Access to specialty healthcare in the United States is already strained and projected to worsen due to a significant physician shortage. This is especially pronounced in rural areas. Henry Ford Health, a large metropolitan health system, offers advanced tertiary and quaternary services, but access gaps persist, particularly for complex cases like inflammatory bowel disease. Telemedicine has been used to bridge these gaps, but challenges such as technology access, diagnostic limitations, and cultural preferences remain. Additionally, physician burnout is a concern, making collaboration among healthcare organisations crucial for addressing these issues. To tackle these specialty care access challenges, authors collaborated to design a model for providing virtual care consultations closer to patients' homes. This model combines virtual care with a cooperative care approach, aiming to expand access, improve care outcomes, and utilisation. Short-term goals include enhancing access, bridging the digital gap, reducing unnecessary hospital visits, and promoting equity. Long-term objectives involve improving clinical outcomes, increasing workforce productivity, and enhancing staff retention. This collaborative model benefits community and tertiary healthcare organisations, ultimately improving patient care. Findings were published in NEJM Catalyst.
A Dual Model of Freestanding and Embedded Clinics to Optimise Healthcare Access
The operational model included two distinct formats: freestanding and embedded clinics. Freestanding clinics were chosen for regions with multiple competing hospitals, aiming to maintain neutrality and avoid favouring any single institution. Despite being more costly, this approach supported the overarching goal of equitable access to care. Conversely, in areas with only one hospital, virtual care clinics were embedded within the facility. These clinics utilised existing examination rooms within the hospital, ensuring privacy-compliant Internet connectivity and electronic medical record (EMR) access through contractual agreements with Henry Ford Health.
The selection of clinic locations was a meticulous process, guided by a blend of qualitative feedback from established Henry Ford Health specialty physicians and quantitative referral analytics. This approach included physician relationship management tools, customer relationship management tools, and an analysis of clinical differentiators that could cater to rural patients' needs.
Strengthening Healthcare Partnerships: Collaboration with Community Physicians
Leveraging decades of strong relationships between Henry Ford Health and community physicians, the project built upon existing trust and collaboration. Endorsement by local speciality physicians played a pivotal role in ensuring the initiative's success, as they best understood the necessity for improved access to tertiary speciality care. Communication was vital, with ongoing engagement between Henry Ford Health and community physicians to reinforce the mission of improving access without undermining local practitioners' practices.
The referral process was deliberately structured to originate from community specialists, allowing them to maintain control over their markets and patient volumes. In-person conversations involving both community and Henry Ford Health physicians were conducted to ensure shared values, comfort, and trust among all parties involved.
Innovative Solutions and Impact Evaluation: Integrating APPs and Assessing Healthcare Outcomes
To address capacity constraints, especially with tertiary specialists initially lacking availability, advanced practice providers (APPs) were integrated into speciality teams as patient volume grew. This integration was speciality-specific, with protocols overseen by tertiary speciality physicians. A simple business model ensured buy-in from tertiary speciality physicians, with revenue staying within the department and overhead costs fully supported by system leadership.
Evaluation of the project's impact encompassed various measures, including clinical volumes, work-productivity indices, disability rates, socioeconomic data, patient experience metrics, downstream revenue, and clinical outcomes such as hospitalisations and emergency department visits. Additionally, a focus on mental health and opiate usage was included in the evaluation, hypothesising that improved access to care could mitigate these issues among the patient population. Data collection utilised both electronic medical records and claims sources, ensuring comprehensive assessment across key stakeholders' interests.
Overcoming Implementation Challenges in Virtual Care: Lessons Learned and Solutions Explored
The virtual care clinic network outlined serves as a model for improving speciality care access, but several hurdles were encountered in its implementation:
Platform: Initially, a non-integrated telemedicine platform caused inefficiencies, but later integration with the EMR system (Epic) streamlined operations. Wi-Fi access was arranged for hospitals with different EMR systems.
Staffing: Initially, there was a preference for advanced practice providers (APPs) for telepresentation, but over time, medical assistants proved more suitable and cost-effective. All staff were hired and trained by Henry Ford Health.
Procedures: Challenges arose in communicating results to ordering physicians when community healthcare institutions did not share EMR data. An electronic solution is being developed to address this issue.
Scheduling: Identifying patients suitable for virtual care clinic visits during scheduling was difficult. Community providers' schedulers were trained to incorporate virtual clinic options, and integration into electronic scheduling platforms is ongoing. Notably, reimbursement and physician time are equal regardless of visit type (virtual, telemedicine, or in-person).
These hurdles provide insight for others seeking to replicate similar initiatives, highlighting the importance of platform integration, staffing considerations, procedural challenges, and scheduling adaptations.
Source: NEJM Catalyst
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