May 25, 2021 | Monica E. Oss
I heard the proverb, “The road to hell is paved with good intentions” a lot as a child. The meaning—good works trump good thoughts. I think this sentiment is particularly relevant when looking at how specialty provider organizations provide person-centered care (or offer self-determination initiatives or address consumer social support needs). Most of the executive teams I speak to on this topic can attest to good organizational intentions (great mission statements and more) to meet the needs and wants and preferences of consumers. But many times, these intentions do not have the benefit of organizational processes or measurement—and are largely dependent on the diligence of individual staff members. There are few standardized assessments and consumer-centric records; there are few decision support tools for care professionals; compliance and outcomes often go unmeasured; and these activities are often not linked with overall health and wellness coordination activities.
For many reasons, executive teams of specialty provider organizations are going to need to give more thought to standardizing how they personalize their services using consumer needs, wants, and preferences as guideposts. Why? Because a positive consumer experience (and net promoter scores), consumer engagement, and integrated care coordination depend on consistency across the service delivery system. Katie Morrow, MPA, BSW, Vice President of Compliance at Streamline Healthcare Solutions, spoke to the issues around standardization of the person-centered care process during our recent executive web briefing, How Your Organization Can Lead The Charge In WPC To Create A Better Community. She emphasized that a standardized approach is fundamental to the success of whole person care (addressing the consumers’ medical, behavioral health, and social service needs) and highlighted three points in the care continuum when this approach has to be applied and tie in with data—assessments, referral tracking, and measuring outcomes.
If clinical professionals want to know what consumers want, they need to ask. But what to ask and how to capture the responses is the key—specificity rather than the subjectivity is the operative word here. The assessments should cover health and social needs—and can be developed in-house or adapted from what’s out there (one example is the social needs screening tool from the Centers for Medicare and Medicaid Services—see The Accountable Health Communities Health-Related Social Needs Screening Tool). Having both the assessment instrument and the responses in the electronic health record (EHR)—or a system that integrates seamlessly with the EHR—is optimal, so the data can be translated into system-generated action prompts for clinical professionals. Ms. Morrow recommended translating needs into goals and objectives by capturing consumer responses in structured data fields that can be scored. She said, “If data from assessments is entered as open text, there’s not much you can do with it. It has to be quantifiable.”
Ms. Morrow also pointed out that consumer perceptions of what they need might differ significantly from what clinical professionals perceive as their needs. Structured assessments can take the guesswork and assumptions out, enabling better engagement and outcomes.
Knowing how to ask is also important, according to Megan Lipman, Vice President, Quality Management and Compliance, Jewish Family and Children’s Service (JFCS) Arizona (see Adding Social Determinants To Care Coordination Programs: The JFCS Case Study). She said that especially when it comes to social determinants of health, you don’t know until you ask. JFCS developed a social determinants assessment tool and embedded it in their EHR. But initially, it was awkward for staff and consumers to deal with questions about social needs and safety—while factoring in different cultural backgrounds and expectations—when consumers came in to have their medical or behavioral health needs assessed and had not built enough rapport yet. So the assessment tool had to be short and user-friendly, and staff had to be trained to get comfortable using it and eliciting answers. And staff were trained to ask questions not only at intake but also annually and as issues come up during visits.
And to take person-centered care to the next level, the standardized assessments can be tailored to each consumer’s circumstances. DeAnna L. Minus-Vincent, MPA, Senior Vice President, Chief Social Integration and Health Equity Strategist at RWJBarnabas Health—the keynote speaker at our upcoming 2021 OPEN MINDS Strategy & Innovation Institute on June 15 (see Making Social Service Supports More Than A Referral)—explained how they are deploying this approach. She said, “One key is that the assessment is universal and administered to everyone but questions are tailored to each consumer’s profile. The first question asked of a person with a higher income may not be if they are worried about accessing food but rather about healthy eating or how many sugary drinks they might be consuming in a day. We take a cohort of our patients and use big data and behavioral economics to segment them in the same way that Target or Nordstrom or Macy’s would segment them for targeted, focused outreach. So the questions for each consumer are going to be phrased and sequenced differently.”
