Reducing leakage through better patient engagement

January 14, 2020 - by Pamela Ellgen

 

In December, WELL and Circulation hosted a webinar on reducing leakage through better patient engagement within the care continuum.

 

Guests included Dr. Sean Kelly and Dr. Monica Rivera. Andrew Spevacek of WELL Health and Lauren Brandon of Circulation, a provider of non-emergency medical transportation, hosted the event.

Click here to watch the full webinar.

Early in the webinar, Dr. Kelly identified a critical factor contributing to patient leakage — the simple fact that patients often wait for months for an appointment and as many as half don’t show up.

“It’s such a crazy scenario because you have all these providers ready to see patients and suddenly there’s a no-show. Or on the converse side, you may have double bookings where you have providers that are so busy that they can hardly get through the patients,” he said. “Literally, just messaging and making sure that a patient confirms an appointment and getting them transportation to that appointment can make the whole process really work much more smoothly.”

Dr. Rivera concurred, adding that as many as 25 percent of missed appointments are due to a lack of transportation. She referenced the 1965 Medicaid and Medicare inclusion of transportation as a benefit. But the solution was clunky. She said traditionally the market has been led by brokers who provide a four- to eight-hour window in which transportation might arrive. That’s a long time to wait for an appointment that may last a mere 15 minutes.

“Now you’ve essentially wasted or lost all day, waiting for someone to pick you up to take you to a medical appointment,” she said.

Cumbersome workflows are bad for health systems

This is not just an inconvenience to the patient, but it also hinders the efficiency of health systems and contributes to patient leakage and poor outcomes. Dr. Kelly presented a scenario in which a non-weight-bearing patient with a knee injury waits for four hours for transportation. All he needs is a visit with an orthopedic surgeon to determine whether he is eligible for surgery.

“It’s insanity that we expect patients, doctors, and nurses to work under those conditions and actually achieve things,” Dr. Kelly said.

In a fee for service world, if the patient doesn’t show up for the appointment, that appointment doesn’t get revenue. The health system is still paying the overhead of the patient and the doctor and all the caregivers there, Dr. Kelly explained. It’s similar in a value-based care system. The whole system is on the hook for preventing illness and disease, and there needs to be cost avoidance.

“Either way, you lose from a financial perspective, you certainly lose from a caregiving perspective,” he said.

Concierge care reduces no-shows and improves care

WELL and Circulation are working together to change this workflow. We provide coordinated communication and transportation all integrated into the EMR. This ensures patients remember their appointments and have the ride they need to actually show up. With WELL, patients can communicate with their providers in their preferred medium without having to download an app, call and wait on hold, or login to a portal. Circulation sends messaging through WELL to the patient to coordinate transportation, again without having to download another app or wait for hours for a ride.

Improving discharge from the ED

In the webinar, Dr. Kelly also identified a pressing concern he faces as an ER doctor. Multiple factors affect his decision to discharge a patient: Is the patient safe to be discharged home? Do they have the referral coordination that they need? Is the discharge planning correct? And do they have access to the care they need to stay out of the hospital safely? The very real risk is a patient going home, decompensating, and ending up in the ER again in a week. Or worse: staying at home and continuing to worsen. 

“If there’s a system like WELL and Circulation in place, we know that patient can go home,” he said.

Simply knowing a patient has their appointment scheduled, reminder messaging in place in their preferred language, and the transportation to get to that appointment brings peace of mind.

“I’m going to be much more comfortable as an ER doc in good conscience sending that patient home,” Dr. Kelly said. “It’s the little things that get you and just having the system in place is like a trust fabric. I can’t quite describe to you what a difference it can make in the care decision making process.”

Uniting disparate resources

Dr. Rivera said that as health systems and payers think about transportation, they’re really looking for a strategic framework. They want something that unites aggregate resources within the continuum of care, such as virtual urgent care, home care, and acute care.

“What they are lacking is the connective tissue, if you will, to really bring all of these together,” she said.

Speaking to the diverse digital health technologies available, Spevacek said, “Each one of those technologies certainly drives significant value in and of itself but without a unifying technology and strategy, the result is disparate, uncontrolled communications with the patient that result in lower engagement.”

“The way we think of WELL and Circulation is those are both the connective tissue that can really accompany the patient or the member across all of those care pieces and really bring everything together,” Dr. Rivera said.

Dr. Kelly said ultimately patients want a digital tool that truly enables them to engage in their care.

“What I love about these technologies is it really makes that digital front door absolutely palpable and real, because to a patient, they can get things done,” he said. “They can get things done on their terms, how they want to do it, when they want to do it, and exactly the way they want to do it.”

About the presenters

Dr. Sean Kelly practices medicine and teaches at Beth Israel Deaconess Medical Center, a level one trauma center and academic teaching hospital in Boston, MA., where he also served for several years as the Graduate Medical Education Director. He is an Assistant Clinical Professor of Emergency Medicine at Harvard Medical School. He is board certified in Emergency Medicine and is a Fellow in the American College of Emergency Physicians. Dr. Kelly is the Chief Medical Officer at Imprivata and serves as an advisor to WELL Health, Inc.

