both not being able to care for patients who need them and the missed opportunities of a no-show. Meanwhile, other staff might question the purpose of their work and grow disengaged. 

Employees who are not enthusiastic about their work have 18 percent  lower productivity and 16 percent lower profitability, according to Gallup. They are also more likely to leave, which increases recruiting and training costs. 

But health systems can make staff and patients happier while decreasing the cost of missed medical appointments by implementing text appointment reminders. 

When Vista Community Clinic (VCC) in southern California implemented WELL’s two-way texting platform, its no-show rate decreased 17 percent. Because more patients were canceling in advance, VCC was able to fill the empty slots. Instead of wasting time preparing charts for patients who weren’t going to make it, staff could focus on patients who would. After launching WELL, VCC’s average number of daily patient visits increased by nearly 14 percent.

The cost of rescheduling

The less patients attend their appointments, the more administrative work for staff.

The roughly eight minutes it took to originally schedule the no-show patient has to be repeated. These patients may also be less responsive (e.g., no call pick up, no returned voice mail) given they didn’t call to cancel their initial appointment. Now staff have an ever growing list of patients to call. 

This “call creep” (one call becomes two, becomes three) and associated labor expenses make up a significant part of the cost of missed medical appointments. 

Patients don’t love traditional phone calls either. As many as 68 percent of patients prefer the ease of online rescheduling. With WELL Self-Rescheduling, they can simply select a new appointment from their mobile phone almost instantly. This takes about one minute, saving time, hassle, and money. 

Actual lost revenue

Healthcare systems lose revenue when they can’t charge for services they didn’t render. When patients don’t walk in the door, cash walks out. 

Unlike a cancellation, where staff could backfill the appointment, a no-show is lost revenue. At an average cost of $265 per missed appointment and an average 18 percent no-show rate, a clinic that’s scheduled to see 22 patients but only sees 18 would lose a significant $1,060 in revenue per day.

Another example comes from a 2013 study on Estimating the Cost of No-Shows and Evaluating the Effects of Mitigation Strategies. In this study, no-shows at an endoscopy unit were found to “significantly decrease the expected net gain” of outpatient procedure centers. The daily loss due to missed appointments was 16 percent of net gain. 

The expenditures on personnel, rent, and equipment have to correlate with patient volume.

Patient reminders via text can help. Take Community Memorial Hospital in Ventura, California. Within two months of implementing WELL’s communication platform, its no-show rate dropped by 29 percent. This resulted in an estimated $1.2 million increase in annual revenue. 

The cost of no-shows in managed care

The cost of missed medical appointments can expose managed care organizations to treacherous financial risk. When spending on services and administration exceeds the fixed monthly fee, they are on the hook to pay for it.  

Unlike traditional fee-for-service systems where providers are paid for services, managed care organizations can’t pass along the cost, making the stakes higher. 

No-show rates for Medicaid patients are often higher than average due to SDOH and challenges accessing care (e.g., changing shift schedules, relying on public transportation, etc.). 

In a 2002 Journal of the American Academy of Optometry study, the Illinois College of Optometry eye clinics were found to have an average no-show rate of 25 percent. The rate for Medicaid patients was 41 percent

These no-shows jeopardize patient health, drive acute care utilization, and delay care across the system. For what could have been routine care, Medicaid patients may end up in the emergency room or be readmitted to the hospital because they missed a much less expensive follow-up appointment. 

As well as a far from ideal (and sometimes precarious) situation for patients, these scenarios also ensure that MCOs are on the hook for all associated costs. They are further financially penalized for ER visits and readmissions because these are Medicaid quality metrics that they’re failing to meet. 

Patient satisfaction is another metric that Medicaid payments are based on. Unsurprisingly, when patients have to wait an extended amount of time for an appointment, which no-shows create, they are usually not happy. Not to mention how delays can endanger their health. Over time, mumps multiply, tumors grow, vision spots proliferate. 

“There are very real quality of life issues here,” Patricia Alafaireet, Director of Applied Health Informatics at the University of Missouri, said when discussing missed appointments at her clinic. “We’ve got to get these folks in.” 

Two straightforward strategies help reduce missed medical appointments. First, text patients appointment reminders. And provide them with the option of self-rescheduling by text. WELL intelligent patient communication hub offers both. Check out our ROI calculator below to find out how much you could be saving across your enterprise.

