medical visits

Scheduling appointments is one of the biggest challenges facing community health centers. Patients often lose those self-addressed postcard reminders, and manually calling patients to book a recall appointment is a major slog for clinic staff. The flurry of activity around COVID-19 tests and vaccines has only compounded that problem, as patients encounter jammed phone lines and long wait times. But starting in 2021, Tiburcio Vasquez Health Center began piloting an automated patient recall system — one that offers easier and more efficient outreach, as well as the personalized text message nudge patients need. Listen and subscribe to our podcast on Apple Podcasts, Spotify, and elsewhere. Below is a transcript of the episode, edited for readability.

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EPISODE TEASER / Caleb Sandford (guest): “...When patients are delayed in coming to their follow up care, when they miss that six month appointment or three month follow-up or one year follow-up, that's when healthcare starts to deteriorate. That's when people start needing more healthcare because they weren't following the care plan that they talked about with their provider. So if we can get everybody onto a care plan, make sure they come back for their follow up visits, make sure we keep their medications up to date, their blood pressure under control, their diabetes under control, if we can get everybody on that pattern, then there will be much less urgent needs. There'll be much less emergency medication visits because we're always keeping people up to date on what they need. So that's how this program that we've got going now. We hope to reduce the number of total visits needed by just getting everybody established on the care plan that they need.” Jessica Ortiz (host): Hello everyone. I'm Jessica Ortiz with the Center for Care Innovations. And today we're talking about one of the exciting projects that Tiburcio Vasquez Health Centers have been working on for six months and launched in September of last year. Our hope is that by sharing the highs and lows of this particular digital health solution, safety net organizations can apply the lessons learned to their own challenges. Jessica Ortiz: I'm here with Caleb Sandford, member of our Tech Hub Learning Network, which is comprised of 14 tech-forward California based community health centers, clinic coalitions, and primary care departments and county health systems that are working to accelerate the adoption of innovative technology. We partner with our Tech Hub members to vet, pilot, evaluate and spread innovative digital health solutions targeting Medicaid markets, and historically under-invested communities. We are excited to bring you this story today. Caleb, can you tell our listeners a bit about who you are in your organization? Caleb Sandford: Hi everybody. I am the Chief Transformation Officer at Tiburcio Vasquez Health Center. The organization has been around for 50 years, 1971. So we got in in the early days of community health centers. We are in the Bay Area of California. We span the area kind of between Oakland and San Jose, Hayward, California; Union City, San Leandro, San Lorenzo. And we take care of about 30,000 people each year. My role here as the chief transformation officer, my transformation team and I, we are tasked with inventing and implementing big new things that will help drive our organization forward and enable our care teams to provide better care to more patients. Jessica Ortiz: Great. We're happy to have you Caleb. So let's just jump right in. Tell us about your project. Where did you get started? Caleb Sandford: One of the most critical things that we do as a community health center is schedule appointments. If we're not good at scheduling appointments, we go out of business. Everything goes through scheduling. One particular area that is always challenging with scheduling appointments is making sure that patients come back for their follow up care. So if somebody has a visit today and they need to come back in three months or six months or a year or two years, how do we make sure that the patient remembers that they need to schedule that future appointment? We may not have our schedules open far enough out to be able to actually schedule the appointment. Caleb Sandford: And so it comes down to the provider and the patient saying, "Okay, patient, I need you to come back in six months. I'm going to give you this little piece of paper that has that on it. Try not to lose it and try not to be late to your follow up appointment because if you are, you may have run out of medications. Your blood pressure may start getting out of control. Your diabetes may get out of control." And so helping, enabling our patients to come back for their follow-up care on time is very critical for patients having good continuity of care and keeping their healthcare under control. Caleb Sandford: And so the problem is we lose a lot of patients to follow up. So it's been a problem. I think it's probably a problem for everyone where they come in today and we don't know if they're going to come back in the future for their follow up appointment. And as you talk to medical assistants and doctors and nurse practitioners and nurses, they'll all tell you their own little unique way that they have to remember who needs to come back. So some of them will write it on sticky notes and they have piles of