Dr. Monica Rivera served as Director of Clinical Services at Brigham and Women’s Hospital and Director of Partners Urgent Care. She received her Masters in Public Health from Harvard University School of Public Health and her MD from Tecnológico de Monterrey. Dr. Rivera serves as Vice President of Business Development and Sales for Circulation and LogistiCare. ♥

Click here to watch the webinar: The Ideal Continuum of Care: Eliminating Leakage Through Patient Engagement

The full webinar transcript is available below:

Andrew:
I really appreciate everybody joining today. My name is Andrew Spevacek, I am the VP of Strategic Partnerships and Business Development here at WELL Health. I am going to be joined by my cohost, Lauren Brandon. She’s Director of Strategic Partnerships, at Circulation and LogistiCare. Hey, Lauren.

Lauren:
Hey, happy to be here. Thanks, everyone.

Andrew:
Awesome, awesome. Before we get into the conversation, I’d like to take a minute to introduce our speakers for today. Dr. Sean Kelly and Dr. Monica Rivera. Sean practices medicine and teaches at Beth Israel Deaconess Medical Center. He is the Chief Medical Officer at Imprivata and serves as an advisor to WELL. Sean is bringing a wealth of knowledge on clinical informatics in healthcare administration. Hey, Sean.

Sean Kelly:
Hey there. Thanks, Andrew. Hi, everybody.

Andrew:
Alongside Sean, we have Dr. Monica Rivera. Monica served as the Director of Clinical Services at Brigham and Women’s Hospital and Director of Partners Urgent Care. Monica is now the Vice President of Business Development and Sales for Circulation and LogistiCare. She brings an immense amount of experience on logistics and the continuum of care with both payers and providers. Hey, Monica.

Monica Rivera:
Thank you, Andrew. Thank you everyone for joining.

Andrew:
Now, just to set the stage a little bit, I’d like to give some background on WELL, Lauren will do the same on Circulation. I think this will help frame the topic of conversation today and give everyone an understanding as to why leading health systems like Houston Methodist felt compelled to bring WELL and Circulation together to solve the problem that we’re talking about today, really eliminating leakage through patient engagement. Again, here are our speakers for today, as well as my cohost Lauren.

Andrew:
For us here at WELL, we’re solving the problem of fragmented communication with patients. What you see on the slide is a common experience we feel for a patient today: the provider has invested in multiple patient facing technologies from self-scheduling to mobile bill pay to portals, telehealth. Really, each one of those technologies certainly drives significant value in and of itself but without a unifying technology and strategy the result is disparate, uncontrolled communications with the patient that result in lower engagement and what you really want to expect from the service that you want to provide to your patients.

Andrew:
WELL took the stance of building communication infrastructure that could unify the communications across those individual pieces of technology and improve engagement with patients across their care continuum, across their journey with their health system, and their care provider. WELL itself enables enterprise health systems and private practices like I said, and vendors like Circulation to communicate with patients, not only through a single channel, but across multiple modes of communication will be covered. Text message, email, phone, and live chat, all of which is built with the goal of creating a single stream set of interactions with the patient and a single source for health system staff to view all those communications that are taking place with the patient.

Andrew:
In summary, for patients using WELL, they receive all their healthcare communications from that trusted source, from their provider. WELL really powers the representatives from our customers to seamlessly converse with patients in real time, ensuring patients are heard and have their problems resolved in real time. Drive that with this increased revenue we’re covering over 100 million communications per year and really pride ourselves on the ability to help our health system customers deliver the right communication in the right context.

Andrew:
I think one good example of that speaking with Houston Methodist of the shared source between Circulation bringing WELL and Circulation together. One of the first prompts that triggered Houston to bring WELL and Circulation together is the fact that WELL is rolling out recall messaging, essentially prompting the patient to schedule recurring appointments based on information as well as consuming from their EMR in this case. As you can see, the results are super positive, we’ve achieved almost the 90% recall scheduled rate after incorporating WELL to prompt the patient to schedule that appointment, that recurring appointment.

Andrew:
Really what came to mind for the folks at Houston was if we’re improving access to care by getting the appointment scheduled, what else can we do? What other technologies do we have in place that we can bring together to better improve the patient access to care and ensure that onset appointment is scheduled, once the patient is leaving an invitation encounter and as a business that they need to present for? How can we bring our other technologies together to better improve that experience for the patient? I think that, that really nicely into the relationship that Circulation has built, and some of the results of Circulation as a product are inspired to improve like Houston Methodist.

Andrew:
With that, I will toss it over to Lauren to get a little background on Circulation.

Lauren:
Hey everyone. Thanks so much, Andrew. It’s funny because the Circulation story definitely started very similar to WELL, but instead of communication, thinking about transportation and how it’s always been a very disparate part of the health system. There was a real need to digitize and aggregate all of the different transportation supply being used by health system. Circulation was actually founded out of Boston Children’s Hospital here in Boston, to help improve emergency room discharge efficiency, and has evolved to be a HIPAA compliant experience for transportation.

Lauren:
Really tying in all of the different options available, tapping into Rideshare, which provides immediate supply. It’s something that in our on demand environment is really, really useful especially in healthcare to get patients where they need to go, and really provide a way to provide access and build upon some of the benefits that are already in place, and get everything into one centralized technology. Really a similar situation when you think about the need as it relates to communication. There’s also, a broad need within the health system space to bring transportation together and coordinate that on a digital technology platform.

Lauren:
As you can see here, there’s a number of different providers and users of the Circulation technology, tapping into all different types of demand, are all different types of supply. We have ride sharing services, and then digital platforms where we can bring on additional levels of service understanding that not all of the population is able to take on demand Rideshare trip. We also integrate with wheelchair accessible fleets, other types of transportation providers and are able to tap into a lot of different resources to be able to manage that for the health system, provide a single source of invoicing, billing and really just transparency as a part of a system that was never really regulated in the past. We’ve seen a lot of savings, a lot of reduction in fraud, waste, and abuse overall by doing this.

