In some ways, Clinica Family Health was a victim of its own success. Known as “La Clinica” by its Latino patients, who make up the majority of its clients, the Lafayette, Colorado-based safety net center was in constant demand by the spring of 2020. But getting an appointment often meant an excruciatingly long wait on the phone, resulting in dozens of dropped calls a day.
Worse, the call center was the only way patients could book an appointment. The call staff were frazzled, and some patients put on indefinite hold were so frustrated that they would march into the clinic clutching their cell phones on hold in a vain attempt to hurry up the process. And if the call center was not already beleaguered enough, the COVID-19 pandemic put that into overdrive.
“It was a pretty crazy time,” recalls Tonatiuh Dansie, the health center’s EHR systems director, recalling how Clinica leaders and staff worked around the clock to convert to virtual and socially distanced care practically overnight. Just a few days after pandemic was official, the clinic had set up camping-style tents with huge canopies for drive-through medical stations in the parking lot. Medical staff began reaching out to patients via phone. The stress and anxiety engendered by the pandemic and subsequent waves of job loss, hunger and evictions led the health center to pilot a plan for virtual depression screening and follow-up. But first the clinic needed a platform in which patients could book appointments with Clinica online.
“If regular call wait times were bad, the pandemic put those wait times on steroids,” Dansie says. “Some patients were on hold for two hours. Normally tech innovations at the clinic take a long time, because you need input and approval from so many people. This could take months or even years. But with the call center imploding and the pandemic, decisions were being made really quickly.”
Clinica Family Health is offer testing for COVID-19 to the public experiencing symptoms. Testing is available via drive-through clinic at Clinica’s Lafayette facility at 1735 S. Public Road, Mon-Fri, 9a.m. to noon, or until daily testing supplies run out. https://t.co/cmtUef60Z9 pic.twitter.com/HlKWwXH4Qb
— Bo Co Public Health (@bouldercohealth) May 4, 2020
No easy task: Creating a booking tool for a medical home model
But the move to online booking was easier said than done. Clinica Family Health uses a medical home model — an approach that involves collaborative team care for each patient. This had worked well in its six community-based clinics, which provide care whether patients have health insurance or not. At Clinica, in fact, 94 percent of its patients live just above or at the poverty level, more than half are children or women of childbearing age, six percent are homeless, and 75 percent are Latinos or minorities. In an online booking model, its patients simply needed to book their primary care physician (PCP) for visits, but this had proven technically impossible in an older attempt at online booking.
“One of our questions was, how do we support a high volume of patients with a scheduling tool?” says Chief Operating Officer Kelly Daugherty of Clinica Family Health. “Calling people to make appointments is incredibly inefficient. For whatever care people need, for example, I can make a finite number of calls, to patients who may answer or not. Or I can send out 20,000 texts in a matter of minutes with a 30 percent return and we can follow up on the rest.”
Clinica Family Health first began looking into online booking for patients six years ago, planning to do so on Next Gen, the center’s electronic health record (EHR). However, the plans had fizzled out for a couple reasons, including “an overwhelming fear that that patients would not know how to use it or would abuse it in some way,” according to Dansie. But the biggest reason it didn’t work, he said, was that booking appointments on Next Gen “didn’t provide continuity with our medical home model.”
“We want our patients to see their assigned provider and team as often as possible,” Daugherty explains. “That way, whenever you come in, you see someone who’s familiar, someone who knows you. All the data support the idea that a medical home improves health outcomes.” As part of this model, Clinica’s six clinics are divided into pods with color-coded practice team areas – each with its own waiting room and a centralized, open office pod were surrounded by exam rooms. The arrangement makes it easy for the staff to communicate and visually coordinate patients, providers, and rooms. With the Next Gen messaging, however, there was no way to drive a patient to his or her primary care physician or care team – a problem that would have disrupted Clinica’s medical home model.
Fast forward to the spring of 2020. This time, Dansie decided to circumvent those problems by designing the online call center himself – a Herculean task, especially given that he had just gone on paternity leave.
