The patient–provider relationship is not merely a series of isolated encounters, but a complex and dynamic set of overlapping episodes.
In nature, there are 4 states of observable matter—solid, liquid, gas, and plasma. Matter can pass from one state to the next with relative ease, or require extreme conditions for change. And despite being of the same substance, the state in which matter exists can dramatically influence how it interacts with the physical world.
Patients exist and behave in much the same manner—residing in 1 of 4 states of interaction with the health care system, having widely variable intensities and diversities of influencers to move from one state to the next. Ours is a health care system that has historically operated based on a series of encounters with differing provider types, with little attention or energy given to the periods of time before and after the patient-provider encounter. But that paradigm is changing dramatically now that stakeholders are choosing a wider-angle view resulting from health care reform’s shared-risk corridors and emphasis on value over volume.
4 States of Patient Interaction with the Health Care System
In 2010, there were 1 billion office visits1
and 35 million hospitalizations2
to go with nearly 4 billion prescriptions filled.3
There are 1.5 million people receiving home health services at any given time.4
That adds up to a lot of patient-provider encounters happening in a country of roughly 300 million people—and with nearly three-fourths of the billion office visits involving a prescribing event, it’s not a stretch to say that our system keeps itself busy with patient encounters.
Yet one must wonder if it makes sense to invest the entirety of our energy, time, and resources on the encounter itself, when most of the benefits of the encounter are not realized until after the encounter and beyond. There’s no doubt that patient encounters have increased, with increased prevalence of chronic diseases and maladies that persist over long periods of time. It is simply a system responding to increased demand for services. But are they the right kinds of services? What percentage of patient outcomes is determined before and after encounters, versus the proceedings occurring during the encounter?
The definition of patient adherence is what happens between encounters. The health trajectory and outcomes associated with the typical procedure are not determined until long after the encounter and are influenced quite often by factors not in play during the encounter. So, perhaps we should begin to view our system of care not as a series of isolated encounters with discrete provider types, but as a more complex set of overlapping episodes of care that are dynamic and longitudinal in nature. In general, for each provider–patient relationship, the patient can reside in 1 of 4 states of interaction with the health care system:
The Pre-encounter State—The period of time between the self-determination of need for an encounter and the encounter itself.
The Encounter State—The period of time during which the encounter takes place.
The Post Encounter State—The period of time after the encounter, during which the provider intends to effectuate the patient’s plan of care.
The Unengaged State—The period of time in which the patient sees no need for provider engagement.
Whether you practice in a primary care clinic, community pharmacy, hospital, home health, or other type of setting, the 4 states of patient interaction apply—all patients will fall in 1 of the 4 groupings and cannot exist in 2 states (relative to a single provider) simultaneously. Their existence is mutually exclusive and complete (in epidemiological parlance) with respect to that individual provider. The states of interaction for each provider affect the states of interaction with other providers. What used to be a focus on 1 of those states (the encounter) in the fee-for-service model is rapidly becoming a multipronged strategy to effectuate more effective population management across multiple providers and provider types.
A Best Practices Approach to the Encounter
Much of the early quality improvement work beginning in earnest in the latter part of the last century focused on how to ensure that providers were exercising best practice during
their encounters with patients. For prescribers, it was making sure a beta-blocker was prescribed after a heart attack. For pharmacists, it was a drug utilization review or ensuring that a patient was counseled on the use of their inhaler when they were at the counter. The idea was and remains to maximize the effectiveness of the patient encounter. However, with precious few moments of face time with the patient, and an ever-increasing set of administrative demands placed on the provider, it is nearly impossible to apply all of the best practices for all of the patients based on their needs, particularly for those with multiple chronic conditions and for senior citizens. More importantly, the success of the encounter itself may be determined more by the set of interactions prior to the encounter, rather than during the encounter.
Maximizing the Encounter Through Better Preparation
The period of time prior
to an encounter may be the most underleveraged state of patient interaction, or noninteraction, as it may be, within the health care system. Since face time between the provider and patient is both limited and expensive, it would be advantageous to maximize the encounter through better preparation, triage, and screening of patients. For instance, could the encounter be more effective if a patient could spend 5 minutes in the waiting room with an interactive tool on a mobile device that is specific to their chief complaint, takes into account their previous medical history and conditions, and walks them through a series of questions that helps identify and confirm gaps in care?