Lauren:
Then you can see here just what the differences are between when you’ve managed transportation and when it’s unmanaged. Really it does come down to lowering the total spend as well as improving member health outcome. If you’re efficiently able to manage access and transportation and leverage the different services available, ultimately the patient and the member going to benefit and then the health system is going to benefit as well. They’re going to see reductions in no shows and improve flow in their emergency rooms, improved outpatient follow up. Working with companies like WELL, we’re able to build upon some of those use cases and really ensure that there’s success and transportation and all the other different digital technologies that are deployed within health systems are combined and aggregated and used in tandem. Happy to move on and talk a little bit more about some of the ways that we’ve done that.

Lauren:
This case study is actually for one of the Circulation clients that we have, it’s an at risk organization. A provider group that’s very invested in their patients and actually is held to a standard where if their patient gets admitted within a 30-day window, they get charged a pretty big fee. Knowing this and understanding, some of the different initiatives around post discharge and engaging patients and getting them back in within, there’s that 30-day window. Or actually, this was within, I believe a four-day window to improve the overall readmission rates. We found that offering trips for the post follow up visit actually improved the readmission rate and it fell from 18% in some cases to 9%. By a huge reduction in no shows for that follow-up appointment, which does result in healthier patients and a much better engagement process throughout the continuum outside of the emergency room, which we’ll talk a little bit about here. We are excited to share these statistics and work through it.

Lauren:
In going back to Houston Methodist, which is our mutual partner here that suggested that Circulation and WELL work together in the first place, saw an opportunity with two successful pilots going on this year to help improve patient access and engagement, and solve a couple of different problems. One of the main problems being patient discharge and emergency room flow, and then going back to post discharge protocol and improves patient engagement post discharge. The solution was really implementing these two technologies, Circulation to help improve the discharge flow and then WELL, to help with some of that proactive follow up engagement post discharge.

Lauren:
Our vision in working together is there’s an opportunity to engage with the patients and make sure that not only are they getting efficiently discharged. When they are discharged what happens after that is a strategy that engages the patient, understands what their needs are, if their needs do relate back to access and needing to have a trip booked for them in order to continue going to those follow up appointments to ensure follow through, this would be a way to identify patients that might be eligible or may have a need for a ride. It’s a nice marriage of these two technologies and a great way to show how there’s an opportunity to build upon what’s already in place to just improve overall engagement throughout.

Sean Kelly:
That’s great, Lauren, thank you. Maybe it’s worthwhile just to take a little bit of a deep dive into some of these workflows. Just because, as a practicing physician, there are a lot of big concepts here and sometimes it’s important just to remember some of the details that go into some of these workflows and just how difficult that can be to deliver a high quality care, at a reasonable cost and in a reasonable time frame. There’s always access to care issue in healthcare, and we have a lot of caregivers that are very highly trained, very busy, very expensive, highly educated, we really want to have them operating at the top of their license. Yet, sometimes these workflows are so complex that as you can imagine they’re dependent on so many multiple factors and sometimes the silliest little things like transportation or lack of communication can actually cause major delays and major costs, even adverse events and errors, poor outcomes, decrease satisfaction, higher burnout rates for providers, loyalty issues for patients, safety, quality, all these issues.

Sean Kelly:
If you just you put yourself in my shoes as an ER doctor, for example, we talk a lot about overcrowding in the ER. Houston Methodist and others realize that a lot of the problems in the ER actually are they’re linked to problems upstairs in the hospital and trying to discharge patients from the hospital can be such a complex process in this day and age. Especially think about, sometimes patients are going home, sometimes they’re going to rehab centers, long term care facilities, skilled nursing facilities and all sorts of different areas across the continuum of care. Sometimes, discharges can be delayed for hours from something as simple as the patient’s family was supposed to pick the patient up and they didn’t show up for an extra three hours and suddenly that bed is occupied for an extra three hours. Therefore, there’s a backup all the way through the system and that overcrowded ER can’t decompress.

Sean Kelly:
Sometimes, the decisions being made to discharge and there’s a lot of upstream and downstream effects on decision making. In other words, just the fact that if you know you have good communications with patients and you can get a referral appointment or follow up appointment, you may be able to discharge them sooner. Either from the ER or from the hospital and if you don’t have those things, well, then you got to wait and go back to square one and start to rearrange everything. They may even cross over and stay an extra whole day in the hospital or more. It’s important just to remember that the patient flow and operations aspect of these patient care scenarios can really almost can overwhelm at times the provider aspect and the actual time that providers have to see their patients.

Sean Kelly:
One thing that Houston came looking for very simply was, you have this ironic situation, if you think about that primary care group that we showed the workflow for before. You have this issue of access to care where sometimes there’s a backup of months where patients are waiting to see a provider and yet, statistically, half of those patients don’t show up for their appointments. It’s such a crazy scenario because you have all these providers ready to see patients and suddenly there’s a no show or on the converse side, you may have double bookings where you have providers that are so busy, that they can hardly get through the patients and the complexity of care can be so great that you could make mistakes, you could have satisfaction issues. Literally, just messaging and making sure that a patient confirms an appointment and getting them transportation to that appointment can make the whole process really work much more smoothly.