sticky notes of patients that need to come back. Some will have little notebooks, some will try to send tasks to themselves in the EHR to try to remember in the future. Everybody comes up with their own method of making sure that the patients that are important to them come back to care. Caleb Sandford: What percent of patients never come back for their follow up appointment or are late? Who knows, right? A lot. And it's hard to know that because our schedules are always full. The providers and the care teams always have another patient to see. But how do we know that it's the right patient? How do we know that the patients are coming back for the care that they need? So that was the problem that we wanted to solve. We wanted to stop losing patients to follow up. We wanted patients to come back on time for their follow-up visits so that we're not scrambling to do emergency medication refills, which bogged down our providers and care teams in their in baskets and the EHR. And so we wanted to just figure out a better way to do this. Caleb Sandford: So we were kind of inspired by dental offices where when you go to a dental office to get your teeth cleaned, they refuse to let you leave their building without your next appointment scheduled. They're really good about that. I've probably been to 15 dentists over the course of my life and they all do it exactly the same way. They will not let you leave without a follow-up appointment. Now, we can't open up our schedules six months, a year in advance to be able to do that for all of our patients. We might have a high no-show rate if we booked patients out a year from now. And so we only book patients two or three months out. Caleb Sandford: But we don't want to lose them. And so what we did is we took advantage of a functionality that's in Epic called Appointment Recalls where you can create, it's kind of a placeholder appointment. You're not really scheduling the appointment. You're not putting a date and time and location on it, but you're putting in Epic. We use Epic as our EHR. You put in what kind of visit it's supposed to be, what the appointment notes should say for the provider, which provider it's supposed to be with. Is this supposed to be with a primary care provider or is it supposed to be with OBGYN provider or a pediatrician or a podiatrist or an optometrist? You can record all of those details in the EHR and then it's there forever. And so then when you go to the patient's chart, you can see which upcoming appointment recalls they may have. Caleb Sandford: Now, that was step one of the project is just starting to do that. Having our care team start to record the follow-up appointment in the EHR. But that's not good enough because then the question is, well, what do we do with those now? So we've got hundreds, thousands of appointment recalls in the system, but what do we do now? So we can run the report in Epic that shows us these thousands of appointment recalls that have been generated, but having the manpower to call all of those patients to say, "Hey, it's time to schedule now." That's really challenging and we don't have the manpower to do that. Caleb Sandford: So what we did is we worked with our text messaging vendor. We use WELL Health for text messaging. And we got them to add in the functionality to be able to pull the appointment recall information out of Epic and into WELL. And so they did that. And then we were now able to set up automatic text messages that go out to these patients a month before their recall appointment is due. And the message says, "Hey, your doctor, Dr. Smith, wanted to see you back here in March. Can we get that appointment scheduled for you?" Caleb Sandford: And that happens automatically now. And the patient will respond, "Yes, let's do it." We get the patient scheduled. And then in they come. And then to make sure we don't have anybody that falls through the cracks, we will still run the report out of Epic of who's left, who hasn't scheduled their recall appointment. And we'll have somebody call those people and track them down to make sure that they come in. But we try to get most of them done by text message so that it's not a burdensome task for the phone call people. Jessica Ortiz: Great. How do you triage patients into visits given that you have more patients that are needing care than you have slots available? Caleb Sandford: Well, the idea with appointment recalls is that if we're having a visit with somebody today and the provider and the care team make the determination that this person needs to come back in six months, to me, that appointment is a priority. And if we get everybody pre-scheduled with their future follow up care so that nobody ever has to call in to schedule a routine visit, that's the ultimate goal with this is that patients should never have to call us to book a routine visit. We should always be proactively reaching out to them. If we can do that, then the only visit access we need to retain is enough for urgent care for patients that are sick or that fell down and scraped their leg or whatever. Caleb Sandford: And so the idea is to fill our schedule with the care that the providers and the patients agree is necessary upfront before everything else starts piling in. Now, do we have enough appointment slots for everybody who wants a visit for everything? No. Appointment access is a challenge. It's a challenge for a lot of community health