“We decided that we could roll it out and tweak it as we go,” Dansie says. “And that’s what happened – we put hundreds of hours into this thing, and the online [booking] center been really, really successful.” The data collected in the pilot project shows that no-shows – patient who didn’t show up for appointments — dropped by about 3 percent and that the thousands of calls booked online helped free up the exhausted call center staff. (We’ll explore how the conversion to a medical home call center model was done in a story coming soon.)
“A critical time for depression screening”
Online booking was just one of a set of virtual care initiatives Clinica was working on. COVID-19 initially made it harder to provide comprehensive integrated services, “which is something Clinica has always prided itself on,” says Ben Schmudlach, Clinica’s vice-president of information systems. “So we had four projects baked into this one instant access project,” including introducing Skype to the care teams, using one common four-digit extension for all behavioral health needs, trying to meet all patients’ needs on one call (“one-call resolution), and developing electronic forms to screen patients, beginning with a depression screening tool – in part because patients’ depression scores had worsened in the pandemic. “There wasn’t a more critical time in like clinic’s history or this country’s history to be focused on depression screening,” he says.
With CHIC, Clinica’s work on such initiatives involved journey-mapping and human-centered design, pulling in everyone from registered nurses, medical assistants, and patient voice committee members to providers, front desk personnel and executive leaders. In meeting after meeting, Daughtery and other team members covered entire walls with post-its as they brainstormed, shared drawings and ideations, prototypes, and feedback. Themes that emerged included managing emotions, barriers and work-arounds, silos versus teamwork, education support, and inefficiencies — all of which would help them improve the tools in progress.
As part of this process, Clinica began developing the online screening tool. However, its work soon screeched to a halt. “We didn’t have the right codes go to the right providers, dropping at the right time and hitting the right claims,” Schmudlach recalls. “And that was a hard stop.” After working with the coding and compliance teams, the pilot debuted in July 2020, and by that September, compliance rates had improved significantly. As Schmudlach recalls, “We saw a 16-point improvement during a relatively short period of time, which was very encouraging.”
Perhaps most impressive, the clinic reached 82 percent of its goal for depression screening during the roll-out. “It’s honestly so cool that we are able to offer patients these screening tools to complete on the phone,” said Emily Vallano, LCSW, Clinica’s vice-president of behavioral health.
Here are some takeaways that Daugherty, Dansie, Schmudlach and colleagues offer for care centers rolling out online scheduling and screening, including an urgent precaution for all behavioral health providers.
Seven Key Takeaways
1) Ensure that ANY online DEPRESSION SCREENING alerts you immediately to suicidal ideation
Soon after Clinica introduced the very first patients to the online behavioral health screen, “we had a giant wake-up call,” says Daugherty. “One patient filled out the PHQ 9, or the short patient health questionnaire for depression, and we found out later that day that person was a no-show whose survey indicated suicidal ideation [suicidal feelings]. That caused a panic, although the patient was soon located and found to be all right. So we’ve had to be much more thoughtful; we learned the hard way not to send out that questionnaire too early. Now we give patients the survey once they check in for the virtual appointment” so the provider can be alerted to any health emergencies immediately. In addition, if the screen is positive for suicidal ideation, Dansie says, “two messages are blasted out to four different people, including the PCP and a behavioral health provider, so everyone is in the loop.” (It’s also advisable to include standard disclaimers and instructions on the forms to call 911 for any health emergency.) The EHR team has since added visual alerts that let providers know if they need to provide urgent or emergency care.
This wake-up call reminded Daugherty of the potential hazards of over-reliance on technology. “I fell victim to this myself,” he says. “The lure of tech seems endless and boundless, but there’s an element of smoke and mirrors, and we have to remember that not all tech is automatically good. The great thing about human-centered design is that you are really involving the end user in your design. The question is, how do you use tech intentionally instead of as a magic pill that supposedly solves everything?”
2) Start with billing and code compliance
As the first takeaway suggests, online screening can be risky without the proper protocols. After the initial wake-up call, Clinica “spent a lot of time with coding and compliance going through what provider type does this encounter need to be tied to and what kind of codes need to drop at what point in time,” said Dansie. “Obviously, if a patient completes a behavorial screen at 2:00 AM tomorrow morning with suicide ideation, then they no show, that’s a significant risk for Clinica and the patient” — one that the health center eliminated by having patients take the depression screen while waiting online for their appointment.