Monica Rivera:
Those are all great points, Sean. I’ll add a couple of things and just to build on some of the things you raised and Andrew and Lauren raised as well. You mentioned missed appointments, we know data shows that 25% of those missed appointments are in fact because patients couldn’t get there due to a lack of transportation. As health systems and as payers think of transportation, it’s really not the end all be all it’s really a driver, a tactical driver, to a larger strategic framework that that our clients look for. The other thing, that if you guys look at the continuum of care side, you see all of these aggregate resources. In many of these integrated care systems, and many of these pairs actually have the resources there and virtual urgent care, home care, acute care, what they are lacking is that connective tissue, if you will, to really bring all of these together. The way we think of WELL in Circulation is those are both the connective tissue that can really accompany the patient or the member across all of those care pieces and really bring everything together.

Sean Kelly:
I love that idea. I was at a conference a couple years ago, where it was on “telemedicine”, and one of the presenters said, “Do any of you tell a bank?” There was like this an awkward silence in the room because everyone was like, “What do you mean? I bank and some of its digital, some of it in personal though precious little that now used to be in person a lot.” Obviously, healthcare is more complex than the financial services but the point was a good one, right? It’s not like telehealth is completely distinct from health, right? It’s not like digital care is different from care that’s delivered in person.

Sean Kelly:
In fact, one way to think about it is digital tools are just more tools. Like I have a stethoscope, I have my iPhone, and I have a laptop and I have my tools. From a patient perspective, if you think about it we’re all patients, right? We’re all consumers. There’re certain things where I’d actually prefer to do it digitally and granted, not everyone in the population is like that. There’s certainly enough of us out there and enough patients where that digital front door that we talked about, it’s an abstract concept until you make it real. What I love about these technologies is it really makes that digital front door absolutely palpable and real, because to a patient, they can get things done. They can get things done on their terms, how they want to do it, when they want to do it, and exactly the way they want to do it.

Sean Kelly:
A lot of data shows a lot of people really do well when they have push notifications, text messages is oftentimes the preferred way. The systems can work through many different types of preferences for patients, but far and away. They all, we all like to have health systems reach out to us in ways that are practical to us in the moment when we need them to make things happen that we need to happen.

Monica Rivera:
Sean, and that’s a great point. Just in terms of transportation, just as a bit of background for those of you guys that don’t come from this world. This really started in 1965 when Medicaid and Medicare started adding it as a benefit and really the reason they added it was because they identified it was a barrier to good healthcare. To your point around the consumer driven experience, traditionally, the market has been led by brokers where you have to call a call center, and they give you a four to eight hour window like your cable installation, to just wait there at home to when you get picked up. Now you’ve essentially wasted or lost all day, waiting for someone to pick you up to take you to a medical appointment. That’s not how we consume financial services, delivery, regular transportation, and we think that the catching up if you will, with these digital features and tools is very beneficial to the consumer.

Sean Kelly:
Right. I think never has been so important to us good consumer technology well, bad pun intended in, although you did say transportation was a driver early.

Monica Rivera:
I did.

Sean Kelly:
Which is even better. I think it’s never been more important than it is now. We have such a high pressured environment, I mean, every caregiver you talk to is overworked and overburdened with administrative burden and coordinating care is exceedingly difficult, even within a system in what you’d think would be the simplest cases, you look at this diagram, and it’s actually enormously much more complex in this season. Let’s take an example, let’s take someone with a knee injury. You get diagnosed with a knee injury, you might see someone in a clinic, you might actually go to PT a couple times as an outpatient. Maybe you’re non weight bearing, so you have some issues you need to arrange for transportation. As Monica said, if you have a four hour window where some transport may or may not show up in order to go see an orthopedic physician, she’s going to tell you whether you can go get your surgery or not.

Sean Kelly:
How can the system sustain that? It’s insanity that we expect patients, doctors and nurses to work under those conditions and actually, achieve things whether that’s in a fee for service world. Because either way, the fee for service world, you don’t show up for that appointment, that appointment doesn’t get revenue, and you’re still paying the overhead of the patient and the doctor and all the caregivers there. In a value based care system, same thing, the whole system is on the hook for preventing illness and disease, and there needs to be cost avoidance. Either way, you lose my financial perspective, you certainly lose some a caregiving perspective. Maybe I’m hobbling around I fall and hit my head and sustain a worst injury. Maybe I get an infection because I’m sitting around all day, complications can happen. Even a simple case like just, getting your knee looked at, there are enormous complications and enormous implications for all the different lack of coordination if that happens.

Sean Kelly:
I think one of the things that we’re all appreciating is that the distributed networks we all deal with are enormously complicated. We all talk about interoperability, but the reality is, in the world we live in, it’s going to be awhile before there’s true interoperability. Look, we’re all trying really hard with HIEs, and we’re trying to not have information blocking, we have to deal with the world we’re dealing with right now. What I love about technologies that are consumer grade are actually better, than are the patient grade, right? They’re actually almost better than consumer technology is that they really allow key transactional workflows to happen in a seamless way and in the now.

Lauren:
Now, and to build upon that, and these use cases here and tying it back to the overarching idea of avoiding readmissions, and continuing to move people through this continuum of care, I want to highlight a use case that was actually recently studied here in Boston, Massachusetts General Hospital within their radiology department. Just a very practical application of using these types of digital technologies to really improve the flow of the clinic. One way that the radiology department has been using transportation and there’s absolutely a way to tie communication into this as well is understanding how to plan for surgeries in the clinic. For example, if a patient needed to get in for some imaging, and had to be in that day, but the nurse general location was completely booked up and the patient was unable to get to any of the other in-network locations. In this case, that would mean a 10 or 15 minute Lyft trip, if you were to take public transit or if you were to find a way to get there, it was just a half.