centers. There are too many patients out there that need us, and there's not enough providers to take care of them. So we do our best. Caleb Sandford: However, when patients are delayed in coming to their follow up care, when they miss that six month appointment or three month follow-up or one year follow-up, that's when healthcare starts to deteriorate. That's when people start needing more healthcare because they weren't following the care plan that they talked about with their provider. So if we can get everybody onto a care plan, make sure they come back for their follow up visits, make sure we keep their medications up to date, their blood pressure under control, their diabetes under control, if we can get everybody on that pattern, then there will be much less urgent needs. There'll be much less emergency medication visits because we're always keeping people up to date on what they need. So that's how this program that we've got going now. We hope to reduce the number of total visits needed by just getting everybody established on the care plan that they need. Jessica Ortiz: Great. And what was that process like in thinking about how this new process would fit into the mission of your organization, the operations around that, and sustainability of this project? Caleb Sandford: Well, our mission as a community health center is to improve the health and the lives of the people that we serve. So I think for decades in the community health movement, we have been scrambling to just meet today's needs. Tons of people calling in needing something, we try to get them in, we try to solve their need and get them out the door. And there hasn't been... The push now that all of us are making are, how do we take it to the next level? How do we focus on continuity of care and actually get people not just what they need today, but get them on a care plan that will help them over time. Caleb Sandford: And so by doing these appointment recalls and ensuring that patients come back for their follow up care, we're not just providing one time urgent care anymore, we're providing longitudinal care that every time somebody comes in, their next visit that they need to maintain their health is already recorded in the system. That's much different than how we've operated for the last 50 years where we see somebody and then we say, "Call us when you need us." People forget about they need to come in for their medication refill. They forget that they need to come in to get their A1C checked. And then things start to deteriorate and that's when the urgent need start, the urgent care and the multitude of people that need to be seen right now, that can't wait a month for a visit but they have to be seen right now because their health is getting out of control. Jessica Ortiz: And how have patients responded to this new approach? Caleb Sandford: Yeah. Patients like it so far. So we've got probably 1,500 at least appointment recalls that have now been recreated and recorded in the system. We started back in September and anybody that needs an appointment in the next couple months, we just schedule that. So the first appointment recalls really hit starting in December. And so we've now scheduled about 250 actual appointments from these appointment recalls. So those patients didn't have to remember that they needed a follow-up appointment. They didn't have to remember to call in. They didn't have to sit on hold for 10 minutes with our phone operators waiting to schedule an appointment. We reached out to them proactively and got their appointments scheduled before our schedules filled up with everything else. So from the patient standpoint, this was much easier for them and they could do it by text message. They didn't have to talk to us at all. Jessica Ortiz: Wow, that's great. I would even like that convenience. And do you have any data supporting the idea that this continuity of care has improved health outcomes? Caleb Sandford: Yeah. It's a little early to look at that. Over the next year as we get more and more people onto this cycle of coming on time for their follow up appointments, hopefully we'll start to see some of the chronic disease metrics that we follow start to improve. We'll start to see the preventative measures that we track, the percent of our kids that are up to date with their well child checks, the percent of our women who are getting their Pap smears, the percent of all of those things. Caleb Sandford: Over time, I think we'll start to see this have a big impact. Right now, those 250 appointments that we scheduled as a result of these appointment recalls, how many of those would never have gotten scheduled if we wouldn't have had this system or may have gotten scheduled late? Half. When I talk to our care teams, that's what they kind of conservatively estimate as the number of their patients, the percent of their patients that don't come back when we wanted them to. And so if we've gotten them to come back, that's a pretty big win. Jessica Ortiz: Great. Thanks for sharing that, Caleb. And could you share with listeners what your top highlight of this project has been so far? Caleb Sandford: Well, our care teams really like it. If you talk to a medical provider or a medical assistant or a nurse, it's stressful that they don't know what happens to these patients once they leave our clinic. They have a conversation, they create a care plan, they write prescriptions, they talk to them