The idea of a physician house call sounds like a romantic nod to the yesteryear of the black-and-white television broadcasts of the 1930s.
Tucked in your pajamas, not feeling yourself, the physician visits your home and helps deliver care without disturbing your recovery and eliminating the concern of spreading your illness to others.
Forget romantic; it sounds like a luxury. In fact, in many places offering the option today, it is just that, a high-priced concierge service. According to the American Academy of Family Physicians, what was once covering some 40% of patient encounters in the 1930s dwindled to just 1% of patient encounters in the 1980s.
Yet, we know the experience of at-home care delivery offers measurable improvements to the patient and system. Home visits improve health outcomes ranging from reduced long-term care admissions and mortalities to fewer repeat hospitalizations for neonatal care. At-home visits for medication management following in-patient hospitalizations also reduce medication errors, a problem that costs the US healthcare system $21 billion every year.
Where are we today? In 2009, approximately 2.3 million house calls were delivered across the United States. There is a growing resurgence, driven by a 2009 policy change that prompted a 50 percent increase in reimbursements for at-home visits, but what happens when a modern health system elevates the traditional home visit by offering a hospital-at-home alternative to patients?
Change starts with the home team
CareMore launched its “Hospital at Home” program in Los Angeles and Orange County, California, in December 2018. Focused on high-risk Medicare patients with specific conditions such as congestive heart failure, pneumonia or flu, or wound care needs such as those facing skin infections, the program is designed to offer a “house call” to patients who would benefit from urgent at-home treatment, estimated at the time to be more than 20% of CareMore’s patients.
“My first exposure to house calls came in the 1980s, joining my father on visits to seniors on weekends, and later it was a part of medical school and our education on patient context,” says Dr. Vivek Garg, CareMore’s Chief Medical Officer, who joined the team more than three years ago, initially to oversee new markets and business development.
“We had this great team – both at the clinics and at headquarters – and we all shared the goal of delivering better care to patients in their homes to improve their health outcomes.” But Garg soon realized that to make the house call effort a success, the CareMore team also needed a tool for collaborative priority setting. “We knew the things we needed to do,” he continued, “but we didn’t have collaboration as a priority. We needed OKRs.”
Keeping the scope broad but simple, CareMore has established its Hospital at Home program with a modern twist on the house-call of the 1930s: sending a nurse practitioner to patients’ homes for in-person visits, with physician oversight provided virtually. The objective is to provide higher quality patient care while lowering costs and reducing repeat hospitalizations.
With their first handful of OKRs, the team set ambitious enrollment goals for the program paired with expected improvements in health outcomes compared to those receiving standard care. CareMore’s plan looked well-considered on paper, but even the most thoughtful plans can fail in the field - especially when even the smallest change in behavior is required. For years, patients asked CareMore practitioners if they could receive follow-up care at home - so to the team’s surprise, initial referrals into the new program were very slow.
“We had identified the success of the Hospital-at-Home program as a priority team OKR for 2019,” says Dr. Sashi Moodley, Medical Director at CareMore Health and head of the Hospital-at-Home team, and he knew it would require both a cross-departmental commitment to assess what was missing and a cross-departmental commitment to solving the problem.
Did patients feel the home visit was too invasive? Would the home visit provide the same quality of care as a clinic visit? Were clinicians and patients even aware it was an option at CareMore? Was a home visit bringing enough value to patients? To clinicians? What needed to change at CareMore to better meet patients where they are?
Dr. Moodley tasked his team with a robust tour of listening sessions with patients, primary care doctors, and other clinical staff and caregivers. The team swiftly noticed their first bottleneck: their enrollment emails felt very impersonal, making the program itself seem impersonal and disconnected.
How could the Hospital at Home team better promote its newest asset: personalized acute care in the patient’s home? They launched a new objective to increase patient referrals from clinicians, counterintuitively scaling back to focus on high-touch support for clinicians within a smaller geographic area.
