Clinical Pathways Guiding Where and When

Clinical pathways most often guide treatment decisions based on a diagnosis, but what about assistance for directing where and when care is most effectively rendered? Improving clinical and financial outcomes requires more appropriate use of care timing and setting. Left unguided, patients often overutilize the emergency department or delay needed care. By using clinical pathways to direct exactly where and when care can be best provided is critical to population health management success.

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Where? 

Where care is delivered should be driven to maximize clinical and financial outcomes. Unfortunately, what is assumed to happen is not always the case. Urgent care serves as a primary example of this. The theory of urgent care posits that its use would reduce the utilization for ED care, but data suggest otherwise.1 Although additional service offerings such as urgent care centers, telemedicine, and other more convenient opportunities have grown in prominence, they have not resulted in an offset in ED utilization. This may be due to the fact that immediate care is often self-directed, without the benefit of a provider-guided clinical pathway.

A decade ago, the New England Healthcare Institute (NEHI) attempted to tackle this problem in their seminal report, Waste and Inefficiency in the Health Care System—Clinical Care: A Comprehensive Analysis in Support of System-wide Improvements.2 Their research found emergency department (ED) overuse represents the fourth largest category of waste in the health care system, and is responsible for up to $38 billion in wasteful spending every year. NEHI identified the key factors driving this costly ED overuse, including who overuses the ED, what causes ED overuse, and what can be done to reduce it. This problem results from the wrong care in the wrong place at the wrong time. The foundation of this problem is timing of urgent care.

The Centers for Disease Control and Prevention reports3 that the number of ED visits was 130.4 million in 2013, which represents 41.9 visits per 100 persons. Additionally, almost 10% of these ED visits result in a hospital admission. A large portion of ED visits fall into the category of avoidable use, resulting from patients seeking nonurgent care or ED care for conditions that could have been treated and/or prevented by prior primary care. Use of the ED for nonurgent (or nonemergency) visits grew from 9.7% of all ED visits in 1997 to over 12% in 2006. Estimates of total avoidable ED use range as high as 56% of all visits. 

Part of the overuse of the ED comes from an inability of primary care practices to provide patients with timely appointments, after-hours care, and weekend availability. As NEHI’s research on the primary care crisis has found, providers are increasingly overextended, providing an opportunity for greater direction in timing and location of care to be provided to patients. 

When? 

Physician offices can participate in the direction of improved timing and location of care through more efficient use of their offices. This is possible with clinical pathways that are built into systems like Zocdoc.4 Zocdoc is to physician practices what OpenTable is to restaurants: An online medical care scheduling service, providing a free medical search facility for end users by integrating information about medical practices and individual schedules in a central location. Zocdoc provides a scheduling system on a paid subscription basis for medical personnel. The scheduling system can be accessed by subscribers both as an online service and via the deployed office calendar software, or integrated with their websites. This system provides an easy point of access for patients to access their primary care providers (PCPs), and may soon have the ability to triage patients based on pathways that direct appointments based on need. 

From 2010 to 2015, telehealth volumes for chronic disease management were consistently low. However, the addition of new care management codes in 2017 may spur future adoption.5 Under its present fee-for-service model, Medicare does not reimburse providers for services administered via telemedicine in the patient’s home. This restriction largely eliminates home-based chronic disease management consults and remote patient monitoring, telehealth modalities that are often used for patients with conditions like congestive heart failure and chronic obstructive pulmonary disease. This year, Centers for Medicare and Medicaid Services introduced a number of new telehealth codes, including services for patients with end-stage renal disease and advanced care planning. This service is best used through guidance provided by professionals to assure appropriate use.

Several new systems are coming to market to provide enhanced PCP services at home, both in terms of timeliness and scope of services. One such service is Dispatch Health.6 Founded in 2013, this on-demand urgent care service provides mobile and virtual health care. Their goal is described as creating an integrated, convenient, high-touch care delivery solution that extends the capabilities of a patient’s care team and provides definitive, quality care in the home—all while decreasing costs. The Dispatch Health providers arrive with the tools necessary to provide advanced medical care, and are supported by a technological infrastructure that ensures quality and improves outcomes. These are services that can often eliminate the need for an ED visit.

Additionally, home PCP services can be provided by community paramedics. Community paramedics trained to evaluate patients in conjunction with a physician via telemedicine can treat acute illnesses in individuals’ homes. They are also well positioned to transport patients to the ED if additional care is needed. A study published in Journal of the American Geriatrics Society found that 78% of patients treated in this system were able to be evaluated and treated in their home.7

Guiding Appropriate Care Into the Future 

Timing is everything, especially when it comes to managing acute exacerbations of chronic conditions. Clinical pathways can be used to improve outcomes for patients. This process begins with health care professionals guiding patients, rather than patients hearing a prerecorded message telling them to hang up and call 911. The use of population health management pathways can better direct interventions outside the costly ED. This process will be easier and more critical to implement as a result of the shift from volume to value under the Medicare Access and CHIP Reauthorization Act of 2015. As a result, risk providers responsible for clinical and financial outcomes will look to processes like these to improve outcomes. Having clinical pathways that inform health care professionals, patients, and their caregivers on where and when to access care will produce improved clinical and financial outcomes. As we move to value-based care, these results will separate winning health systems from losers. 

References

1. Martsolf G, Fingar KR, Coffey R, et al. Association between the opening of retail clinics and low-acuity emergency department visits. Ann Emerg Med. 2017;69(4):397-403.e5.

2. Waste and Inefficiency in the Health Care System—Clinical Care: A Comprehensive Analysis in Support of System-wide Improvements. New England Healthcare Institute website. http://www.nehi.net/writable/publication_files/file/waste_clinical_care_report_final.pdf. Published February 25, 2008. Accessed August 28, 2017.

3. Emergency department visits. Centers for Disease Control and Prevention website. https://www.cdc.gov/nchs/fastats/emergency-department.htm. Accessed August 28, 2017.

4. Zocdoc. https://www.zocdoc.com/. Accessed August 28, 2017.

5. Walsh T, Goerlich C. A surprising trend in telehealth: It’s growing—but not what you might expect. Advisory Board website. https://www.advisory.com/research/market-innovation-center/the-growth-channel/2017/03/growth-trends-telehealth. Published March 30, 2017. Accessed August 28, 2017.

6. Dispatch Health. https://www.dispatchhealth.com/. Accessed August 28, 2017.

7. Abrashkin KA, Washko J, Zhang J, Poku A, Kim H, Smith KL. Providing acute care at home: community paramedics enhance an advanced illness management program—preliminary data. J Am Geriatr Soc. 2016;64(12):2572-2576.