Millennials lead telehealth trends (and signal what’s next)

The audible sigh from the corner of the waiting room. The exaggerated shifting in the chair.

The head shake at no one in particular. And finally, the drafting of a biting online review or tweet about the long wait, before they have even left the room.

In poll after poll, year after year, tech-savvy millennials (born between 1981 and 1996) have said they are over the waiting room. This includes the time and money needed to get there and the hours of missed work, not to mention the scramble for childcare. Eighty percent of new moms are millennials.

Millennials and telehealth were a thing before the pandemic

The time-consuming and sometimes inconvenient nature of in-person care is a key reason why 20- and 30-somethings were the most likely generation to have swapped the doctor’s office for their couch at home and used telehealth even before the pandemic, according to Amwell’s Telehealth Index: 2019 Consumer Survey.

Millennials continued this trend during the first few months of the COVID-19 pandemic, when as many as 80 percent of all appointments were cancelled.

According to WELL Data Analytics Team, which analyzed appointment data from 116 hospital systems, adults ages 40 and under had the highest overall telehealth adoption rate. They also continued to use virtual care for 20 percent of all appointments through mid-June 2020, twice the rate of other age groups.

If the largest generation (millennials) continues to drive healthcare decision making for themselves, their children, and increasingly their aging parents, telehealth will stick around long after the pandemic.

So what else do millennials want? Because what they pine for is what health systems will ultimately need to pony up.

Some healthcare disruptors have ruminated on this, and as a result, begun to appeal to them by:

Expanding availability for faster access

“Saturdays.” This was the one-word answer 38-year-old Mitch Lao* gave when asked why he chose a walk-in urgent care clinic over a visit to his primary care doctor.

Only 40 percent of millennials would tolerate a wait of more than one day to receive care for something like the flu, according to a 2019 Primary Care Consumer Choice Survey conducted by The Advisory Board.

Take a millennial mom who is growing increasingly anxious about her toddler’s climbing fever at 3:30 a.m. She might have to wait five hours to talk to someone in a doctor’s office. Or she could download the Teladoc app and “talk to one of our doctors right away by phone or video,” according to the provider’s site.

Although drop-in retail clinics like Walmart Health do not tend to provide the 24/7 accessibility of some of these telehealth apps, they are open longer hours and weekends compared to traditional practices. And millennials, dubbed “the drive-through generation,” love the convenience.

According to a 2017 Blue Cross Blue Shield study, “Young adults are frequent users of retail clinics, visiting almost three times as much as older patients, even though older age groups use more healthcare overall.”

For health systems looking to care for more millennial patients, leaving more slots open can increase your ability to offer same-day appointments. Better messaging and bumped up branding around this faster access might raise awareness so you can go toe-to-toe with these fast-growing apps and clinics.

Staying in close digital touch

What are nails on a chalkboard to millennials? Phoning to schedule an appointment. Scrounging around for a pen to fill out a paper form. Fishing a bill out of the infrequently checked mailbox.

These digital natives want to tick off these logistical to dos digitally, and they’re even willing to pay to not make phone calls and mess around with paper.

Disruptors like Teladoc listened. In addition to its online features, the app provides a proactive steady stream of update messages, such as, “Dr. Ortega is reviewing your lab results.” After all, if a millennial’s burrito place keeps them abreast of their order, they assume their medical provider will too.

Health systems can employ texting and messaging through patient engagement providers like WELL to deliver what millennials expect: real-time, personalized and two-way communication.

Posting prices clearly

The poorest and most price-sensitive generation, millennials are nearly twice as likely to request and receive healthcare estimates upfront (41 percent) as baby boomers (21 percent), according to a 2015 PNC Healthcare survey. That number will likely increase in the wake of stand-out millennial unemployment numbers and millions losing their health insurance.

To help millennials anticipate what their care will cost and appeal to their strong desire for transparency and comparison shopping, many disruptors post their prices online, such as CVS Minute Clinic.

Interestingly, more expensive disruptors geared at millennials do too. Newcomer Parsley Health, which provides holistic in-person and online physician care, has a clearly marked “Plans & Pricing” tab on its main menu. Prices range from $175 to $250 per month.