Lauren:
What the clinic decided to do was triage these patients and offer them a ride to keep them within their network, while also making sure that they receive the imaging that they needed that day, which ultimately helps the patient, get ahead of any findings that that image would show and keep them within the continuum as it relates to the Massachusetts General Hospital network. That’s one way that we’ve seen this very practical application used in a way that’s had tremendous success for the organization.

Monica Rivera:
Just to build on what both of you guys are saying there is sometimes we have a hard time understanding either as patients or providers or payers, how a member or patient can or cannot get there. Because we miss out the social determinants of health, so many of these people are living with unemployment or addiction or are in rural places, they don’t have access to food. Again, going back to Lauren’s example, of MGH, many of these patients couldn’t get to the appointment on time, because they’re working two jobs and don’t have enough time to go to and from their two jobs and then the appointment. That’s something that needs to be addressed, if you want to look at the clinical piece as well, and look at communication and transportation to really enable those social determinants of health.

Sean Kelly:
Yeah. What I love about that example is, it’s so practical. It really does, it shows you how it’s a win-win, right? The system is motivated because they want to distribute that care to the right resource at the right time in the right place. That’s good for the hospital system, it’s good for the provider system and the network as far as a cost and in revenue perspective. It’s even better for the patient, right? Because like Monica is saying, this poor patient sitting there has all these concerns that we may or may not know about, to give them more options to automate that to allow artificial intelligence and a really robust automated system to integrate with scheduling systems across the network, the EHR, and then message that patient the way they want to be messaged in the now.

Sean Kelly:
For them to be able to then quickly choose, we can’t predict for them what the best option is. But if we give them several options, and they say, “You know what, I don’t mind getting to this other appointment, even though it’s 15 miles away, especially if the healthcare system is actually going to get me that transportation.” When you do the cost analysis is incredibly beneficial for the provider systems. Let’s not forget the fact that it’s incredibly beneficial for the patient and the family to actually get their study done, when and how they want it. Through whatever social determinants they have to battle through, and just to get their study done so they can move their terror along one more step. I love that example, for all those reasons.

Andrew:
I think there’s a nice tie in as well to managing the patient’s referral process coming out of the discharge knowing as the provider what that patient needs to go through to be able to consume the next step and care time both to the fact that well is consuming that information from the MR. Understanding when that has reached a point where you’re going to say you’ve been discharged and referred to this specialist to the following premiering patient procedure. Knowing when that is ready to be consumed by the patient and presenting that to the patient in a way where they know that if transportation is a barrier to them getting that appointment book to schedule the service, like Circulation is available to them. I think that gets back and will be talked about before in the recall example that providing the right content in the right context. I think that’s what’s really powerful about the depth of integration that both Circulation and WELL have. We know when the patient is ready to consume that service and together we’re better able to present that service at the right time.

Lauren:
Sean, I’d be curious to hear your experience as a practicing provider, as a practicing ER doc. You’re in one of the busiest emergency departments in the city of Boston. What do you see in lack of fragmentation that actually happened? We’re not talking about it, but it just happened today. What do you see works well and what doesn’t work well, and how can these tools improve that?

Sean Kelly:
I’ll touch briefly on the fact that a lot of the decision making effects actually go upstream and downstream just from the part of the workflow we’re talking about and what I mean by that. Again, put yourself in my shoes, I’m in the ER it’s 2:00 AM, a patient is in front of us and they have CHF, Congestive Heart Failure. They were admitted recently, they’re now back in front of us. I can think of two specific patients on the last shift, one fluid overloaded so fluid in the lungs and other one had a heart rhythm issue, Tachycardia, atrial fibrillation, rapid ventricular response. Both patients are there in front of us with some complications of their underlying illness. We’re caring for them, we’re resolving the acute problems. We’re giving a number of medications in one case we cardioversion. There are a number of factors in play of whether that patient is safe to be sent home or needs to be admitted.

Sean Kelly:
You’re at the crux of this decision making process and I got to tell you a lot of what dictates what happens at that juncture in care in these high stakes gambles are, is that patient safe to be discharged home? Do they have the referral coordination that they need? Is the discharge planning correct and do they have access to the care they need to stay out of the hospital safely, not decompensate, get worse, and come back or worse, get even sicker at home. That patient with fluid overload once we get some of that fluid off, and they’re reasonably stable, if there’s a system like WELL and Circulation in place, we know that patient can go home, sleep at home where there’s less risk of infection, they can actually do better they can get some rest, they can be monitored. We know they have their cardiology CHF service appointment already on the books or the messaging gets to them the way they needed to in the language they needed to, to actually comply with it and they have arrived to see doctor so and so in two days. I’m going to be much more comfortable as an ER doc in good conscience sending that patient home. Where I actually want them to go and their family wants them to go if it’s all tucked in tight and ready for them to succeed at home.

Sean Kelly:
Now you take away those two simple factors if we’re not sure they can get back to their follow up appointment, or if we just don’t even know if we can get them one. Because look, we’re headed into a holiday weekend this week, right? I mean, there’s so many practical considerations that pop up. It’s the little things that get you and just having the system in place is like a trust fabric. I can’t quite describe to you what a difference it can make in the care decision making process. To have these things set up, knowing someone’s got access in they’ve got good referrals and they’ve got a good care coordination can make all the difference. Because otherwise, guess what I have to do? I readmit them. You can’t send them home if you think they’re going to decompensate.

