Doug Wilson's Profile
Washington State Hospital Association claims success with their program. However, their statistics appear similar to what you have already achieved. http://www.wsha.org/quality-safety/projects/er-is-for-emergencies/
New Mexico ran a 24-hour free nurse triage hotline for several years, reportedly with some success. Ultimately it appears they couldn’t figure out how to fund it, as MCO’s went their separate ways. http://www.santafenewmexican.com/news/health_and_science/health-hotline-nurseadvice-new-mexico-at-risk-of-going-silent/article_edf26060-e5d0-549e-a396-199df3fed31f.html
Probably there will be no significant change until PCP’s provide an alternative (open access/walk in scheduling, telephone/internet nurse triage, extended office hours) that exceeds the value proposition experienced by patients who visit the ED. It is interesting that some countries require PCP’s to provide after hours access.
Quite a challenging situation. I presume the population feels desperate for change, if they tolerate such measures. Increasing referrals is important, both for your institution, and as a public health measure to help prevent patients from running afoul of this extreme approach to drug dependence. However, I’m skeptical about simply putting up billboards in your current climate, because it may have unforeseen political consequences. Maybe there is room to “nudge” the public conversation in a direction of compassion, or possibly to engage law enforcement and/or national leadership to be supportive of this alternative or supplementary approach. Many people have family members they worry about and probably could be reached, with the right message. Who are the patients you want to attract? Who are the most vulnerable and/or most in need of your services? Do you treat dual-diagnosis patients? Should you focus on some specific type of patient who needs you and will trust you? Are there populations you aren’t equipped to help? Being explicit about inviting (for example) non-violent patients who struggle with psychiatric issues could decrease fear, resulting in increased admissions of appropriate patients.
I am sympathetic to your doctors’ resistance to the EMR. It comes at high cost, tends to decrease efficiency in many settings, and can create new types of errors. Hopefully, all that will improve someday. Perhaps pre-printing prescriptions, with standardized instructions, could help. If, later, an electronic system is implemented, it could be helpful to have these procedures already established.
We also learned from experience that medical assistants should not be allowed to “discontinue” a medication from the list; that could perhaps be viewed as a scope of practice issue. However, they can review medication adherence with patients, and to flag them appropriately. Attestation of “review of medications,” while imperfect, is a metric that can be monitored and feedback given to physicians with reference to peer averages and an institutional goal. Also, consider presenting physicians with an anecdotal case to illustrate the problem they want to prevent (e.g. someone stops their beta blocker, it’s inappropriately removed from their list, and then they have an MI and end up in the ICU). Finally, I would attempt to standardize rooming/medication reconciliation process across departments, so that for example, primary care is empowered to discontinue clearly expired acute medications (even if prescribed by a specialist), and so that your top performing specialty groups will at least notify a PCP, if it is noted that a patient has stopped taking one of their chronic medications such as aspirin or statins. Calling out certain departments or providers for helping other departments in this way could be powerful positive reinforcement.
Another idea is to be sure some kind of root cause analysis is performed for patients who no-show. A simple follow up phone call questionnaire would suffice: Did they receive a reminder via their preferred method of communication? Did they lack transportation? Did they know how to call us, to cancel or reschedule? Would a specific day or time be better? Do they have trouble attending appointments during our normal hours and days of operation? The responses could reveal a pattern to address.
This is a challenge for us as well. Is there more opportunity for generating engagement, either at the staff level, or (ideally) at the union leadership level? Patient satisfaction scores being tallied by patients now will affect net income over the next few months to years, so we all have a stake in improving HCAHPS. What is less certain to me is what exactly these surveys measure, and how responsive the results are to our interventions. However, it seems likely that frequent messaging and role modeling around patient service would bend the metrics in the right direction. I hypothesize that the global message to staff is more important than any specific intervention. Staff benefit from being reminded that a large percentage of whatever healing occurs is dependent on a caring, trusting relationship perceived by the patient. Our patients rely on us to overcome all our technological and institutional barriers in order to be present for them. When rooms are clean, call lights are responded to quickly, food is warm, and care teams know what each other are doing and saying, then the patients will have positive regard for their caregivers. It’s hard to reduce this to a formula or a checklist, but the spirit of it needs to be over-communicated, until it is part of the culture of the institution.
I agree that telemedicine has the potential to be a very disruptive technology. The price point for primary care visits using mobile platforms appears to be in the range of <$20 US. In my rural Western US region, we have found telemedicine to be successful for certain specialty services such as cardiology, psychiatry and anticoagulation management. We think it will also work for some primary care visits, especially chronic disease management. It seems less likely to be effective for more procedurally oriented specialties such as urology, although follow up visits could be done remotely in many cases. Fee for service reimbursement is expanding in the US. However, when it is not available, telemedicine can still provide value in capitated or bundled payment scenarios.