Health systems that post their prices will likely win favor with millennials for transparency, even if the costs are high. Like Parsley Health, you may want to emphasize the quality of your clinicians and care to set your health system apart.

Delivering heaps of quality information and content

“I’m like a detective,” said 28-year-old Christina Merry*, describing her approach to ailments. As do many millennials, she scours multiple online sources, including YouTube, WebMD and Healthline, for health information before visiting a doctor, if she visits one at all. She believes her DIY research is faster, easier and cheaper.

In a bid to become the trusted go-to source for a millennial like Christina, health systems and disruptors have been generating content (e.g., Facebook live, podcast) that aims to provide answers to searchers’ health questions.

But what some disruptors like hers, a telemedicine company for women’s health, does differently is to delve deep. For example, its comprehensive blog post “Birth control effectiveness: which method is best?” clocks in at some 2,500 words.

By providing clinician-approved information on each method, the post does not leave readers wanting. This quality content may shape a positive view of hers and encourage social shares.

Health systems, however, can compete by prolifically producing detailed doctor-led content that strengthens your reputation among millennials.

Doing good

Millennials favor socially responsible organizations. So when a disruptor like Hurdle, which provides culturally sensitive self-care support and teletherapy for the Black community, says, “We are here to help,” millennial ears perk up. In response to COVID-19, the startup offered to cover clients’ first out-of-pocket session.

Of course, traditional health systems do good often. Maybe it wouldn’t be a bad idea to remind millennials of all the extra you do on Instagram or Facebook. After all, that’s what they’re hanging out, writing reviews, absorbing information and shaping the healthcare horizon. ♥

*names changed where noted to protect patient identities.

Preventive screenings down 94 percent due to COVID-19


“In my years as a urologist and prostate cancer surgeon, I’ve never been more concerned for my patients than now,”

said Dr. David Samadi, director of Men’s Health and Urologic Oncologist at St. Francis Hospital in New York, in a July 2020 press release. “By putting off preventive services and screenings to avoid potential exposure to COVID-19, will very likely lead to another huge health crisis of a significant increase in undiagnosed cancer cases in the next few years.”

More and more clinicians and patient advocacy associations across the country are fretting over the recent lack of screenings for time-sensitive diseases such as cancer and diabetic retinopathy, which is the leading cause of blindness in American adults.

In March and April 2020, screenings for both screeched to a halt. Many were canceled or postponed in order to mitigate the risk of COVID-19 spreading and to preserve staff capacity, personal protective equipment and beds. At the same time, patients also chose to delay due to fear of catching the coronavirus during screening appointments or to heed stay-at-home orders.

Preventive screenings dropped by as much as 94 percent

According to analysis by Epic published in May 2020, appointments for screenings of prostate cancer dropped by 60 percent while screening appointments for breast, colon and cervical cancer tanked 94 percent, 86 percent and 94 percent respectively. The study reviewed data from 2.7 million patients across 23 states.

Data from a June 2020 study by Harvard University and Phreesia, a health tech company, and published by the Commonwealth Fund, also found that patient visits to ophthalmologists fell 79 percent. This is significant because diabetic patients receive annual eye scans by ophthalmologists to spot sight-threatening disease (i.e., diabetic retinopathy).

Fallout from delayed preventive screenings

With patients not being screened for fast-growing diseases during COVID-19, it follows that doctors are not catching them. An ABC News report in May 2020, for example, stated that the number of new skin cancers diagnosed at the University of Pennsylvania Health System decreased some 80 percent in March 2020 from early February.

The fallout from delayed cancer diagnoses will likely decrease survival rates because the disease will be at a more advanced stage and less treatable.

“There can be no doubt that the COVID-19 pandemic is causing delayed diagnosis and suboptimal care for people with cancer,” wrote Dr. Ned Sharpless, director of the National Cancer Institute, in an editorial published in the journal Science in June 2020.

He predicts 10,000 more people will die from breast or colorectal cancer in the U.S. over the next decade because of COVID-19’s impact on oncology care.

Overcoming patient fear by putting safety precautions in place

To stave off such dire predictions, health care systems must tackle the root of why patients are eschewing preventive screenings: fear and anxiety.