Monica Rivera:
Now, those are great points. Just the other point that both of these tools provide is the closed loop and the feedback. Besides booking the ride, besides communicating with the patient, you’re actually able to see if the patient says, “Yes, I’ll be there.” You’re actually able to see when the ride is dispatched to go and pick them up, or you’re pinned if they didn’t show up to the ride. You’re able to proactively manage that as a care coordination team versus see that patient in the ED five to 10 days later.

Lauren:
Just thinking about it from the patient experience side as well. For me personally, knowing I was being discharged from something that traumatic and my caregiver was going out of their way to put all these tools in place to put the white glove experience to the patient is something that as a consumer is so refreshing and effective and makes you want to continue going back for care. It’s one of those things retiring consumerization into healthcare and just taking that member experience and treating people differently and treating them, in a way that makes them want to get care and want to get better. I think that if I were to be discharged and someone was to do all that, for me, I would be really happy. Thankfully, it hasn’t happened to me recently.

Sean Kelly:
Yeah. If you’re going to care for the patient, you actually have to care about the patient and systems like this make a patient feel well cared for. The great part is we’re just scratching the surface about where this technology can go. A lot of the use cases that are most well demonstrated right now are incredibly valuable, and they are taking care of these very logistical issues. Certain places have started to build even more logic into the system and really putting intelligence in there with AI and machine learning and automating it and scaling it up where you can touch so many patients so quickly and the system can sniff out if someone’s having trouble, right? If the word shortness of breath or chest pain pops up, bang, it alerts right out, it turns red, it goes to human being it says call 911 and a number of things can be triggered.

Sean Kelly:
The other really interesting piece of this is that, because the technology is so robust in both WELL and Circulation, there’s a ton of data and analytics and parsing through that data and observing the effects and seeing the real talk about return on investment but its value, right? The tangible objective value is so high never mind all the intangibles that Lauren you just spoke of where, you engender patient loyalty and trust. You don’t have leakage you have keeping if patients feel like at any time. When they get text messages from the health system, it’s from their doctor’s office, it’s not from some random number they don’t know that they think is a spammer and they ignore. It feels like very high touch concierge service at scale, which is, that’s not easy to do. Come on, like there’s consumer technology now, that as a doctor, I really feel like we need to advocate more for our patients in ourselves or caregiving selves to force more this high level technology into our system and use it to its utmost capability.

Andrew:
I think that’s one of the things Sean, you mentioned before being almost more advanced than your typical consumer technologies of patient technology needs to take it a step further. `I think that outside of meeting the patient has the right mode of communication that they want, using that same contact point that they’re familiar with, interacting with their provider, it really is dependent on those technologies being able to integrate effectively and consume information from the EMR. To be able to integrate in the way that Circulation and WELL are able to share information about where the patient is at in their journey, to really take that next step beyond just on consumerism tool to a patient as a consumer tool.

Sean Kelly:
I think we should move the Q and A post, I think there’s a bunch of questions coming in and the things we had planned on talking about we’ll address in the questions probably anyhow.

Lauren:
Yeah. I’m looking at the questions that have come in. One of the ones that I’m reading is what’s one creative or tactical way you have seen your product used? You guys hear us talking about getting the member or the patient to and from appointment? Some of our clients have really reinvented that paradigm and have said, “Well, does the patient really need to travel?” Really use the resources to go to where the patient is at. They’ve used these tools to really transform home health providers to the patient home. The interesting things and again, we mentioned that at the start, no pun intended is that it’s really a strategic driver.

Lauren:
The way to think about it, it’s not just about getting the provider from point A to point B. It’s really around looking at provider productivity, and looking at time of transportation using that time in the car effectively to chat or callback patients or do other things. Then to really have an employee satisfaction tool for those employees that might not want to drive in the snow or don’t want to park in the city are afraid to be walking at night, that sort of thing. Those are the clients that just think about things a little differently.

Lauren:
Then the other interesting use case is a pair that is looking at the tool to really close gaps in care. Looking at their frequent flyers to the ED they’re high utilizers, and really making a proactive outreach to them saying, “We can offer you a ride to this appointment or that appointment.” Instead of really just offering it as a blanket to offer it in a targeted basis. I don’t know what your experience has been with WELL.

Sean Kelly:
Look there are a number of different really cool implementations. I think one thing that I’m incredibly impressed with is just the language capability. It’s something just knowing from our human interactions in the ER, when someone is not a native English speaker, it’s really difficult to give them the care and the respect that they deserve. One thing I love about the WELL technology, I think it’s 19 different languages or something. You can tell if someone’s responding in the language, you can actually triage that out to the call center providers that actually can speak that language. Or like, for example, I think one customer in California sends over 50 percent of their messages in Spanish. You can take an automatic feed from the EHR on language preference and the better other systems and technologies around WELL get, the better the messaging gets.

Sean Kelly:
I think that very first concept architectural diagram that was drawn and shows an amalgamation of all these different platforms, integrating into that one Unified Communication layer and conduit is a good way to think about it. That’s one of the cool things I’ve heard about linking and you had talked about Monica, high cost and payer, just linking into co pays and things I think in automating that process is another thing that has been done with the messaging with WELL. I think as the AI continues to be used more and more and gets trained up, we see places doing things like encoding logic into responses where patients as they start to say specific things that are medical, they can actually triage out to proper follow up and get more and more advanced as they grow into that system.

