Two important ingredients for the successful implementation of population management programs for integrated clinical care teams are often overlooked: Ensuring that the workflows and roles adopted by the integrated care teams have been thoroughly designed and implemented using a quality improvement framework, and deploying project implementation personnel who have deep content knowledge and can liaise between IT build experts and the eventual clinical and administrative end users of the tools. Although these steps might sound obvious at first glance, they are nuanced processes and staff roles that can take a significant amount of time to refine and perfect.
First, approaching population management implementation projects using a quality improvement approach ensures that they are methodically designed so that the new tasks and tools are specifically aligned to the aims that the integrated care team or health system program is trying to achieve. This method also requires that all of the eventual players and users of the new workflows and/or tools have a seat at the table from the beginning of the process. The entire spectrum of integrated care team members who interact with patients – whether they be schedulers, navigators, nurses, physicians, social workers, community health workers, or others – should all be considered for participation in tailoring a population management program to meet the needs of both the patient and the health system. By taking this approach, the integrated care team won’t end up in a situation where crucial feedback was overlooked and the new processes will not function ideally for a key segment of the team. Charging headfirst into designing new workflows and tools based solely on the anecdotal experience of one member of the integrated care team, or relying on the way things have always been done, are unlikely to ensure the sustainability of the new processes or the likelihood of achieving the desired clinical outcomes.
Second, having a project leader with clinical operations expertise who can serve as an implementation lead as well as a knowledgeable liaison between clinical care teams and the IT build experts who are creating the new EHR tools and/or databases is also crucial for success. Often the tendency of these two groups (clinical care teams and IT analysts) is to be very siloed around their own areas of expertise, making it hard to understand the pain points and opportunities experienced by the other team. The ability to translate the clinical needs and feedback provided by integrated care team members into the most efficient, accurate, and streamlined tools that can be built by the IT experts is a skill that is honed over time only through interfacing with many clinical teams and learning to anticipate their needs. The ability to translate and effectively manage what can often seem like competing priorities between clinical teams and IT also requires quick thinking to offer solutions for compromise on the fly (which sometimes means starting with a “less is more” approach, testing it out as a pilot with a small patient population, and then expanding once ready) and to truly understand and offer possible improvements for the pain points being articulated by care team clinicians and administrative staff. Many of the core population management processes around care coordination and proactive patient outreach can be replicated in various ways across different clinical programs, but it is never one-size-fits-all, and there are always slight nuances needed for the patient population and provider team involved. The more that these nuances and adaptations can be anticipated and tested during the implementation phase, the better off the program will be in terms of garnering quick buy-in and improving prospects for sustainability.
After navigating through the design, build, and implementation steps of a population management program, integrated care teams are left with new workflows and tools that they will naturally continue to enhance and innovate around as needs arise. A recent example of this process is some of the ways in which the COVID-19 pandemic created, out of necessity, the opportunity to rethink the ways that many integrated care teams did their work. Teams shuffled some of their administrative and visit preparation tasks to be completed remotely, and used EHR-generated panels of patients to document and track outreach in one central “space” during different remote shifts, which was instrumental for success. Personal paper spreadsheets or notes are clunky and error-prone even in a typical shared office setting, and they become even less effective when care teams are spread out in a hybrid model and need to efficiently pivot and redistribute tasks and responsibilities. Having population management tools that live in the EHR as the single source of truth, and which can be seamlessly integrated into daily patient outreach tasks no matter the location of the care team member or the patient, have ensured that proactive patient tracking and outreach work is executed consistently and not duplicated unnecessarily.
During the pandemic, care teams not only utilized these tools at higher levels than they previously had, but they also innovated and created some new workflows and use cases at a grassroots level. For example, some large teams trialed a new virtual version of “house calls,” where individual care team members used EHR tools to systematically identify and proactively call patients who were overdue or due soon for refill orders of important medications. When many visits for care lapsed during the pandemic, integrated care teams wanted to make sure that their points of contact with their patients didn’t lapse too. Having to identify patients due for medication outreach from memory or through manual chart review would have been an onerous and time-consuming task, but having population management tools already available in the EHR allowed these care teams to easily identify and complete outreach for all appropriate patients, ensuring that nobody was overlooked.
Wellconnex places a strong emphasis on utilizing a quality improvement lens to approach all of our projects, as we are committed to demonstrating that our population management solutions have impact for patients and health systems alike. At the forefront of this approach is our belief in the importance of hearing from and creating solutions for all integrated care team members from the outset of a project, and we use our clinical operations expertise translating between clinical care needs and technology options to navigate these solutions. With these two pillars of our approach in hand, we look forward to partnering with health systems to ensure that these solutions are within reach for all integrated care teams and the patients they serve.