3) Publicize your new online tools
With the stress of the pandemic, Clinica did not immediately market its online booking system to patients. “We worked so hard to get our online booking system ready, and then when we went live, we had maybe 10 bookings a week,” says Dansie. “I mean, I could have called 10 patients a week and booked them! The problem was that patients just didn’t know about it. But once we got the word out, things began to pick up quickly.” The health center sent a text blast to its patient population about the new tool and added information about it to the center’s webpage and communication center “hold” message. In addition, almost every other outreach activity for patient care included a link to the online scheduling tool. These changes and solving a mystery glitch (see #4) soon resulted in a flood of online bookings.
4) Test for glitches that might explain puzzling results
Investigating the initially low bookings, Dansie and team also found that some patients seeking to schedule their appointments online had been driven to a dead end: An obscure and hard-to-understand web-based form, an artifact from an earlier pilot by the operations team. Once patients were directed to the new easy, streamlined process developed by the EHR systems team, online bookings from patients soared from a few bookings a week to 120 to 200 bookings a day. “It was a huge increase,” Dansie recalls.
5) Trust patients’ good intentions
When Clinica first explored online patient booking six years ago, some health care personnel were worried about potential abuse of the system. “I remember someone saying a patient might book 30 appointments for the same day,” Dansie says. “Well, patients are smart, and a lot of them are used to using online booking for all kinds of things.” He pointed out that the health center still offered a phone appointment system for patients who lack computers or smartphones, but that patients liked the convenience of the online booking system: “We never saw the kind of misuse from patients that some people thought would happen.”
6) Be patient with workplace culture change
Care team workflows are just as important as technical workflows, notes Schmudlach.“When we start these new workflows electronically – sort of automagically — it’s easy to forget that the staff is still really important to monitor and ensure its completion,” he says. “So we want to make sure that the whole team is involved in the process and knows where they fit into the workflow.” He stresses integrating visual cues or flags to identify screenings with adverse outcomes so front desk staffers and others will know when to take action. While being patient in understanding everyone’s ‘new normal,’ “don’t forget the best practices you used pre-pandemic,” he adds. “If a care team member was involved before a certain workflow got rolled out, make sure that they are involved moving forward so that we’re catching patients that might otherwise fall through the cracks.”
7) Integrate intelligence reports into your online toolS
Online tools and forms are an ideal place to use all that patient data you’ve been collecting. “We use our intelligence reports, which have clinical triggers, to schedule annual well-being exams or follow-up visits to, say, diabetes tests,” Daugherty says. “It’s kind of like the Kaiser experience. We use our text platform to send reminders. We are finding a strong response among younger demographics although not great engagement among those 70 or older, so we would contact those patients by phone.” (Data does show, however, that a few patients 100 or older have self-scheduled a provider visit.) The data from the online forms, in turn, is integrated into the EHR. Says Rebecca Johnson, a nurse practitioner at the Lafayette clinic: “It’s so convenient to have the patient complete these on their own and to have all the information flow right into the chart.”
After completing its self-scheduling tool, online depression screening, and virtual integrated team initiatives, Clinica is resuming its work on projects involving online forms and one-call resolutions as well as expanding video visits. Approximately 70 percent of its patient visits are in-person and 30 percent are virtual, with some far-flung patients expressing gratitude for the ability to see providers without having to travel for hours.
Next steps also include “just continuing to build an internal awareness and see how much juice can be squeezed out of this whole process, says Schmudlach. “That’s what really interests us – we’re really trying to lean hard into reintegrating the care team model, which we’ve been very successful with historically, and expand our screenings beyond the depression screen.”
At the time of our interview, Clinica was also gearing up to roll out its COVID-19 vaccination program. Providers were grateful to be able to offer the vaccine, especially since many of their patients fall into the groups at highest risk for infection. “We’re doing necessary and important work to help all the people we serve,” Daugherty concluded. “And we’ll continue to build out our online offerings as part of our medical home model. The challenge, as always, is to find new and integrated ways to deliver care more effectively on a budget.”
“It’s ultimately the patients and staff who get us out of bed in the morning,” Daugherty adds. ”That’s who makes it all worthwhile.”
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