Episode 11 – Patient Experience & Choosing SNFs

INTRODUCTION
Julie: This is BACON, Brief ACO News from the MaineHealth Accountable Care Organization. A medium rare monthly podcast for health care providers. I'm Julie Grosvenor.

Mike: And I'm Mike Clark. Julie and I are practicing physicians and liaisons with the MaineHealth ACO.

Julie: During this episode, we introduce a new way to choose the most appropriate skilled nursing facility for a discharged patient and discuss patient experience surveys.

Mike: Yes, patient experience is our Meaty Topic this month. So let's dig right in.

MEATY TOPIC

Julie: Today's theme is "I can't get no satisfaction."

Mike: Okay. What you mean by that?

Julie: At the end of January, the local news media reported that, quote, Maine doctors are the worst in the country.

Mike: What? What? Says who?

Julie: Well, that's according to the results from the 2020 Patient Sentiment Report issued by HealthGrades and MGMA, the Medical Group Management Association. So, to discuss this finding and dig a little deeper into the larger topic of patient satisfaction, we've invited Dr. Omar Hasan to the studio. Omar is the chief quality and safety officer for the Maine Medical Center and MaineHealth system. Welcome, Omar.

Omar: Thank you for having me.

Mike: So, Omar, I took a look at this report and I tried to understand how they came to these conclusions and the data that they used.

Julie: Yeah, it doesn't feel right.

Mike: Well, it was interesting because HealthGrades is one of those online web sites in which your patients can kind of go on and read some data or just make a comment. It isn't something that is done, I don't think, very systematically. Is this the best way to really get to improving our patient's experience of care or are there other ways to get to that?

Omar: So it MaineHealth, we try and get information about the patient experience of care through various different channels. Patient experience surveys are one such mechanism and we generally rely on a set of survey questions that involve a patient giving a rating or ranking to their experience in a domain like communication with their doctor or communication with the front desk staff in a practice and such. We also look for information through patient complaints and grievances, and then we also have patients who are members of workgroups that are striving to improve the quality of care. So we rely on a number of different channels to get information. And each channel is important in itself but I think we then try and make sense of all the information that that's coming our way.

Julie: So are there any ways that we know that patient satisfaction actually links to patient care quality?

Omar: That's an interesting question. So I shy away from using the term patient satisfaction, but I think I do like the term patient experience and we know that that patient experience can be measured quantitatively using validated surveys that are based on the published evidence. So that's a reliable source of information. The approach we have at MaineHealth is that we consider patient experience to be a central tenet of patient-centered care, which is a core value in our health system. So I would say that we really are keen on improving patient experience. I think patient impressions or satisfaction are kind of terms people use loosely. But if I were to make a decision or design a program or an effort, I would try and gauge the patient experience. And it pertains to the interpersonal relationships that the patient has with the care team members. And we know from some studies that were conducted in the past decade that patients who are more engaged in their care, who have a better relationship with the care team, tend to have a better time carrying out the instructions that they're provided for looking after themselves that may play into medication adherence or getting tests done in a timely manner. And that can, in fact, impact the quality of care. And at least one study that was published, it demonstrated improved patient safety and lower risk of potentially an error or harm happening.

Mike: That makes a lot of sense. It really does. And as I think about our efforts in my own small primary care practice to improve quality, we've become reliant upon on RC Picker data, for instance, and the paper surveys that have been sent out and some of our patients expressed frustration that the survey would come, you know, a couple of months after the visit and they didn't remember if it was from us or from some other provider within our network. My understanding is that MaineHealth has made some changes in the patient satisfaction or patient experience survey that they've used. Can you talk about that?