about health, about eating, about exercise. And then we have no idea what happens after that. And our care teams may have 1,000 people on a primary care panel. It's just too hard and stressful for somebody, for a primary care provider to own all of that, to like internalize that they're responsible for these 1,000 people when they really have no idea what's going on. Caleb Sandford: And so the fact that we can take that away from the primary care provider now and say, "Look, Dr. Smith, we are going to make sure your patients come back for follow up. All we need you to do is practice medicine, do your medical decision making, and tell us when the next appointment is supposed to be, we'll do the rest for you." That allows our care teams to really live in the moment more and not worry about whether this patient or that patient is going to come back that they're really worried about. Caleb Sandford: Our care teams care about their patients. They love them. They want to see them succeed. They want to see their patients be healthy and live happier lives. But if they don't know whether somebody comes back, it's hard to do that. And so they're all keeping track of this on their own. And so that's the big win for the providers and the medical assistant. They don't have to keep their little notebooks of really important patients that they want to make sure come back, that they're going to call in six months if they don't see. We're doing that for them now and we're doing it in an automatic way. Jessica Ortiz: That's amazing. Just I can imagine having a patient walk away or get off of a call and wonder how they're doing. But having that reassurance that there's a wraparound system to help support that. And could you share with listeners what the biggest challenge has been so far with the project, on the other end? Caleb Sandford: Well, anytime you do something like this, this is one more little task that the care team has to do during the visit. At the end of the visit, they have to create this recall appointment in the system. Now, it's not hard. It takes 30 seconds to do, but it's one more thing they have to remember to do. And so our care teams are really into this concept, but it's changing a behavior. Instead of just sending the patient on their way and telling them to call back in six months to schedule their follow up, they have to go through the process of recording that appointment recall. So that's a change in behavior that's required us to continue to talk about this and remind everybody why we're doing it. Caleb Sandford: But talking about the results, sharing the number of patients that have been scheduled as a result of this. And over time as our care teams start to see more and more of these people coming back, they'll really start to see the value and understand why they've been doing this for the last 3, 6, 9 months. They'll start to see the fruits of that. And I think they'll be really satisfied that now they can trust that Tiburcio Vasquez Health Center will make sure that their patients come back when they want them to. Jessica Ortiz: And expanding a little bit more on challenges, how did COVID-19 factor into this project, and broadly, what has it been like to innovate in the middle of a pandemic? Caleb Sandford: Well, one of the big challenges with COVID-19 is that our phones are just slammed. For the last two years, our phones have been off the hook with people needing COVID tests, COVID vaccines. They can't go to school because they were exposed and now they need a visit with a provider to clear them to go back to school. So our call volume has just increased dramatically, which means that our call wait time has increased more than we would have liked it to. And so that makes it even harder for patients to come in for their follow up care. If they need to call to schedule their follow up visit, and they have to wait on hold for 5, 10 minutes, people hang up. We have a call abandonment rate of people. They're like, "Ugh, I'll try calling back later." But then they forget to, or there's hold that time too. So it's been harder for patients to reach us by telephone. Caleb Sandford: Our appointments slots have also started filling up much more. So now we may be a few weeks out for getting an appointment booked. So that's why with these appointment recalls, if we can get them scheduled a month in advance before our schedules get clogged with everything else, even though we're meeting the urgent needs of patients with COVID, we're also able to get in patients for their routine care so that the people that we serve, that their normal healthcare that they need for their chronic diseases, their preventative care, that that doesn't slip more than it already has during the pandemic. Caleb Sandford: And so by funneling those appointment recalls through our text messaging platform, it provides a different outlet for patients to be able to schedule that care with us. Instead of having to call us, we prompt them by text message and they can just respond to that text and get their appointment without having to pick up the phone. Jessica Ortiz: Great. And if another federally qualified health center wanted to try this same approach, what do you think is the most important thing for them to know? Caleb Sandford: Well, we were fortunate for two reasons. One, we had switched to Epic about two years ago. We converted from NextGen to OCHIN Epic. And this was a feature that was