Questions might include, “It looks like you turned 50 since we last saw you, have you had a colonoscopy recently?”, “Here is a list of medications we have on record for you. Are there any missing from this list that you are currently taking?”, or “Are there any medications listed here for which you are unsure why you are supposed to use them?”, or “Are there any medications that you have a hard time affording?” For pharmacists, many of the same questions posed to a patient prior to a visit to the clinic or pharmacy or admission to the hospital could aid the effectiveness of their patient encounters and better match patient need with the necessary interventionists.
For community pharmacy, it may work well to know ahead of time who needs or requests counseling to better prepare work flow. Could we not send a text message to the patient that says “It looks like you’ve been prescribed a blood glucose monitor and we don’t have a record of prior use. Would you like the pharmacist to show you how to use it properly?” If so, perhaps you could let the patient know the best time to come to the pharmacy would be on a Saturday afternoon rather than a Monday morning.
Value = Benefit/Cost
After the encounter is maximized, the real work begins. Value is defined as the amount of benefit received for the cost relative to other services that produce similar benefits. Yet for the vast majority of health care services, the benefit isn’t realized until after the encounter.
Thus, follow-up, adjustment, and reinforcement of the patient’s care plan are essential for realizing the benefits coming from the investment made by the patient or the payer in the encounter. For providers seeking to maximize the encounter, the post-encounter follow-up should continue until the patient outcome of interest is realized.
Accountable Care = Population Management
Gone are the days when a provider’s success would rest solely on his or her performance during the patient encounter itself. Increasingly, patient outcomes such as glycated hemoglobin test results and medication possession ratio (or proportion of days covered) influence the level of reimbursement. Rare is the health care service that can be successfully provided without regard to encounter preparation and follow-up. And increasingly, providers are being held responsible not only for patients they’ve seen recently, but also patients who have not seen them for some time and don’t intend to any time soon, even though that patient may be due for a lipid panel. New models of reimbursement, such as per member per month payments for ongoing management and shared costs/savings, are extending the time horizon of interest for providers and forcing them to enact population management strategies rather than a singular focus on the encounter itself.
The New Focus: The Unengaged Patient
For cost-effective treatments, procedures, and encounters that affect quality-of-care markers and, ostensibly downstream, lifelong total cost of care, a renewed focus is being given to the population of patients in an unengaged state—particularly for primary care, home health, and pharmacy—as a method and mechanism to avoid more expensive forms of care delivery in the hospital. Once upon a time, I placed a pharmacist in a large, multispecialty clinic to focus on a population of patients that our analytics team had identified as high utilizers of emergency department and inpatient facility resources. The pharmacist did a wonderful job of embedding herself in the practice, gaining the trust of the physicians and extenders, and creating an altogether wonderful and effective practice model. I anticipated the results of an analytical run roughly a year after the first day she set foot in that practice and was disappointed to see the findings. Although it appeared that the patients she was seeing were benefitting from her presence in the practice, roughly two-thirds of the patient population of interest had not been seen at that practice in the prior year. Lesson learned: population management is not about the patients being seen in your clinic or pharmacy, but rather the patients not being seen in these cost-effective settings of care.
From Chaos to Coordinated Care
One of the conundrums of accountable care is that everyone is responsible for, or at least at risk or affected by, everyone else’s work, yet no mechanism exists to enforce coordination. A patient’s relationship to each provider and their respective encounters determines a patient’s state. Thus, a patient can reside in many different states simultaneously when engaging many different providers, and as in the example of the pharmacist above, patients may be disengaged from providers with whom they desperately need engagement.
We are hurtling headlong into a movement toward outcomes-based reimbursement and risk-sharing with payers and purchasers across multiple provider types at a population level. Any health care provider who says “I did everything I was supposed to do when I saw the patient” subjects theirself to the ability of the patient and the other providers involved in that patient’s care to effectuate an optimal, well-coordinated care plan. The movement toward coordinated care is not a passing fad; it is at the core of driving quality of care and bending the cost curve. This is why so much attention was given to shared risk, coordinated care, and the health information technology solutions that support them in the first 3 supplements of the Directions in Pharmacy
series. It is the future.