According to a May 2020 survey by the American College of Emergency Physicians, 70 percent of consumers said they are very or somewhat concerned about contracting the coronavirus if they receive care for issues not related to COVID-19 at a health care facility.

From the start of the pandemic, health care centers have established significant new safety protocols and workflows to protect patients and staff. The overwhelming majority separate COVID-19 patients, require masks, take everyone’s temperature before they can enter, regularly test staff for COVID-19, enable social distancing, reduce time spent in the waiting room, sanitize rooms between patients, bar visitors and much more.

Taken together, these safety precautions reinforce a frequent refrain from health care executives: the hospital is safer than the grocery store.

Communicating “we’re safe” with more visual and specific content

Of course, just because health care systems put extensive safety precautions in place does not mean that patients know about them.

Starting in March and April 2020, however, most health systems added COVID-19-related content to their web sites, newsletters and other external communications, which included a variation of “we’re keeping you safe”-type messages.

Although many sites posted helpful bulleted lists and FAQs on patient safety, there were limited images and videos.

Towards the end of April 2020, health systems recognized that patients aren’t always going to take their word for it; they would have to show them, as well as tell them, about their safety protocols and processes if they hoped to bring patients back for in-person, preventive screenings.

Whether it’s Dr. Amy Williams providing a guided tour of what a patient can expect when they walk into Mayo Clinic for an appointment or a Tidelands Health video of how a patient is greeted, screened and provided a mask by a Safe Care Navigator outside the front entrance, health systems have been posting videos on their respective sites and YouTube channels to dive deep into the details and build trust.

In a similar vein, many health systems have moved away from just one or two web pages about patient and staff safety during COVID-19 to entire dedicated areas with multiple pages and links. For example, the Mount Sinai Safety Hub has a video on cleaning protocols, among several others, and Q&A on various safety-related topics.

Just like health systems have created more videos that are narrower in scope, they have applied the same approach to their blogs, transitioning from more general safety pieces to specific ones tailored for select populations. In Northwell’s “Dear Doctor” series, they strike at the heart of a fearful patient toying with the idea of getting screened for breast cancer in the blog post “My annual mammogram was postponed because of the COVID pandemic: Is it safe for me to reschedule?”

In her response, Dr. Nina S. Vincoff writes, “Studies have shown that having annual mammograms beginning at age 40 reduces your risk of breast cancer death by 40%.“

According to Chris Gasiewski, Director of Corporate Communications for Northwell Health in New York, these types of blog posts have garnered strong engagement.

Additionally, in its Facebook Live videos, such as, “Are hospitals safe?” Northwell’s Stephen Bello addresses minimizing COVID-19 while ensuring individuals get the care they need. They have had “views in the millions, not the thousands.” He believes the reason for patients widely watching (and reading, in the case of the blog posts) is because Northwell is “creating content that people are looking for.”

Engaging the media to engage patients

On the other side of the country, six health systems in greater Los Angeles have banded together to ensure residents don’t forgo care. They are running multilingual radio and TV ads, which they’ve been posting on their social media channels, with the message, “Life may be on pause. Your health isn’t. We’re here to take care of you.”

Providence, UCLA Health, Keck Medicine of USC, Kaiser Permanente, Dignity Health and Cedars-Sinai have also launched these public service announcements called BetterTogether.Health on web sites, billboards, newspapers and magazines.

As well as paid media, some health care systems have also been trying to forge stronger ties with both local reporters (to line up interviews with their clinicians and executives) and editors (to place op-eds and articles). The goal for each is the same: to raise awareness around screening.

For example, the Contra Costa Herald ran this Sutter Health piece in June 2020, “Pittsburg radiology tech shares her story: COVID postpones mammogram, breast cancer discovered.” It discussed mammographer Norma Lester-Atwood attending her regular mammogram as soon as screening resumed, and how a follow-up biopsy revealed a tumor.

The article also included the steps Sutter is taking to keep patients safe while getting screened, as well a section on “Resources to help with health insurance disruption.”

Given millions of people are losing their employer-sponsored health insurance or can’t afford to pay for the costs associated with screenings due to the recession, some health systems are increasing their communications around payment options (e.g., grace periods).

Going direct to the patient, in a personalized way

To effectively coax patients back to preventive screening, health care systems across the country are supplementing their public information tactics. They’re using proactive, direct and personal communication in the form of phone calls, texts and emails.