already built inside of Epic, appointment recalls. So we were able to take advantage of that. I'm not sure if other EHRs have that kind of future appointment recalls system set up. The other benefit we had is we had a very good relationship with our text messaging vendor, with WELL Health, where we were able to get them quickly to pull in appointment recall data as an additional data set along with the appointment data, and then enable us to be able to create appointment or automated text messages from that appointment recall data. Caleb Sandford: So, because of the relationship we had with WELL and with OCHIN, we were able to make that happen relatively quickly so that we could get this off the ground. Now, we probably would've done it even without the text messaging component, but the manpower it would've required to call back all of these patients manually by telephone would've required a couple FTs potentially. And so by integrating it with our text messaging platform, we were able to do that without having to add any staff. Jessica Ortiz: I'm curious, going back to innovating during a pandemic, what was that like just on the operational side in kind of planning for this rollout, kind of the human factors of the organization? Was there any impact COVID on that process? Caleb Sandford: Well, COVID-19 has been a crisis situation for all of us. One of the advantages of crises is it enables teams to really come together around a common purpose and get things done. So most community health centers, us included, we were able to transform our care over the last two years significantly more than we would've been able to without this pandemic. So overnight, community health centers started providing telehealth care, phone consults and video visits. And that's something that we all wanted to do, we all talked about doing it. The billing wasn't there. And so it would've taken us years and years to like really roll that out. But with the pandemic, we were able to all push it through kind of overnight. Caleb Sandford: So being in a crisis situation with COVID-19 allows us to really get more clarity on what's important and what needs to get driven forward. Now, one of the advantages of Tiburcio is we created this transformation team that I'm in charge of where we are not in charge of the day-to-day fires of running clinics now. We're not in charge of dealing with the ins and outs of the pandemic on a daily basis. We're able to really take a step back and think about, okay, what big things do we need to do in this organization to help get us through this pandemic, help provide better care to our patients, enable our care teams to get through the day in a way that works better for them, where they're not burning out as much. And so having myself and my team able to think about that and not just be bogged down by the day-to-day fires of running clinics, especially during a pandemic, has really helped. Jessica Ortiz: Great. Thanks for sharing that. Yeah, that's come up constantly is the pandemic being this catalyst for innovation and change. It's nice that you have a team that's dedicated to kind of focusing on that, "What's the next step," that broader strategy moving forward. And in the spirit of collaboration and learning and not reinventing the wheel, you're part of the Tech Hub Learning Network. Just curious, how did your peers in this program support and help you move this project forward? Caleb Sandford: Well, I think it's always important just having these conversations and being part of these groups where we're not just complaining about the pandemic today, we're not just mulling about the challenges of not having enough appointment access and there being too many people needing care. Like having these kind of innovative discussions where we can all get our creative juices flowing and break out of the day-to-day whirlwind of running clinics is very useful. Whether we're all working on the same idea or not, just getting us all thinking differently, thinking outside the box, stepping away from the day-to-day is very valuable. It's valuable to me to have this kind of conversation. And I think the more people that can get involved in this, that can take a minute to step aside from their day jobs and think about how to make things better I think would benefit all organizations. Jessica Ortiz: Great. And in the spirit of sharing, would you be willing to share the charter for a care transformation team? Caleb Sandford: Good question. We are in our infancy. So our transformation team was created about six or seven months ago, and it's not dedicated staff where they don't have other jobs. It's really a group of really amazing people. I have an amazing team that I love working with. They all have their day jobs, but they're in strategic positions throughout the organization where by pulling them together on a team, we're able to get a lot of different expertise. We have a doctor on our team. We have a IT director on our team. We have a registration services specialist on our team. We have a medical assistant. He's more than a medical assistant, but he's a medical assistant by training, so he brings that perspective. We have a data analyst who's able to run whatever kind of report that we need to out of the system. Caleb Sandford: And so by bringing all of these skillsets together where we all have our strengths, we all have our weaknesses, we're able to really process through challenges