White Paper

Health Advocate White Paper

Report for the October 22^nd, 2015 HVAC Health Hearing

Table of Contents

I. Executive Summary 2

II. Background 4

III. Project Motivation and Potential Benefits 5

IV: Health Failure Mode and Effects Analysis 6

V: Meaningful Use 6

VI: Non-VA Examples of Scribing and Health Coaching 6

VII: Training for Health Coaching and Scribing 7

VIII: Health Advocate Proof of Concept Pilot Project 8

IX: Return on Investment 10

X: Concluding Comments 10

I. Executive Summary

The use of medical scribing to enhance efficiency and productivity of health care providers has become increasingly popular since the advent of the electronic health record. The scribe has the ability to transcribe the provider’s comments during the visit with the patient, thereby saving the provider documentation time while also allowing more visual contact and better communication between provider and patient. The scribe may enter many orders and consults if signed by the provider. Scribing was first used predominantly in specialty care and emergency medicine settings, but more recently has been introduced into primary care. To enhance the scribes flexibility, the Offices of Primary Care of the VHA have developed a role for the medical scribe which would include health coaching in addition to scribing during the patient visit. The rationale for this approach is that the scribe accompanies the patient during the provider visit and is therefore well positioned to coach the patient of the provider’s recommendations, advice and intent. This scribe/coach, called a Health Advocate (HA), then becomes an excellent patient advocate who can ensure that all of the patient’s questions and concerns about their care are addressed.

A Health Advocate Proof of Concept Pilot Project has been in progress since 2014. The piot is an innovation to enhance VHA PACT model functioning and improve Veteran care management and coordination. The Patient Aligned Care Team (PACT) model was founded on three major principles: patient-centered care, coordination of care, and access to care (Patient Aligned Care Team (PACT) Handbook, 1101.10, VHA, 2014). The implementation of this model is accomplished through the PACT teamlet, which is comprised of a primary care provider (PCP), registered nurse care manager (RNCM), clinical associate, and administrative associate. Each teamlet staff member has different but complementary roles in partnering with the Veteran to address health care needs. The health advocate is a modification of PACT to add an additional team member, the Health Advocate.

The purpose of the Health Advocate Proof of Concept Pilot Project is to evaluate whether there is value in changing the configuration of the PACT teamlet from four to five staff and shifting the roles and responsibilities by adding one HA position and converting the existing clinical associate to a second HA. By increasing the support services of the primary care team serving the Veteran, we anticipate that the HA will improve both the patient and the provider’s experience. The scribing function enhances the provider’s attention to and communication with the Veteran, while the coaching function improves the Veteran’s experience by allowing the HA to use behavorial techniques such as motivational interviewing to improve patient engagement and adherence.

The Office of Primary Care Services (10P4F) and the Office of Nursing Services (10A1) have co-led the Health Advocate Proof of Concept Pilot Project. The aim of this small primary care pilot is to assess the feasibility of medical scribing and evaluate the inclusion of health coaching into this role. Additional objectives are to explore the operations, efficiencies, and implementation barriers of the health advocate role. During this stage, the pilot sites in White River Junction, VT and Albuquerque, NM are drawing from their varying experience and situations to create a robust health advocate role that can be implemented throughout VHA. The VA in Erie, PA also contributed to lessons learned, although they are no longer participating in the pilot. VAs in Greater Los Angeles, CA, Long Beach, CA, and Loma Linda, CA are in a planning stage to participate in the pilot. Oversight and evaluation of the pilot is being conducted by the VISN 23 PACT Demonstration Laboratory (for applied research), which thus far has been largely qualitative. The Health Advocate Proof of Concept Pilot Project began at the end of FY14 and is expected to be completed by the end of FY16. This initial pilot has been well received by both Veterans and our primary care teams.

An alternative to the medical scribe is the use of voice transcription software, an approach to enhance the efficiency and speed of provider documentation in the electronic health record. This approach has been used successfully by many providers within the VA. Dragon Speak is software that is available throughout VHA and is currently being used by 11,000 providers and staff members. This technology allows for increased efficiency because it is roughly three times faster than typing and is 99% accurate. To better compare benifts of voice transcription with the health advocate concept, we are proposing a request for proposal (RFP) to be submitted for national response. In this RFP sites will have their choice to improve efficiency and productivity in one of two ways:

1. Add a 5th teamlet member, the health advocate

2. Train the PCP in voice recognition technology, specifically Dragon Speak.

Within this context, we are evaluating expansion of the pilot project to additional sites with two or more teams at each site. We will then be able to more formally assess the effects of the health advocate concept (both scribing and coaching) on Veteran experience, as well as professional satisfaction of the health care team with their work and workload. Additional parameters of importance include PACT efficiency, productivity, and evaluation of cost-benefit.