As well as working the phones to reschedule patients whose screenings were postponed by the health care system or delayed by the patient during the early days of the pandemic, some staff are calling again shortly before the patient comes in. During these calls, they often walk the patient through what they can expect in terms of safety protocols, and what’s expected of them, such as not bringing others to the screening.

Some patients are receiving this same information by email and text, the latter being what many prefer. Conversational messaging eases the burden on staff, requiring significantly less time than placing calls and playing phone tag.

This peace of mind could not be more urgent as a July 2020 Gallup poll found a record 65 percent of Americans saying that the coronavirus situation is getting worse.

Given this number, patients will understandably continue to be fearful about coming in for preventive scans. As such, health care systems will need to increase their focus on assurance messaging and exhaustive communications so the “second public health crisis” does not come to pass. ♥

I didn’t go to the ER — Here’s why and what you can do to change it


As I lay on my hardwood living room floor, I pondered whether I was up to the task of sitting up.

My legs and arms felt like bags of sand. Could I safely inch myself into a vertical position while countering my dizziness and the threat of blacking out?

My breathing was shallow. My feet and hands were purple with the cold, even though it was in the high 60s. I aspired to vomiting so the nausea would subside. My brain was a murky soup as my blood pressure plunged to dangerously low levels.

I had ovarian cancer when I was 32. One of the long-term side effects of chemotherapy for me is episodes of very low blood pressure. Whereas a normal blood pressure reading is 120/80, mine has tanked so low as to set records at certain hospitals.

But even in my haze on the floor, I knew I should go to the hospital. I should get a drip. I needed care.

I pictured capable and good-natured doctors and nurses hooking me up to an IV, halting my body’s freefall. But this comforting thought was interrupted by another: the coronavirus. Then I was faced with one unknown, jarring hurdle after another.

Patients like me have questions. A lot of questions

Would the overburdened medics who I had seen in tears on social media have the time to see me at the ER? Or would I be waiting for hours amidst corridor chaos? Would I be distracting them from higher-priority patients? Would the hospital be teeming with people who might have COVID-19 like I saw on the news? Was the entrance to the ER the same? How could I lie across the seats in the waiting area if there were traces of the virus?

And if I got COVID-19, would I survive it? What if I passed it on to my 72-year old mom?

Nope. I was not going in. I’ve had bad episodes like this before. And I always (and eventually) pulled through without permanent physical damage.

In my mind, this was the responsible choice. Going to the hospital was the risky one.

The disastrous results of delayed care

I was far from alone in delaying or even forgoing necessary medical attention.

Nearly a third of American adults (29 percent) say that they have delayed or avoided medical care because they are concerned about contracting COVID-19, according to an April 2020 poll from the American College of Emergency Physicians. Providers didn’t need a poll to tell them that. They have seen patient volumes at emergency rooms drop by 40 to 50 percent nationwide.

While injuries from traffic accidents may have declined due to stay-at-home orders, heart attacks and strokes likely haven’t.

“People are in this fear mode,” said Dr. John Harold, a cardiologist at Cedars-Sinai Medical Center in Los Angeles and board president of the Los Angeles chapter of the American Heart Association, in an interview with Kaiser Health News.

Many of these patients who aren’t seeking timely care — whether for crisis situations or chronic conditions — are ending up with exacerbated and complicated injuries and illnesses, or in the worst cases, dying at home.

With millions of patients delaying care, coupled with the postponement of months’ worth of elective surgeries, services, and office visits, the financial fallout on healthcare organizations has been described in terms usually reserved for summer action movies: “apocalyptic,” “carnage,” “bloodbath.”

Don’t start with “dear patient”

So how can healthcare systems convince patients to seek in-person medical attention for non-covid related care?

In my case, I just needed personalized reassurance from my health system that it was safe to return. A generic web page or email wasn’t going to cut it.

From early March until mid-April, I didn’t receive any proactive calls or texts from my providers. But I did get nearly a dozen emails. They were sent from “,” as opposed to the doctors and nurses I’ve seen for a decade — the people I like, respect, and trust.

Proactive outreach from my providers would have increased my confidence in their ability to safely take care of me. But the no-name, generic emails that said “our emergency rooms are safe” and “we’re taking extra precautions” while skimping on the details didn’t convince me.

