It is now widely appreciated that the health care system is moving from volume to value. In the outpatient world, this means a much greater focus on population health, prevention, and the use of technology to manage patients with chronic conditions and comorbidities across settings. While few argue with the need for such reforms, the multiple imperatives can lead to burnout, which undermines all of reform’s best intentions.
That’s why, over the last year or two, the Department of Medicine’s outpatient efforts have focused on improving both the patient and the provider experience. In UCSF’s different health systems with very different challenges and patient populations, outpatient teams often use “lean” methodology to rigorously examine existing practices, identify new skill sets and design new processes. The goal is to improve team-based care, advance patient management techniques, expand access to care, and communicate more effectively with patients and among clinical teams – without overburdening providers.
If you have every been a patient, you know that attending a clinic visit can be taxing. Long travel times, missed work, expensive parking, and wait times are some key dissatisfiers with doctor’s visits. UCSF Department of Medicine recognizes that these barriers to a patient attending their visits and offers video visits in most departments.
UCSF’s home telehealth program continues to grow, with over 40 clinical groups—up from 17 in June of 2015—and more than 200 providers currently offering the service. Since January of 2015, over 4000 visits have been completed, serving patients in 51 of California’s 58 counties and saving over 150,000 driving miles.
UCSF Telehealth uses Zoom, a highly reliable, easy to use application, particularly well-suited to low-bandwidth connections, including 3GS. Clinic staff are trained to help patients download the application and test out connections prior to their visit.
Advanced Patient Management
As health systems seek better ways to manage chronic conditions across entire patient populations, increasingly sophisticated mobile apps offer simple, affordable ways that, in theory, help patients and clinicians better measure and manage key clinical indicators. “But the apps are only useful if integrated into the care delivery process and the electronic health record – with someone inside of the patient’s health care team interacting with that information,” says Nat Gleason, MD, medical director for practice innovation at UCSF Health. Several groups in the department are taking that idea to heart, including the Division of Cardiology. Concerned that many patients were not reaching their prescribed blood pressure goals between quarterly appointments, cardiologist Rajni Rao, MD, and her team piloted the use of an app that made it easy for patients to take their blood pressure twice a day and transmit that information electronically to the cardiology team. When measurements fell outside a physician-prescribed range, the team received an alert, and a pharmacist engaged the patient to titrate his or her medications. More than 80 percent of patients reached or exceeded their prescribed goal within two weeks.
“Patients became super engaged in their own care. Life-style changes were much more transparent to them, and they owned their number so much that we could often reduce their reliance on medications.”
Rajni Rao, MD MD
“Patients became super engaged in their own care,” says Rao. “Life- style changes were much more transparent to them, and they owned their number so much that we could often reduce their reliance on medications.”
Rao’s team is also bringing team-based care and technology to its Cardiac Outpatient Recovery (COR) clinic. The clinic’s nurse practitioner (NP) meets patients in the hospital who are at high risk for readmission to prepare them for their follow-up appointment and address any barriers to getting there, such as transportation and social work needs. The NP also walks families through the use of an online portal and mobile health application that facilitate patients’ abilities to communicate with providers. Using these techniques, the clinic has significantly reduced the no-show rate for follow-up appointments and successfully connected the vast majority of its patients to primary care, outpatient cardiology, or cardiac rehabilitation programs, says Rao.
Even as the department continues to pursue innovation, it has not lost sight of how change fatigue can lead to burnout for physicians transitioning from traditional ways of delivering care.
“Asynchronous care has had a big effect,” says Coleen Kivlahan, MD, MSPH, UCSF Health’s executive medical director of Primary Care Services. “After a full-day clinic, physicians still have to finish patient notes and respond to patient emails. This can make it feel as though there is no end to our day.”
In response, UCSF Health is implementing a number of interventions, including on-site or off-site scribes who help create physician notes and communication training courses, that ensure the focus is on the relationship between a patient and their doctor. The department is considering new technology-enabled approaches, including emerging voice recognition programs to act as scribes, to further improve the efficiency of the process.