Omar: Thank you for raising that. I think it's a great point. When we were doing paper surveys, which is now I'm glad to say at least six months in the past, patients would get a lengthy survey with about 40 or so questions in the mail and it would be from a month to six weeks after they had the encounter in the clinic. And by then, a lot of people don't have a good recollection of what transpired. So I think there was to some degree selection bias. But the bigger issue for us was that the response rate was very low, which became a challenge when having a conversation with care teams around improving the patient experience. People doubted the results of the survey and so forth. So about a year or so ago, we made a concerted effort to transition to electronic surveying, which is fast becoming the industry norm. What this means is somebody could be seen in a clinic or in the emergency department and within 24 to 48 hours after the encounter, they would receive an email at the email address they provided during registration, or they would receive an automated interactive voice response phone call to conduct the survey. That has significantly improved the response rate and the turnaround time. The survey only has about a dozen or so questions and people can complete it within about three minutes or so. Now, one of the criticisms we encountered earlier was that fewer questions might in some way dilute the messages we were receiving when in fact research has shown that having a survey with fewer questions is just as good as having a survey with more questions. So we now feel confident that we are getting the information we need, but more importantly, we're getting it in a timely manner and a quantity of information coming back is sufficient to allay any concerns people might have about the data not being reliable. And that has led to greater engagement with care team members across the board. I think we're getting really positive feedback from our physician colleagues, medical assistants, practice managers and other staff and other team members that they like having this information come back in real time almost.

Julie: So it sounds like we have a good understanding of how patient experience is important and now we have an even more improved way of getting that information about ourselves. My understanding is that patient experience also factors into our reimbursement. How does that work?

Omar: I think that's a great question, and I think it's important for someone in my role to emphasize that not only is this the right thing to do and therefore we must absolutely do it, but also that this has financial implications for our practice or for the hospital. So I'd say that most importantly, if we have a better patient experience then patients and their family members are more likely, if they should fall ill again and have a choice, to come back to us for their care and also encourage their family members, their community and friends to do the same. And I think we want that. We believe we do a good job providing care in our communities, and we want people who need health care to come to us and seek advice from the qualified team members that we have. Beyond that, we have seen a trend over the past decade among health insurers, the payers so to speak, of using patient experience survey information as part of the reimbursement or pay for performance framework. We see that with the CMS hospital value based purchasing, where the scores on the HCAHPS survey, which is one of a family of surveys but is directed at inpatient discharges, is a factor in the reimbursement that we get through the CMS hospital value based purchasing program. We've seen that also in some of the ambulatory contracts with commercial insurers as well. But it's a complex picture and it varies over time. But I would say there is a tie in there as well.

Mike: You know, I'm thinking about our colleagues listening to this podcast. And I suspect there's a few cynics out there who would say, you know, you just can't make everybody happy. Can you really improve patients’ experience of care? Is there evidence that we really can figure out ways to improve what we do, change ourselves, change how we interact and improve patient satisfaction?

Omar: Yes, I believe so. And there is a body of evidence that's growing every year that shows that that's possible. I would also offer that if somebody did not have a positive experience, I see that as a very valuable piece of information. It's something that can inform us about how to make things better. So even if patients vent a little bit, I think that's all right. That's good information for us to have. I would offer that in the past decade, we have seen the emergence of truly evidence based interventions that have been subjected to rigorous evaluation, not quite like a randomized control study, but I would say it's come pretty close. We are rolling out a couple of interventions at MaineHealth currently. One of them is empathy training and that's really a training that's offered in a classroom setting. It's based on cognitive behavioral therapy and there's role-playing involved. And we know from studies that empathy training has been shown to improve experiences of patients with care teams that went through their training. Similarly, there is some experience with another form of essentially measurement and feedback for care team members, for providers in particular, called provider coaching. And that entails having a trained coach accompany a provider as they see patients during the course of the day and then using a checklist, monitor their behavior and interactions with patients and then provide feedback at the end of the day in a confidential manner. And we found that that has both provided much needed information for our providers, but also helped improve score on measures such as provider communication. So those two interventions are really evidence-based and we've committed to implementing them as time permits throughout MaineHealth.

Julie: All right. Well, I think you have been a fantastic guest, Omar. Lot of great information. Very helpful for us.

Mike: It's been great. Thank you so much, Omar, for helping us unpack this topic.

Omar: Thank you so much for having me today.

THE SIZZLE

Mike: For The Sizzle this month, our producer Paul Santomenna interviews Dr. Heidi Wierman. Heidi is the division director for geriatrics at Maine Medical Center and the medical director for MaineHealth Healthy Aging. Heidi has been a central figure in establishing the MaineHealth ACO's Skilled Nursing Facility Annual Index. The index categorizes skilled nursing facilities or SNFs based on how well they perform on key clinical and administrative metrics. The ACO is releasing the results of the 2020 annual index this month.