Sean Kelly:
We’re very excited because we think the ingredients are there, the architecture is there, and really the sky is the limit on what you can do with a lot of this. Patients starve for it, right?

Lauren:
Yeah.

Sean Kelly:
We’re all starved for just better communications.

Lauren:
Speaking of communication, one question that came in was, “Are you integrated into the EHR workflow?” Can you talk a little bit about how you interface with the EHR and to your point about communication, does that trigger direct report responses, or how does that work?

Monica Rivera:
As far as Circulation, we are able to do APIs and single sign on. Again, that’s very client dependent as all about you guys know, there’s multiple different EHR. What we do with some clients is single sign on when they’re on Epic or Cerner or other EHR. Again, the care coordinators don’t have to navigate through different tools. We are working with multiple EHR vendors at this point to really have that easy button from staples and that it is actually embedded at the EHR. Again, just circling back on what we said to start, the intention of this is not to make the job of a care coordinator, whoever’s requesting this harder. Then the other component that we’re really working on is again, closing the loop. How do we use that data to inform clinical decisions?

Sean Kelly:
I’ll start and I’ll hand it off to Andrew when I get over my technical. From what I’ve seen, absolutely WELL integrates with the EHR takes feeds from EHR is oftentimes HL7 feeds and whatnot to get information, like we just talked about to book appointments, integrate back into EHR as well. I think one question from a technical standpoint, a lot of integrations are possible already existed or underway. One thing we’ve seen with provider systems is, it’s a good chance to think about the processes and understand what do you want to put back into the EHR? You may not want an entire messaging workflow, put back into an EHR, but you may want to be able to manually cut and paste some in or you may actually automate certain aspects of that.

Sean Kelly:
We’re seeing this as an evolving field, but I think one of the strengths of the WELL platform and it sounds like the Circulation platform is integration with ecosystem around it, including EHR, because that’s one major source of information both for input and output. Andrew, do you want to add to that?

Andrew:
Yes. Sean, I think that’s a perfect summary, and we’ve heard a few of the examples here. The way that I think about WELL integrating with the EHR is that it’s not just a tool to consume information and push content to the patient. It’s a way to close the loop when that patient actually responds and interacts with that content. Think of the recalls example that we gave at the beginning of the presentation. It’s one thing to ask the patient to actually schedule the appointment but knowing when that scheduling has taken place so that we’re not reaching out to the patient again, and we can actually close that loop in the EMR. That’s taking it to the next step beyond pushing, like I said, content.

Andrew:
Same with peripheral coordination, if we know that referral is ready to be scheduled. We know that a blocker to that patient scheduling that appointment is having transportation to that that encounter. Not only can WELL pass along what it knows as a byproduct of integrating to the EMR, the passing along that information to a product like Circulation so we can get that outstanding item closed for the patient. We can also tell the EMR, “Hey look, we’ve arranged transportation and we will know from the EMR when that patient actually follows up and schedules that specific referral.” I think it really speaks to the fact that being two ways to EMR not just consuming information and pushing content, being able to close the loop is especially important.

Lauren:
Thank you, Andrew. One of the other questions, we got really great question. “How do we convince administrators and providers to invest in patient engagement?” What I will say is you don’t have to convince them they are already convinced that good patient engagement will give them loyalty and provide leakage. What you have to work on is making sure that the tools you provide will further patient engagement. In order to do those things, at add both WELL and Circulation, we think that, that you need to do a couple of things. One is you really meet the consumer or the patient where they’re at with digital tools where they can track and really empower members. The second piece is really again, around closing the loop, and seeing what the members and the patients are doing. We have the case studies and the experience that really prove that ROI in terms of weekends or loss of leakage.

Sean Kelly:
I have a ton of thoughts on this. I find it fascinating. Patient engagement is such a big term that first you have to understand what does a stakeholder really mean by patient engagement? Some ways it’s like a bunch of blind men and an elephant, right? Does patient engagement to the patient access person mean the same thing to risk and compliance to the patient engagement officer to the chief of that department, to the patient’s themselves to family? In some ways, it’s an unanswerable question until you figure out who is interested in what exactly they want out of it.

Sean Kelly:
Some of that, falls into some predictable patterns, but sometimes you just ask, or sometimes what you do is you actually don’t try to push a new technology at a big problem that’s fuzzy, you actually pull a technology into specific problem points or pain issues or areas that the hospital or the provider systems actively engaged in. Those fall into categories that are reasonably predictable, right? People want patients to be able to get to their appointments and have access to care. They want their patient satisfaction to go up, they want patient loyalty, they want higher revenue, they want lower costs. I think attaching it to ROI and metrics, the beauty of some of these newer technologies is the analytics are built right in. If you come at it with, “Let’s go at risk together, in the next three to six months.” We’re going to show you just like those case studies that resonated, we’re going to take your no-show rate and we’re going to cut it in half, we’re going to take your ROI, we’re going to double it this way.

Sean Kelly:
When you put numbers to it, and you put specific goals, you can’t do all patient engagement for all people all the time all at once. You can certainly pick off several really, really important use cases and demonstrate traction. Oftentimes in the beginning that’s budget neutral because you have some other legacy technology doing things very poorly that you can just rip and replace. Then once it’s in, patients love it and then you can really, really start to grow it. That would be my technique is a few really solid wins with demonstrated KPIs for certain stakeholders around specific aspects of patient engagement. One bite at a time.

Lauren:
That perfectly goes into this next question here, which is what has been a successful way to reach post hospital patients in order to get them scheduled with a provider in clinics? Talking about how do we engage with patients once they’ve left the hospital, which seems to be one of the overarching themes of avoiding readmissions and leakage and everything we’ve discussed today.