the organization is facing and be able to think through what big ideas can we come up with and realistically implement that'll help drive care forward at the organization. So it's not like Tiburcio Vasquez spent hundreds of thousands of dollars on new staff. My position was new as the leader of this team, but everybody else's positions existed already and we just combined them into this really amazing, powerful team that's able to do great things for the organization. Jessica Ortiz: Is there any last advice that you have for our listeners that are thinking about implementing a similar technology or a similar type of project or program. Any key takeaways from your learning so far? Caleb Sandford: Well, the biggest thing I talk about, whether it's this idea or other, is an organization has to focus. If we try to do too many things, we won't be successful. And that's very common in most organizations that everybody's trying to do too much. And so I think it's really important to take a step back, even if that means slowing down for a minute, and really thinking about what are our current priorities? What's most important right now to drive the most value and the most impact to the most people? Caleb Sandford: And if you can take a minute to have that conversation and think through that, and then hold yourself to it and not let other things distract you and other projects come up where people are used to hearing about the project of the day like, oh, here's the new idea they're talking about this week, and next week it's going to be something else. We have to figure out what we're focusing on and hold onto that tight and drive it to completion. And so that's how my team is organized. We come up with the projects that we're working on and that's all we talk about and we don't allow outside distractions to infiltrate us being able to drive these things forward. Caleb Sandford: And so that would be my advice to others that want to do things like this is make sure it's a priority, make sure all the way up to the top of the organization it's agreed that it's a priority and that you're going to be resourced and have the time you need to drive it to completion. People lose heart and lose confidence when great ideas are suggested and started but then never implemented or never seen through, never gotten to the sustainability phase. And so that's super important that whatever you put your heart into, you get it done and you make sure it's sustainable before you move on to the next thing. Jessica Ortiz: That's great advice. Thanks for sharing, Caleb. We're really curious, what's next for you? What can we hope to hear from you in the coming months, over the next year? What's next? Caleb Sandford: Well, this is really just the beginning for us. So my vision long term is that patients never have to talk to somebody to schedule any appointment. Some patients will always want to, they'll always want to call us and sit on hold and book that appointment manually. But for the people that don't want to have any human interaction, my goal is that they can book every single appointment they need without having to pick up the phone or interact with anybody. So this process started a few years ago actually when we implemented our text messaging platform, WELL. We created this new way, this new outlet for patients to be able to communicate with us. Caleb Sandford: Now, it's still two-way communication where we have to have conversations by text, but it doesn't require picking up the phone. So that was step 1. This is the next phase of that where now we're recording future care appointment recalls, and then using text messaging to remind people it's time to schedule. The next phase is I'm working with WELL to develop the capability to allow patients to actually schedule these appointments automatically without interfacing back with us. So my goal is that WELL in these text messages that go out to remind the patient it's time to schedule, that they'll be able to include a link in that text message where the patient can click the link, see all of our available times for that specific provider, that specific visit type, and they can just select the one that works well for them. Caleb Sandford: The next phase after that will be using the same capability. Us being able to send out campaign messages by text where if I have 1,000 kids that are overdue for their well-child checks, I can blast a text message to them right now reminding them, which I can do today, but if I can include that link for well-child checks in there where those 1,000 kids can just click the link and select the time that they want, that will be powerful. And then if they need to reschedule their appointment, they can get another link that allows them to select a new time. So that's really my long game here is working with, together with OCHIN Epic and with our text messaging vendor to develop all of these capabilities so that patients never have to sit on hold again. Jessica Ortiz: Wow. Yeah. I'm really excited to hear how this project continues to unfold and just to find out how many patients utilize this compared to how many you've reached out to. So looking forward to hearing more in the future. I want to thank you for joining us and sharing with the learning community and just thank you for being a valuable member of the Tech Hub learning community. So, thank you. Caleb Sandford: Thanks, Jessica. Great to be here with you.