Heidi: So the Skilled Nursing Facility Index has been developed over the last, I think, three or four years as a collaboration between the ACO and MaineHealth to recognize and identify skilled nursing facilities that perform particularly well. There has been a group called the Senior Living Collaborative that's met over almost the last decade, I think eight or nine years to allow any nursing home that accepts patients from any MaineHealth hospital to kind of have a voice. It's turned into an avenue to improve quality. And so the SNF index is a way of trying to measure the improvement that people are having to supplement what's available on the CMS Nursing Home Compare web site. So it's different than that, but incorporates some aspects of that.

Paul: And how many facilities participated?

Heidi: We have, I think, around 40 to 45 facilities that participate in the senior living collaborative. Not all of them have chosen to participate in the SNF index. I think we had about thirty five facilities participate in the SNF index this year. They are scored and then they fall into categories based on their score: gold, silver, bronze or what we call standard, which means they are participating but didn't score higher level. With the gold facilities, we invite them to meet with the ACO and MaineHealth to talk about things that are important to them and help us continue to improve the quality across the system. With with the ACO, they're participating in shared savings, if there's some savings to be shared. We're using the rating of the facilities in order to provide them some payout from that. So a gold, someone who scored gold or the highest level, in theory is providing the highest level of care in the SNF environment and would also get a higher level of payment back if there was achieved savings to share.

Paul: And there's certainly quite a bit of work involved in participating in the index and providing data.

Heidi: So, we have the SNF index broken into three sections. The first section we call cost and quality and it takes some metrics directly from the CMS web site that we think are particularly important things like readmission rate, ED transfer rate, pressure ulcers, vaccinations, that sort of thing. And folks are compared to the nation, but then also compared to the state of Maine and get points depending on where they score in that. So that's what we call the cost and quality section. We also have an engagement section, which is where we really acknowledge the facilities' participation in initiatives that are important to MaineHealth and the ACO. With a lot of the quality projects, we first develop them at Maine Medical Partners Geriatrics and then share them through the senior living collaborative with any nursing home that wants to and is willing to participate. And so that is a part of the engagement section. And then the last section is the organizational operation section. So it has to do with people taking complex patients from the hospital, folks with, say, end stage renal disease or very complicated social situations. We look at leadership stability in the facility as far as having medical directors and administrators in place for a number of years, just knowing that that helps promote quality when you have continuity. And then staffing rates and then we look at what the rates of uptake are for home health after people leave SNF as well. And so there's some scoring related to that. So each section has a certain number of points associated with it. We bring it all together with a sum and then that's where we rate people from gold, silver to bronze. The ultimate goal and where we're at now with this tool is to be able to share it, to share it with care managers, discharge planners at the hospital who can also then share it with patients and families. We know that for patients and families, choosing a skilled nursing facility after a hospitalization is a daunting process. They often don't get any specific information other than geography. And this tool is intended to supplement what they can find on the CMS Nursing Home Compare Web site as well. And so it's one more tool for them.

Paul: And why is it important for providers to know about the index?

Heidi: Well, I think patients and families look to the people that they know and trust, which are often their physicians, to help guide them. And so I think it's important that physicians educate themselves a little bit and have some tools so that they can help guide patients and families to make the best decision for them. So, you know, ultimately, we want our patients to be home and healthy and not in and out of the hospital. And so in Maine, we don't have really big nursing homes. And so in other areas around the country, hospitals may partner with one or two nursing homes because that's all they need in order to have places to discharge patients. In Maine, we do not have that. All of our nursing homes have some skilled nursing facility beds. And so this process of quality improvement is really hoping to improve the quality across the health system, not targeting in just one or two nursing homes. And the skilled nursing facility index is a way of trying to help us measure that.

Julie: Learn more about the Skilled Nursing Facility Index at the Web page for this episode. Episode eleven. You can find that at MaineHealthACO.org/BACON.

OUTRO

Mike: Thanks for listening to BACON this month. You can find information related to this episode at our podcast web page MaineHealthACO.org/BACON.

Julie: And if you have questions, comments or suggestions, email us at BACON@mmc.org. We'd like to hear from you.

Mike: Bacon is produced by the MaineHealth Accountable Care Organization with help from MaineHealth Educational Services.

Julie: Thanks for joining us. See you next month.