Situation: Alcona Health Centers (AHC) were experiencing inefficiencies in closing gaps in care due to inadequate staffing, lack of consistent workflows, and a failure to utilize the full potential of the electronic medical record. In addition, inconsistent outreach to patients and documentation in the EMR hindered the communication of the clinical staff. Finally, redundancy existed between their Quality Improvement/Quality Assurance (QI/QA) committee workgroups, and the work of a newly formed Care Management Department.
Strategy: AHC’s care connectors, primarily LPNs, were incorporated into the Care Management Department to cover most, if not all, of the clinic sites. A monthly meeting with the care connectors in addition to the department-wide meeting was instituted to help address specific care connector issues. Representatives from payers attended to explain their company’s requirements and methods of reporting (i.e. online/fax.)
Karen Koenig RN, Care Management Department Manager, developed a consistent workflow for the care connectors which included a monthly review of insurance reports with the support of an “insurance calendar”. This calendar insured that reports from all payers are worked every month and that gaps are closed if appropriate documentation is in the patient record. Patients are contacted if a service is needed and a non-billable chart entry is created to document the outreach. If unable to be reached by phone, a letter is sent to the patient and a copy is filed in the EMR. In addition, with the establishment of a new Health Information Department, AHC has more robust and accurate use of a Clinical Events Manager feature within the EMR. Alerts appear for needed services when a patient’s chart is first opened, allowing gaps to be identified by medical support staff, providers and/or care connectors and addressed at point-of-service.
Additional barriers became evident as the above changes took place. For instance, patients were not showing up for the appointments scheduled via phone by the care connector. Care connectors were coached on how to explore the patient’s reasons for declining a service. Issues such as lack of insurance or transportation could then be addressed with an outreach and enrollment specialist or community health worker. The importance of respecting a patient’s right to refuse was also emphasized.
There were many recognized improvements. The status of the missed opportunities workgroup of the QI/QA committee was changed to “Monitoring” largely due to the success of the care connectors. In addition, every gap is addressed with the insurance carrier monthly, allowing flexibility to correct deficiencies in a timely manner as they are identified, rather than focus on a few selected measures for an entire year. These changes have led to BCBSM, Molina and Meridian health plans reporting improvements in closing gaps in care.
For more information on this success story or closing gaps in care please contact: Karen Koenig @ KKoenig@alconahc.org