Each site involved in the comparative analysis would be encouraged to have at least two providers/teams who are willing to choose between the HA and voice recognition, as well as contribute to data collection to help determine which strategy is the most appropriate for VHA implementation. Ideally, ten sites would be selected first to begin with an education and training phase, and then transition into a head-to-head comparison.

The HA integrates the best aspects of the health coach and scribe into a role that not only increases efficiency, improves workflow and allows for increased panel size, but also increases the quality of care as well. This expansion will allow the VA to further explore viability, practicality, and cost-effectiveness of these approaches to improve our primary care health care delivery model.

Health Advocate White Paper

Report for the October 22^nd, 2015 HVAC Health Hearing

General Overview

II. Background

The Patient Aligned Care Team (PACT), VHA’s brand of the patient-centered medical home was developed and launched in 2009. This team-based care model was founded on three major principles: patient-centered care, coordination of care, and access to care (Patient Aligned Care Team (PACT) Handbook, 1101.10, VHA, 2014). Implementation of PACT in primary care is largely accomplished through the work of the teamlet, comprised of a primary care provider (PCP), registered nurse care manager (RNCM), clinical associate, and administrative associate. The role of a clinical associate is filled by a licensed practical nurse (LPN)/licensed vocational nurse (LVN), health technician (HT), medical assistant (MA), or nursing assistant (NA).

Despite dedicating considerable effort and resources to implement and spread PACT over the last four years, there continues to be variability in the degree and speed of process and workflow at the clinic and teamlet levels. In 2010, even high performing PACT teamlets voiced difficulty finding the time to fulfill all of the PACT priorities, including health coaching to promote Veteran’s engagement, self-care, and wellness. Effective health coaching is essential to provide patient-centered care and to promote self-care and self-management. Also, clinic access is improved since the launch of PACT but open access to care is still not available in many clinics.

The HA is a role designed to provide individual health coaching for every Veteran at the face-to-face visit and reduce the PCP’s documentation burden during the primary care clinic visit. The HA role changes the structure and dynamics of the current PACT team. The current clinical associate role is converted to a HA, and an additional HA joins to create a five-member teamlet. The HA position, proposed to be at a GS-6 level, may be filled by any of the current clinical associate roles, which include, the licensed practical nurse (LPN)/licensed vocational nurse (LVN), the health technician (HT), the medical assistant (MA)and the nursing assistant (NA).

In addition to the clinical associate duties, which are outlined in the VHA Patient Aligned Care Team (PACT) Handbook, the HA will be responsible for:

1. Rooming the Veteran during the primary care clinic visit to include data collection such as vital signs and clinical reminders.

2. Assisting the Veteran with their personalized health plan, then briefing the PCP on the Veteran’s perspectives, desires, and health care needs and expectations.

3. Accompanying the PCP during the clinic visit, serving in a scribing role.

4. Debriefing the Veteran after the PCP visit, using empathic listening and motivational interviewing to maximally engage and activate the Veteran.

5. Providing education as instructed by the PCP and reviewing/ verifying understanding of the next steps in care.

6. The second HA prepares the second Veteran for the PCP visit, allowing the PCP to shift quickly from one Veteran to the next.

III. Project Motivation and Potential Benefits

The purpose of the Health Advocate Proof of Concept Pilot Project is to evaluate whether there is value in changing the configuration of the PACT team let from four to five staff by adding one HA position and converting the existing clinical associate to a second HA. The project would provide an opportunity to prioritize patient-driven goal setting and activation, as well as PCP and team efficiency. Dedicated time and specific processes would guide the health advocate to accomplish the two priorities of health coaching and scribing. The HA would enhance Veteran engagement and Veteran-driven goal setting and attainment through personalized health coaching while increasing clinic efficiency, especially during the red zone (provider-patient interaction time during clinic visit) with documentation assistance for the PCP. The goals of scribing and health coaching are outlined below:

Many of the private sector models use only the scribe function, whereas some others use both scribing and health coaching. This project proposal will offer a higher level of health coaching than other models reviewed, as well as scribing that meets the specific needs in VHA. These benefits are broken out according to the function:

Scribing

• Improved patient-centeredness as the provider will be able to focus on the patient rather than the computer. (This is a common complaint with our current processes in VA as well as non-VA organizations)

• Improved access since the clinic work is spread over the entire team. The PCP focuses on actions that require their high level of education and training (assessment, diagnosing, treatment, and plan of care development), and most other actions are performed by other team members; thereby improving provider availability (and access).