So that afternoon when I lay on the floor and weighed up the concrete images of the hospital horror I’d seen online versus some vague email language, it was easy for my fear of a swamped, understaffed hospital to win out.

But, what would have convinced me?

Where are all of the patients?

When I drove past my healthcare system two weeks after the incident, I was stunned. The first thing that struck me was all the empty parking places. I had never seen this.

I saw several masked-staff in scrubs and white coats dotting the hospital curbs, eager to see who was pulling up and who needed help. Outside the ER, I spotted tents billowing in the wind with numerous staff standing idly by.

I didn’t see any indication of patients. This was the exact opposite of what I had envisioned.

All I could think was, Why didn’t they show me this? Why did they send me abstract assurances of new protocols when they could have sent me photos of these calm, controlled scenes? Scenes that screamed, “We’ve got this. You’re safe.” I would have believed those images. And I think other patients might have, too.

The drive-by made me appreciate even more how hard my healthcare system was working to help its patients during this pandemic.

Not only were they risking their lives to take care of us, but also they were putting in extra hours to do everything from erecting new facilities and adapting current ones to repeatedly cleaning armrests in the waiting room.

What frustrated me was the disconnect between all their effort and how little I really knew about it.

What patients need to hear from you

Of course, many healthcare organizations have put together useful information on how non-covid patients should seek care. Most have informational pages and FAQs on their web sites. Some have set up hotlines. Others have issued press releases and PSAs like this video featuring ER doctors from across Boston’s hospitals to spread their messages of, “Don’t delay!”

But the generic PSAs do little for the individual patient — especially when contrasted with the startling headlines and images we see on the news and in our social media feeds.

We need concrete and compelling communication delivered in a personal way.

For example, my health system could have sent me a link to a map of my hospital that marked where there would be staff at the curb to guide me. They could have texted me about the separate entrances and areas for COVID-19 patients and the new check-in tents. They could have sent me and their other chronic care patients information about how we could safely access care during the pandemic.

All of these would have answered some of my worrisome questions and provided the reassurance I so desperately needed. Maybe then I would have concluded that staying on the floor — not going to the hospital — was the dangerous choice. ♥

How technology can change patient behavior

The gap between what we say we’ll do — hike the trail — and what we actually do — hit the couch — matters. A lot.

According to the CDC, up to 40 percent of annual deaths from each of five leading U.S. causes are preventable.

But we can’t improve health outcomes for patients with many of the most chronic conditions and prevent new ones from arising if we can’t change patient behavior. That requires influencing the choices patients make about entrenched behaviors.

“In the past, physicians’ way of treating the behavioral part has been to say something like, ‘You really should stop drinking,’” said Colleen Christmas, Director of the Internal Residency Program at Johns Hopkins Bayview Medical Center. Not surprisingly, the success rate for that intervention wasn’t very high, she said.

Today we know that fear-based warnings have little power to change patient behavior. Instead, positively-grounded approaches that tap into our human tendency to feel in control, confident and connected to others trigger action.

Mobile technology can empower patients to make healthier choices at scale, but only if the tools are based on social science research and health behavioral models. Otherwise, patients are likely to ditch tech-driven change programs as quickly as the latest fad diet. Here are key science-backed strategies that work best to shift patient behavior.

1. Help patients set meaningful goals and plans with assessments

“What matters to you?” in the context of health is one of the most powerful questions a healthcare professional can ask a patient because it places them in the driver’s seat.

Unearthing what the patient values and what realistic goals will inspire them, however, can sometimes take longer than a 15-minute visit.

With mobile technology, you can ask the patient more questions through text or messaging to help determine goals and plans they’ll fight for because they are personalized to the patient’s unique preferences, values, and needs.

2. Increase patients’ knowledge

“Patient behavior is driven by fear of the unknown,” says Dr. Kevin Pho. And this fear causes patients to freeze, not act.

But you can educate patients about a new mindset and behavior by texting them links to how-to videos or reinforcement quizzes. This information increases their sense of autonomy, competency and the likelihood they will take action. Knowledge is a powerful predictor of behavioral change.