Sean Kelly:
I mean, I’ll go back to the most simple use case just people want to be communicated with very directly in the way they want. I mean, something a system like WELL will communicate with them. However, they want to be communicated with, cell phone, email, call but they almost all just want to text. The simplest easy way is you figure out which patients are most highly at risk and which ones you want to connect with the best. You set up an automated feed from the EHR that tries to get them to commit to an appointment and actually get a date and recalls them just like the workflow we showed in the beginning and you just set up that automated texting. Now if they have problems getting transport and they can’t get there, then adding in the Circulation piece could be priceless as well, because they might not be telling you why they’re not committing to an appointment.

Sean Kelly:
The ability to also then feed right back into the scheduling system, automatically have it look up and find the next four appointments if this one doesn’t work for them and offer it to them like the MRI radiology studies we talked about. Another great way to do it. Without going too far afield text, text, text right away and then automate it, and give them options. Then if they commit to one book it, send it right back in the system and book them down right then.

Lauren:
Now that’s that’s a great point, and we do the same thing at Circulation. There’s the opportunity to either use call centers or emails or text and obviously the preference is text. The very unique thing and again,  it goes around engagement and empowering the patient is we have the capability to text a patient. With clicking that link on a text, they can actually book the ride themselves. That really speaks to the engagement piece. As far as how we’ve seen payers and providers do it, there’s both the blanket approach and the target approach. We’re working with a couple of payers that really want to use transportation as an enabler to their clinical care.

Lauren:
They’re sending mailers saying, “Heads up, this is within your benefit package, call this number of you want to learn more.” Then there’s a targeted approach, where payers or address providers go to high utilizer or look at their clinics where they’re having a ton of no shows or just their data around no shows and saying, “All right, let’s survey those members and understand where they’re at.” Going back to meet the patients where they’re at, or they know showing due to transportation and then how do we catch them so they don’t miss the next appointment.

Sean Kelly:
I just want to clarify one thing, the technology needs to be really good. Because if you’re just robot spamming people, we all hate that, right? If you get some random number, and you just get a bunch of gobbledygook, nobody wants that, but if you have a system that’s really adept. It’s plugged into the EHR and to the appointment system and it’s odd, if you have 1,000 patients that you’ve decided upon discharge are high risk, you can now hit all of them all the time.

Sean Kelly:
Then if they start, if there becomes a communication loop where for some reason they can’t pick an appointment, and they start texting something that’s free text that really, is just explaining something else. Who knows, that can flag right to a human being and a human being can get on the phone. Because you’ve now re-tasked those human being resources to more high level, they’ve got the time and the energy to actually respond to the high level issues where patient really isn’t able to just quickly text back and forth. Many times mean, a big deficit in the system is transportation. I think that that is a valid, concern to address up front all the time.

Lauren:
Awesome. We only have a few minutes left, for anyone that had questions that came in that we did not have a chance to get time to answer, there is some contact information, please reach out to us directly. I’m more than happy and I know Andrew is more than happy to answer your questions directly. I wanted to just close everything up by hearing in your opinion, what can we do better as digital technology companies, as healthcare organizations to bring all of these tools together and be effective and really, at the end of the day, just impact patients in a positive way that trickles up to everyone?

Monica Rivera:
From my perspective, there’s an abundance of data everywhere, right? Big data is everywhere, and really the differentiator not big data, because that’s everywhere. It’s really the group that knows how to mine that data and understand the patterns, and how you can use those data points to improve patient outcomes. To me, that’s the one of the key pieces. The other piece that we need to understand is consumers and patients are also flooded by that big data. Going back to what Sean was saying, it’s really around meaningful interaction. You only have a number of shots with the patient. As soon as you start what they perceived to be spamming or over communicating, you’ve lost them. It’s around how do you use that data in a meaningful way? Then how do you stage or really impact along meaningful interventions with the patient so that you can accompany them across the care continuum? Sean, we’re about to hear what you think about that?

Sean Kelly:
I totally agree. I think for me, it’s all about partnership this is an iterative process where technology companies really need to listen and be good partners with providers systems, and healthcare systems, who internally really listen to patients. You can’t expect to start some big project over the course of a year and never really check in on things, right? I mean, this is like, you have to be incredibly agile, and you have to really listen to patients, you need to act, but you also need to be sensitive to course correction. To me, this is all about picking off what the biggest pain points are for both the provider side on the patient side and having the technology take one cycle at that, but then very quickly, course correct and say, “Okay, this part of it works great. We need to build more logic in here, we need to take this away here. We actually went too broadly here, we need to narrow this.” We see that all the time that some of the most successful provider system are the ones that have regular cadence meetings. There’s representation from all stakeholders within reason, right? Even with the patients somehow if there’s some way to understand from patient advocacy, what’s really successful and what’s not successful. It’s not always easy, but without that I don’t think there is success, it’s partnership.

Andrew:
Well, I appreciate that everybody. Great conversation. I think just tying it off, definitely reach out to us, our contact information is here. Happy to pull in Monica, Sean, Lauren and myself for follow up questions after the webinar. We will be distributing information as a wrap up here to everybody that attended. We’ll have some additional follow up content, a little more detail on the way that WELL and Circulation in particular are working together that we’ll share with everybody that attended today. I appreciate everybody’s time, have a great rest of your day and great holiday and looking forward to chatting with you all more.

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