The Trend Toward an Omnipresent and Watchful Delivery System
Although the concept of “4 states” may seem ethereal and otherwise impractical, we have many examples in our current system of care and reimbursement that suggest an impending explosion of processes that transcend the patient encounter:
30-Day Readmissions—Nearly every hospital in the country now has a post-acute care transitions program that, not surprisingly, lasts roughly 30 days following the hospitalization. Medicare’s penalty for poor readmission rates has triggered a tectonic shift in the concept and time horizon of risk for hospitals.
Medicare Part D Star Ratings—In another example of “If you pay for it, they will come,” medication compliance and persistency programs are experiencing exploding growth. Since prescription drug plans and Medicare Advantage Prescription Drug Contracting plans are now being incentivized to increase prescription fill rates for key therapeutic categories, unengaged Medicare enrollees not following through on a prescriber’s care plan for their medications are rapidly becoming the most popular patients in the country for engagement.
Pre-encounter Patient Interviews—We are seeing only the very tip of the iceberg here with appointment reminders, tablet apps in the waiting room, and call centers preparing patients to be better prepared for their time with providers. Expect a trend of making an appointment with a clinic rather than a specific provider of care and a determination of provider based on a pre-visit interview to gain traction.
Medication Synchronization Programs—In an effort to create more simplicity out of chaos, medication synchronization programs are the hottest trend in pharmacy today. These programs have many benefits for both the patient and the pharmacy provider, including the ability to schedule a patient with complex medical conditions during slow hours of the week for an encounter, reducing the total number of disconnected encounters, and bringing a patient-centered focus (rather than a drug-centered focus for the particular drug they are picking up that day) into a single, comprehensive review of a patient’s monthly medication. These programs maintain focus in all 4 states of patient interaction, with scheduling and preparing for the encounter, comprehensive medication reviews during the encounter, and follow-up for the planned encounter in the ensuing month, as well as patient outreach for those missing their encounter. Nowhere else in our system do all 4 states of patient existence receive as much attention—save for perhaps home health, where the patient is “captive.”
Troy Trygstad, PharmD, PhD, MBA, is the director of the Network Pharmacist Program and Pharmacy Projects for Community Care of North Carolina (CCNC), a parent organization of 14 regional care management networks. These networks bring together medical practices, county health departments, hospital systems, and mental health providers to integrate care delivery for Medicaid, Medicare, private plans, employers, and the uninsured. CCNC and its networks are responsible for developing and evaluating accountable care systems in North Carolina.
Under his direction at CCNC, the Network Pharmacist Program has grown to include pharmacists who are involved in a number of diverse activities ranging from patient-level medication reconciliation to practice-level e-prescribing facilitation to network level management of pharmacy benefits. Dr. Trygstad also plays an integral role in health information technology adoption and proliferation with CCNC practices and across the state, leading e-prescribing adoption efforts as well as the development and deployment of a statewide medication management platform.
He has been involved in novel adherence implementations as well as the development of adherence technologies that use administrative claims data to predict, intervene, and triage adherence interventions and coaching opportunities. Dr. Trygstad received his PharmD and MBA degrees from Drake University and a PhD in pharmaceutical outcomes and policy from the University of North Carolina.
He is co-editor of the Pharmacy Times series on Directions in Pharmacy.
National ambulatory medical care survey: 2010 summary tables. Centers for Disease Control and Prevention website. www.cdc.gov/nchs/data/ahcd/namcs_summary/2010_namcs_web_tables.pdf. Accessed March 10, 2014.
Number, rate, and average length of stay for discharges from short-stay hospitals, by age, region, and sex: United States, 2010. Centers for Disease Control and Prevention website. www.cdc.gov/nchs/data/nhds/1general/2010gen1_agesexalos.pdf. Accessed March 10, 2014.
The use of medicines in the United States: review of 2011. IMS Institute for Healthcare Informatics website. www.imshealth.com/ims/Global/Content/Insights/IMS%20Institute%20for%20Healthcare%20Informatics/IHII_Medicines_in_U.S_Report_2011.pdf. Accessed March 10, 2014.
Caffrey C, Sengupta M, Moss A, Harris-Kojetin L, Valverde R. Home health care and discharged hospice care patients: United States, 2000 and 2007. National health statistics reports; no 38. Hyattsville, MD: National Center for Health Statistics. Published April 27, 2011.