3. Provide coaches and care team support

Patients struggle to stick with a new behavior when the emotional side of the brain becomes exhausted trying to wrestle with a nearly automatic action (e.g., a morning cigarette with coffee) and self-control plummets, according to Chip Heath and Dan Heath, academics and authors of Switch: How to Change Things When Change Is Hard.

As a result, patients need more than a care team member following up with them every few weeks or months; they need ongoing check-ins, reminders and encouragement to stay on track. Numerous studies demonstrate that health professionals and coaches who cheer and counsel help.

With automated texts or one-to-one messaging, you can provide patients with this critical day-to-day support. You can also pro-actively intervene when patients slip from their regime.

4. Connect patients to peers

In addition to emotional support from family and friends, peer-to-peer groups (both in-person and virtual) are powerful at aiding behavioral change. Research shows that patients with the same health condition who interact with each other have better outcomes. The element of social pressure wanting to conform to what others do and do it better  drives action.

The problem is time-strapped patients can’t always attend in-person groups, assuming they exist. Virtual groups and social communities, however, allow patients to engage and connect in ways that work best for them.

5. Provide immediate praise

Patients should be recognized or rewarded for making progress in achieving their health goals instantly.

Why? According to neuroscientist Tali Sharot, when a behavioral change, such as taking medication at a specific time, becomes associated with an instant reward, adherence is more likely to become a habit.

Without certain technologies, however, it’s nearly impossible to always know when a patient has succeeded at a task, such as taking a daily walk. As a result, you can’t congratulate them at that moment, which might be 5:30 a.m. on a Saturday.

However, a texting program can ask a patient if they have completed a loop around the neighborhood. If they confirm, the system can text back a “you’re-crushing-it” emoji or a reward. Positive, real-time feedback motivates.

Here are three examples of how mobile programs grounded in behavioral theory are making it easier for patients to take better care of themselves.

Teens quit smoking at double the average rate with SmokefreeTXT

Although the majority of teens want to kick their smoking habit, only 2 to 3 percent are smoke-free six months after quitting on their own.

The SmokefreeTXT program, led by the National Cancer Institute, has managed to double this dismal cessation rate by sending 13- to 19-year-olds text messages that contain behavioral treatment elements.

The user begins by selecting and texting a quit date, which elicits a feeling of being in charge. The program then asks the user questions around mood, craving and smoking status. After assessing the responses, the program texts back tailored content that instantly praises progress or empathizes with the user’s difficulties, eschewing a shame-based approach.

For example, if a user texts that they crave a cigarette, the program sends actionable tips, such as “do jumping jacks” and a “stay strong!” message. And to stave off future cravings, they receive follow-up texts, such as how to identify their top three triggers.

Behavioral scientists designed the program. It has succeeded where others have failed by meeting teens where they are. It incorporates personalized goals such as quit date, along with knowledge and praise.

A “change your brain, change your body” app helps patients lose weight

For the 86 million Americans with prediabetes, hitting weight loss goals has taken on a new level of urgency.

One thing seems to be helping them make healthier choices: the Noom diabetes prevention app.

A study published in 2016 in the British Medical Journal Open Diabetes Research & Care found 64 percent of participants who completed Noom’s 24-week program lost over 5 percent of their body weight. They were also highly engaged with 84 percent completing the program.

On the heels of this study, Noom became the first virtual provider to receive full recognition from the CDC.

Why has the program worked?

“Ultimately, we wanted to tackle what everybody was failing to address: the psychology of health behaviors,” said Saeju Jeong, CEO of Noom.

Indeed, Noom focuses on the mental and social side of weight loss and injects an element of fun. Users of the app message with human coaches and swap information and stories with other “Noomers” in virtual support groups. They also complete daily to-do lists based on their personality and preferences and read short health and psychology lessons.

By including the key elements known to spark behavioral change, Noom appears to be making headway in reducing the chances of users progressing to type 2 diabetes.

Breast cancer patients’ stress decreased with text support

Just over half (51 percent) of patients don’t remember advice their physicians give them unless prompted, while others may hesitate to ask certain questions.

For those patients undergoing chemotherapy who are trying to navigate a multitude of side effects on their own, these information gaps can cause anxiety.

Fox Chase Cancer Center conducted a randomized study with women diagnosed with breast caner. One group of women received a booklet on chemotherapy. The other group received daily text messages.

