The Michigan Value Collaborative

Helping Michigan hospitals achieve their best possible patient outcomes at the lowest reasonable cost

Tag: patient engagement (page 1 of 3)

Reshaping Care Delivery: Using Models of Care to Understand Patient Engagement

Abeer Yassine

Abeer is the MVC Hospital Engagement Associate

Patient engagement is frequently cited by health systems as a root cause for sub-optimal outcomes. Studies have supported the importance of understanding individual and population behavioral trends to increase patient engagement and improve outcomes. To improve patient engagement outside of a procedural setting, hospitals such as Massachusetts General Hospital (MGH) are seeking non-conventional methods to better address the needs of a specific population.

Upon receiving the results from a community needs assessment, MGH’s Substance Use Disorder (SUD) population was determined to be a primary focus for intervention to improve patient engagement, coordination, and outcomes. This population includes patients with an alcohol use disorder, opioid use disorder, or other drug/alcohol use disorders.1 By engaging this population in different hospital-led interventions, MGH has seen significant outcome improvements related to readmissions while helping physicians gain a deeper understanding of SUD in general.

To strategically address this population’s needs, MGH launched a multi-faceted Institutional SUD intervention. This institutional intervention includes a variety of features such as an inpatient consulting team, recovery coaching, and primary care support. To provide for a more personalized patient experience, recovery coaches include individuals who are in SUD recovery as well. These coaches provide an additional layer of support by assisting SUD patients in navigating the health system for appropriate care. 1

A study analyzing the impact of the program found the inpatient consulting teams have helped improve physician attitudes and preparedness when treating SUD patients.1 This was evidenced through a physician survey in which 66% of the respondents who had encountered clinical components of the initiative demonstrated positive attitude changes related to caring for SUD patients.1 This emphasizes the impact of an institutional approach to address a patient population.

Another intriguing feature of the SUD intervention is a post-discharge “Bridge” Clinic. This unique transitional clinic helps address the “What happens to the patient after discharge?” question that clinicians long to answer. The outpatient clinic serves patients who have been discharged from the emergency department and have not received follow-up care. The clinic accepts walk-ins, and provides a variety of clinical and social services to holistically treat the SUD patient population. There are no barriers for individuals accessing the clinic, helping them receive appropriate care. Not all services at the clinic are billed (e.g.: resource specialists, clinical pharmacist, etc.) by the hospital; as this is MGH’s method of contributing to the reduction of costs related to avoidable readmissions. More specifically, patients who have sought care at the clinic were readmitted 7.5% less frequently compared to those who did not receive interventional services.2 More information about this program can be found here.

Nonetheless, health systems across the country are exploring unique models of care to help improve patient coordination and engagement. Features of MGH’s non-traditional, yet effective, model of care helps address a main concern for various different populations: lack of access to services. By connecting patients with timely post-discharge care, MGH’s Bridge Clinic helps coordinate with patients during a critical, yet often overlooked, time period.

Questions or feedback for future posts? Feel free to reach out to Abeer (abeery@med.umich.edu)!

Wakeman SE, Kanter GP, Donelan K. Institutional Substance Use Disorder Intervention Improves General Internist Preparedness, Attitudes, and Clinical Practice. (July 2017)

2 Common Wealth Fund Feature, September 2017 and MGH SUDs Initiative

McLaren- Lansing: Using Change as an Opportunity for Optimizing Palliative Care

Kim Hecksel

McLaren- Lansing Palliative Care nurses from left to right: Kim, RN, Paula, CNP and Carol, RN

Although the palliative care program at McLaren- Lansing has been around for about a decade, health care organizations are constantly changing and evolving to meet patient and family needs. The MVC Coordinating Center had the opportunity to speak to the team of case managers and nurses from McLaren- Lansing to hear about the different successes and barriers to palliative care at this facility. One distinct characteristic of this palliative care program is that patients and families are seen by and interact with consistent faces, rather than different clinicians, each time they visit. McLaren uses this consistency as leverage through transitions of care, especially at a time when clinician duties and health organizations are constantly changing.

The palliative care program at McLaren- Lansing also keeps up with the constant changes in health care by utilizing different online resources. One resource available to hospitals interested in palliative care programs is the Center to Advance Palliative Care (CAPC). CAPC offers a platform to help provide different health care organizations across the nation the tools and resources needed to advance palliative care programs in their respective institutions. For example, some CAPC resources help palliative care teams set up and develop a business plan for their respective palliative care programs. CAPC resources are helping guide the McLaren- Lansing team in creating a business model that illustrates the financial impact of a palliative care program on the health system. For more information on CAPC and the resources they can provide, visit www.capc.org.

The palliative care team also looks at the big picture of the care provided to patients and consequently putting together different pieces of information to ultimately develop a course of treatment that best meets the needs of the patients and the family involved. One of the barriers McLaren- Lansing has with their palliative care program is working with patients, family members and other health care providers on understanding the value of palliative care and what it really offers. When met with this resistance, the palliative care team works in different ways on learning about and discussing the care plan and goal setting to find the right format for communication and understanding a diverse patient population. For example, the palliative care team engages with physicians one-on-one and attends presentations on the benefits of palliative care to better understand and work with patients and their families about their diagnosis and individualized care plan. Taking advantage of different resources available, such as CAPC, and instilling a strong support system among the palliative care team and liaising teams are factors that aid in instituting a successful palliative care program.

If you are interested in learning more about the palliative care program at McLaren- Lansing, please feel free to reach out to Deby (debevans@med.umich.edu) or Abeer (abeery@med.umich.edu) for more information and contact.

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