Continually tracking key results drove refinements to the referral program, reducing friction in the enrollment process. A hotel concierge-inspired training helped clinicians feel comfortable having one-on-one conversations with patients about the Hospital at Home program during appointments at the office, replacing multiple patient referral channels with a universal referral number reduced confusion for clinicians, too. Top referring clinicians were recognized for their successes with identifying and referring the patients who would most benefit from the program. And then the numbers came in: enrollment was both thriving and producing cost savings.
“The transparency of OKRs offers connection, not competition.” Dr. Moodley added.
Sharing OKR spreadsheets in meetings and virtual workspaces, the team swiftly identified dependencies in their product development and program implementation. The structure of crafting cross-department OKRs illuminated a common but unintended consequence of a decade of growth and evolution – siloed teams. Each cycle of OKRs required new introductions and team deployment, gradually bringing about a greater sense of belonging and connection among the CareMore staff.
Once they achieved their initial OKRs for enrollment, the team began to focus on stretch goals, including documenting reductions in emergency room visits. Initial failure had swiftly become a success story.
“OKRs are about three things for me,” says Dr. Garg, “They offer teams a great opportunity to work together, to learn how to set something meaningful in motion, and to recognize their own system-wide dependencies across a large operation. OKRs help us get things done and build a growing foundation for meaningful work.”
OKRs: a practice in patience
Laying the foundation for new clinical care delivery models is neither easy nor immediate. Goal setting with OKRs was, in and of itself, a process they had to grow into over time. At first, CareMore’s practice was used more as a scaffold for managing expectations and communicating priorities. Like many orgs, the challenge of scaling the CareMore model uniquely to 3 states initially, and growing quickly to staff and support these systems made communication complex.
Entrepreneurial by nature, clinicians in practice management frequently function independently, with little to no engagement with other like-practices, breeding feelings of isolation, and discouragement. CareMore’s clinicians had been recruited for their excellence in care delivery and unique thinking as individuals. Still, there was a steep learning curve to communicate effectively as a team rather than as individual contributors.
Reflecting on the CareMore landscape and with an expansion to even more states on the horizon, Garg knew to truly make a difference, the staff needed to become a cohesive team. “Early on, we had the best of intentions and great passion – with greatly misaligned priorities and expectations, and I thought OKRs could help,” said Dr. Garg.
Every voice needed to provide input and every responsible party had to provide transparency on progress and accountability. Sharing OKR spreadsheets and inviting others to give feedback, provoked new awareness of overlaps and helped the team craft tools to streamline task triaging and matching responsibility to the best fit.
“It took several quarters for everyone to settle in to the OKR process,” Dr. Moodley admits. “What level do you set for objectives? How do you build out cross dependencies and know you covered them? We kept working through it, and leveraged the OKR-setting experience as an excuse to better understand our colleagues in product development, analytics, behavioral health, clinical operations, and case management.”
As the cadence of OKR creation and planning continues to expand at CareMore, project management and goal setting muscles of staff members refine and strengthen. Dr. Moodley adds, “OKRs force thinking about the big picture strategies – even documenting stretch goals. When you stare at those ambitious goals together as a team, that visibility crafts express lanes to collaboration.”
CareMore built itself on a commitment to patients to provide tools that reduce the burden of chronic disease and slow disease progression through new initiatives, program integration in a patient’s lifestyle, and discovering new ways to promote health across a patient’s life. OKRs offer the documentation of that commitment, the structure to pursue discovery and create progress against the known hurdles of behavior change and system evolution. To-date, more than 400 patients are enrolled in the Hospital-at-Home program and growing, with each clinician focused on providing the care needed, in the best setting to receive it: the comfort of your own home.
“When it becomes what we do, in the absence of even calling it OKRs, we will have the structure and path to call out the next generation of ideas and discoveries. That’s what I’m looking toward when I work with the clinic teams.” Dr. Moodley reflects.
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