Over the past two years, over 20,000 people in San Mateo County have gained insurance through Medi-Cal. San Mateo Medical Center implemented telephone visits to address access issues.
With the influx of new patients, the availability of clinic appointment slots continues as a major challenge for San Mateo Medical Center (SMMC). The San Mateo County Health System and the Health Plan of San Mateo entered into a “capitation” contract for newly eligible Medi-Cal members rather than reimbursing on a traditional “fee-for-service” basis. This new value-based payment structure aligns SMMC’s financial incentives with its patients’ clinical needs and presents an opportunity to invest in creative strategies for improving access to care as well as preventive care. To address, in part, SMMC’s access issues, phone visits were selected as a promising innovation to improve access to care. Virtually all patient needs are addressed with a clinic visit, including many that could be taken care of more promptly and conveniently over the phone. SMMC implemented this innovation as part of CCI’s 2015-2016 Spreading Innovations program.
San Mateo Medical Center began conducting telephone visits in two clinics: Daly City Health Center and Coastside Clinic. With this as their starting point, the innovation team has been quite successful in spreading this innovation across sites. In September 2015, the innovation team started with one provider and one nurse at the Daly City Health Center and six providers and five nurses at their Coastside Clinic. A year later, staff has conducted about 1,000 telephone visits across five primary care clinics and one specialty clinic (Endocrine Specialty Clinic) and telephone visits have been adopted by 15 providers and nine nursing staff. The innovation team spread the use of telephone visits to their main campus and to the South San Francisco Clinic.
As part of this process, the innovation team developed a coding scheme to document telephone visits and track whether they were coded appropriately. According to Melissa Rombaoa, MPH, Operations Strategist in the Office of Managed Care at SMMC, “This ties in with the alternative payment initiatives in California. SMMC’s immediate goal was to log the calls to document how many telephone visits were conducted. Eventually we’re going to have to submit those for the Global Payment Program and the ‘Wrap Cap’ for FQHC’s.” Over the course of the Spreading Innovations project, the team significantly improved the percentage of telehealth encounters that were coded correctly from 56% in September 2015 to 93% in June 2016. In addition, one of the biggest lessons the innovation team learned upfront with launching televisits was to give providers some flexibility with the types of encounters they were comfortable doing over the phone. As Rombaoa explains, “From the outset, we didn’t put parameters around what you can do over the phone versus what you can’t do. It was more up to the provider to decide what they’re comfortable with because it varies among them. So, there has to be clarification among the providers and whoever is scheduling visits as to what providers are comfortable with and what they’re not. We suggest that when you’re first trying televisits, it should be provider-initiated only.”
Patient experience was another major goal of San Mateo’s CCI project. The team documented patient experience through one of their patient satisfaction measures on “likelihood to recommend”. The team was able to improve this score over the course of the project at their Coastside Clinic. Qualitative feedback from patients revealed that telephone visits saved them a lot of time, providers paid more attention to their needs, and they appreciated not having to come into the clinic.
Moving forward, the innovation team plans to compare health care utilization patterns for pre-telephone visit services vs. post-telephone visits, especially in the emergency department. While in the past year the project focused on rolling out the telehealth service, the innovation team will now focus their attention on the financial sustainability of using telehealth visits to see if it makes a difference.
“Our focus for the Spreading Innovations project was on work flow and documentation. For us, one of the big things that we learned was the work flow around scheduling and the way you use telephone visits is going to vary among sites. One site focused on using it for triage which is a different work flow from the other site, which was doing actual scheduled visits for providers.”
Melissa Rombaoa, MPH, Operations Strategist Office of Managed Care, San Mateo Medical Center