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All We Need Is … a Good Patient Navigator

Time is of the essence.

In the crushing world of fee-for-service medicine, both patients and providers often get the short end of the stick.

Our practice templates have tiny time slots that we are encouraged to fill up and then overbook, seeing more and more patients in less and less time to make our RVU targets, to make the bottom line of the budgets look good, as if what we do is about volume and money and quotas.

How’d We Do?

There have been lots of studies looking at how little time patients actually get to spend in the room with their doctor in a face-to-face encounter, and even more studies showing that this lack of time to slow down and think and really take care of patients leads to poor outcomes, lower patient satisfaction, and provider burnout.

How can we truly believe that it is patient-centered care that we’re providing when we are expected to handle all of a patient’s healthcare needs, get to the root of their healthcare challenges, overcome barriers to access, complete all their screening requirements, engage in shared decision-making, explore social determinants of health, and achieve health equity, in 7 minutes flat?

Yet somehow, miraculously, we just received some of the metrics for our practice, and at least based on this (somewhat questionable) data, the doctors were scoring in the mid-90’s on almost every measure they had. Communication. Listening. Quality of care.

However, when we got to that question about having the phones answered during business hours, our practice sat at 44%. Same neighborhood we have lived in for longer than I can remember.

To me, this begs the question of whether the best model to take care of patients is indeed shoving more patients onto the schedule, rather than figuring out better ways to more humanely take care of the patients we already have.

If the systems were set up, if our teams were adequately staffed, if the support was there, then more than likely we would be able to get to so many more things; if we didn’t have to spend so much time on all the rest of this stuff.

Digging into Endoscopies

Over the past couple of years our institution has created a remarkable Quality Improvement Academy, which trains clinicians in QI research methodologies and project development and implementation. Those selected to participate spend a good chunk of the year learning how to be leaders in quality improvement around patient care. This week they showcased their final projects at Grand Rounds, as well as an afternoon poster session, highlighting innovative and insightful work fixing some of the many things that are broken in our healthcare system.

One of the presentations looked at the problem of inpatients not being ready for their procedure in the endoscopy suite, and thus having the procedure cancelled.

The team that reviewed this problem did root cause analysis, fishbone diagrams, and an intensive deep-dive into why patients who were scheduled for an upper endoscopy or colonoscopy ended up not being ready to be brought down to the procedure room, and thus cancelled.

When this happens, that resource was left unused, so not only does the intended patient not get the needed procedure, but that time slot is unavailable for someone else to have what could have been a life-saving procedure for them.

The investigators uncovered a lot of issues, including poor communication between the team taking care of the patient and the team doing the procedure, lack of understanding about the guidelines and requirements that needed to be in place before the patient could be brought down, and even things as simple as the patient being off at another procedure when they were called for their EGD [esophagogastroduodenoscopy], or the patient not being told they needed to drink the nasty prep solution.

To address these issues, they developed a set of guidelines and some improved communication tools, which seemed to dramatically decrease how often these procedures got canceled at the last minute due to patient, provider, or other factors. But as I mentioned to the principal investigator, this study only looked at the inpatient endoscopy suite’s workflow, not at the four outpatient endoscopy suites. He told me that the situation there was often even worse.

A no-show rate from 10% to 25% for outpatient endoscopies seems like an ideal place for some low-tech, low-cost interventions to prevent these procedure rooms from lying fallow. The gastroenterologists who work in these rooms already have a pretty good idea why patients no-show for these procedures: difficulty traveling to our facility while undergoing colonoscopy prep, anxiety about the procedure, fears about the results, and other reasons.

But a no-show patient for a major procedure like a colonoscopy or upper endoscopy has big negative effects. Not only does that patient not get the procedure done — which could be invaluable to their health — but another outpatient who could have been fitted into that slot missed their opportunity.

And the cost of having that space set aside, the salaries for the employees that need to be paid, the facility fees that were not collected — that is all lost. While this is money that seems to get lost in the budget numbers, it should be taken into account when trying to decide how to allocate resources to prevent this no-show appointment from happening in the first place.

Adding a Helping Hand

I’ve written before about how my dentist’s office texts me the week before my appointment, then 48 hours before, then the day of the appointment, giving me ample opportunities to confirm or cancel, and as a result, on the morning of my dental visit, they’re pretty sure I’m going to be there.

Sure, unforeseen things like illness or work emergencies happen, causing people to cancel at the last minute. But if we paid for someone to guide patients to their endoscopy appointments and deal with issues like transportation, childcare, insurance coverage, and procedure prep, would this not balance out the massive losses from that patient just not showing up?

Translating this back from a subspecialist to the primary care setting, we need to do a better job of making sure our patients can get here, that they want to be here, that they know we want to see them, and that we’re really going to pay attention to them when they get here.

We need to be able to heap resources upon them; have nurses educate them about their health conditions; have pharmacists communicate with them about their medications and answer their questions; and have care coordinators to make sure we know what happened at that hospitalization last March out-of-state, or with that specialist they saw in their neighborhood who uses a different electronic health record.

We need a team of people answering the phones, clicking all the boxes, ordering the tests our patients need, and completing all of the mandated screening guidelines that all those agencies are insisting we do.

And just like that, the endoscopy procedure suites will be full, our no-show rate will go down, our patients will appreciate the attention, and our providers will get to do what they love to do, which is actually taking care of patients.

In no time at all.