The texts asked them if they wanted information on how to manage symptoms, such as fatigue and neuropathy. Patients were also able to text the program with questions about their treatment.

The 48 women in the texting group sent more than 8,000 texts seeking information. More importantly, they reported decreased symptom distress and increased quality of life compared to those who were only given the booklet.

“Women felt like they were getting bursts of information over time rather than all at once and it was always on their phone to go back and look at,” said Kuang-Yi Wen, Assistant Professor in the Cancer Prevention and Control program at Fox Chase Cancer Center and lead author of the study. “They want to feel supported, empowered, and in control.”

Researched-backed strategies work

When based on behavioral theory, mobile technology’s ability to personalize content, provide support and connect patients at scale can nudge them to healthier choices and better days ahead. ♥

The link between compassion and patient outcomes and why it matters

Compassionate care can sound like an empty slogan. But it’s an evidence-based way to improve patient outcomes.

A step beyond empathy, compassion focuses not only on how patients feel and shares their distress but also demonstrates kindness. Compassionate care takes action to alleviate patient suffering, such as a nursing assistant who spots a patient’s unsteady gait and walks with them to their car.

“Compassion is not only the right thing to do, it’s also the smart thing to do in terms of providing the best conditions for healing to occur,” said Dr. Stephen Trzeciak, Chair of Medicine at Cooper University Health Care and author of Compassionomics: The Revolutionary Scientific Evidence that Caring Makes a Difference.

His research documents the close ties between compassion and patient outcomes. When patients perceive that providers treat them with compassion, they’re more likely to implement providers’ instructions and take better care of themselves.

Compassion improves treatment adherence

Further studies show that patients who feel empathy are more likely to take their medication and adhere to post-surgery guidelines. That means, when you tell a patient to take a short walk daily, they’re more likely to actually do it. These positive changes in patient behavior can slow disease progression and enable them to bounce back faster from medical procedures.

Compassion speeds healing for better patient outcomes

When patients feel connected to their providers, they experience accelerated recovery from the common cold and fewer diabetic complications.

Compassionate providers ease emotional suffering, too. Their patients present with decreased symptoms of depression and anxiety, as well as post-traumatic stress disorder (PTSD).

Compassion reduces unnecessary medical care

Healthcare organizations focused on compassion also benefit. Studies demonstrate that care delivered with empathy results in fewer diagnostic tests, referrals, and medical errors, and increased patient satisfaction.

Here are three ways to build compassion in your health system:

When hiring, ask questions that reveal compassion

You want to hire staff who puts the best interest of patients first. It starts with understanding that compassion is a skill, not an innate characteristic. Some job candidates have developed it more than others.

Annie McKee, Senior Fellow at the University of Pennsylvania Graduate School of Education and author of How to Be Happy at Work, suggests adopting a behavioral interview technique. This can help you determine which candidates know how to practice compassion and value doing so.

Ask them, “Can you walk me through a difficult situation at work and how you dealt with it? Tell me what you were thinking, feeling and what you were doing at each stage.”

In a 2016 article for Harvard Business Review, McKee said this question tells you whether the candidate is aware of their own feelings, how they manage them, and their awareness of their impact on others.

Continuously train your staff in compassion skills

Compassionate care, and the communication skills that form its foundation, can be learned and improved. And contrary to some traditional theories around providers’ emotional exhaustion, research demonstrates that exercising compassion can buffer against burnout.

At Cleveland Clinic, Communicate with H.E.A.R.T uses in-person training to teach employees to hear, empathize, apologize, respond, and thank. This training has increased employee engagement and HCAHPS scores. And patients who rate their experiences positively often have better health outcomes.

Your practice can achieve similar results with ongoing staff training, not a one-and-done event. Focus on active listening and increasing observation skills and identifying behaviors associated with respect and kindness. Training should also address how to deal with difficult conversations.

Be compassionate with your staff

A 2015 white paper from the Schwartz Center for Compassionate Healthcare emphasizes that your staff can’t care for patients with kindness if they don’t feel cared for. Empathy and compassion start in-house.

A few ways to support staff include offering group-bonding activities and conducting mindfulness and self-care workshops. Also, recognize and reward acts of compassion with public recognition or even gift cards. When staff feel cared for, they’re better equipped to offer compassion to patients.

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