Acting on consumers’ needs as perceived by them and connecting them to the right care and supports in the community is the next step in operationalizing person-centered care. But the challenge is how to keep the referral directory current and how to ensure “closed loop” referrals. Again, embedding both in the EHR would be ideal, said Ms. Morrow. Train the case managers and care coordinators to manage referrals within the system, invest in cultivating strong community partnerships, and figure out up front how to share data with community partners you refer to for health and social services, she advised. In addition, develop shared goals and define a process for who should do what when a consumer does not follow up on referrals.
Increasingly, we are seeing efforts among payers and health systems to coordinate referrals for health and social services. Horizon Blue Cross Blue Shield of New Jersey uses the community referral platform NowPow in its Horizon Neighbors in Health social determinants of health project (see Horizon New Jersey Health Completes Expansion Of ‘Neighbors In Health’ Program To Address Social Determinants Of Health). The RWJBarnabas pilot to address social needs, Health Beyond the Hospital (HBH), is also using NowPow to connect consumers to personalized services that are matched to both their health and social needs. NowPow tracks consumer engagement throughout the process so that clinical professionals and community-based partners are able to monitor the outcome of referrals and follow up as needed. And ConsejoSano is a connected app that provides culturally and linguistically-tailored engagement and care navigation to help HBH reach consumers (see RWJBarnabas Launches ‘Health Beyond The Hospital’ To Address Social Needs).
The structured systems and technologies should be paired with a nuanced understanding of consumer needs and limitations. John Lovelace, President of UPMC For You, said that provider organizations need to ask themselves what all the pain points are for the consumers they are serving and how to address them. For example, clinical professionals need to better understand what resources consumers have—or don’t have—that influence their ability to follow instructions. “If consumers can’t read the label on the prescription, if they can’t afford the drugs, if the doctor wants them to walk a mile a day but they live in a neighborhood where they can’t walk, if they have to have more vegetables and fruits but the bodega in their neighborhood only sells chips and bologna—all these are factors the clinical professional needs to know in the course of providing medical care to make a sustainable impact on consumers’ health,” Mr. Lovelace explained this in his presentation, A ‘Whole Life’ Approach To Managed Care: Emerging & Future Health Plan Models, at the 2020 OPEN MINDS Executive Leadership Retreat.
To demonstrate the effectiveness of person-centered care, provider organization managers should set up quantifiable measures tied back to consumer needs and perceptions. Measures should be automatically generated by the EHR system, based on data that staff capture as part of their workflows, shared through dashboards accessible to the entire care team, and be accompanied by clear direction for how to act on the results for future improvements in care.
Collect and share the data automatically and electronically so it does not add an extra burden on staff, advised Ms. Morrow. For example, build consumer surveys directly into the EHR patient portal and make sure the responses are integrated into any analysis of impact. Determine what information you can leverage from and share with community partners through health information exchanges, without creating new reporting mechanisms. And you want to look at the holistic picture—not just how successful consumer target groups are with lowered emergency room and hospital readmissions but also how they are doing with employment, housing, and transportation, and overcoming other barriers they’ve expressed through the initial assessments. It would also help to share de-identified, population-level data with community partners so you can collectively identify where the gaps in care are and how to close them.
As the pressure for value and demonstrated outcomes steps up in a competitive market, specialty provider organizations need to focus on a data-driven approach to lend structure and purpose to the best practices they may have used for decades. They may know what is best for their consumers but operationalizing that knowledge within a defined framework and letting payers and stakeholders know the impact is key.
For more on operationalizing and standardizing best practices in care, check out these resources in The OPEN MINDS Circle Library:
And for even more, join us on August 24 for the session Organizational Change Agents: How To Be A Flexible & Nimble Organization at the 2021 OPEN MINDS Management Best Practices Institute in Newport Beach, California. OPEN MINDS Senior Associate Paul Duck will share effective ways to streamline and enhance organizational compliance and best practices for building a healthy organizational structure.