• Improved PCP satisfaction and retention with enhanced consistency between the PCP role and their medical education and training.

The PCP also has better time availability to follow up on medical issues and concerns that require their high level of skill. Many PCPs report that they are usually able to complete their work within normal hours rather than habitually staying late or needing to follow up from home. Most PCPs that use this model say they would not go back to the old system. Others reversed decisions to retire since they can focus on the aspects of medicine that they love rather than administrative functions.

• Using this model may decrease the need to hire difficult to recruit PCPs (as well as an entire team let with each provider) as a result of improved PCP satisfaction and retention.

Health coaching

• Promoted patient-centeredness through personal attention to each Veteran (rather than a focus on task completion).

• Encouraged effective communication between the Veteran and team due to improved team continuity (fewer hand-offs since the HA stays with the patient throughout the visit and is available to interject information as needed during the PCP part of the clinic visit).

• Ensured that patient-driven goal setting and attainment is a priority and has dedicated time (uses TEACH for Success and motivational interviewing).

• Guided the patient toward focusing on wellness and prevention.

• Assisted the Veteran to take an active role in self-management.

• Improved the Veteran’s understanding of next steps in care (The Veteran hears the instructions an additional time during the scribing process, and the health advocate hears the instructions directly from the PCP, so they clarify questions as needed, and accurately reinforce them).

IV. Healthcare Failure Mode and Effects Analysis

A healthcare failure mode and effects analysis (HFMEA) was held on June 10-11, 2014 to explore the possible negative impacts the HA role may have on Veteran safety, satisfaction, and adherence to accreditation requirements. The findings confirmed that the proposal could be implemented with minimal risk to the Veteran and health care team.

V: Meaningful Use

There are several aspects of Meaningful Use that apply to the Health Advocate Proof of Concept Pilot Project. The most pertinent is the:

Computerized Provider Order Entry for Medication, Laboratory and Radiology Orders

The objective is to enhance patient safety through Computerized Provider Order Entry (CPOE) by eligible professions (EPs), specifically for medications, laboratory, and radiology orders. Scribing of provider orders by licensed healthcare professionals or credentialed medical assistants, as permitted by the state, local and professional guidelines is also described in www.healthIT.gov. Specifically, more than 60% of medications, 30% of laboratory and 30% of radiology orders created by the EP during the EHR reporting period are recorded using CPOE (www.healthit.gov, 2014). Also, any order entry requiring the use of clinical decision paths are excluded from scribed order entry and require PCP order entry. The Health Advocate Proof of Concept Pilot Project will strive to fulfill these CPOE requirements, and the justification is listed below:

The guidance states that any licensed healthcare professionals and credentialed medical assistants can enter orders into the EHR for purposes of including the order in the numerator for the objective of CPOE if they can originate the order per state, local and professional guidelines. Credentialing for a medical assistant must come from an organization other than the organization employing the medical assistant (www.cms.gov, 2014). Consequently, staffing recommendations for scribing includes LPN/LVNs or credentialed medical assistants to meet the Meaningful Use requirements.

VI: Non-VA Examples of Scribing and Health Coaching

Scribing

In an attempt to find the best practices of primary care teams, there was a study performed by Dr. Christine A. Sinsky and her team, which surveyed 23 high-functioning primary care practices in both the VA and non-VA setting. During that time, they explored several factors, one of which was how to eliminate time-consuming documentation through scribing and assisted order entry. The group found that primary care providers were spending 2 hours a day on visit note documentation and an additional hour on other EHR documentation. They found that six sites were overcoming this problem by empowering the medical assistant to scribe the note, enter the order, prepare the after visit summary and reinforce the plan with the patient (Sinsky et al., 2013).

The Cleveland Clinic - Strongsville utilizes this strategy and has the PCP work with two medical assistants. In this model the medical assistant first rooms the patient and performs all pre-visit activities. The medical assistant then returns to the exam room with the primary care provider to record the notes while the patient examination and assessment takes place. During the first year of using this model the access and continuity improved, resulting in the PCP being able to see an additional seven patients per day, representing a 38% increase in capacity. Patient and physician satisfaction scores improved as well, with one provider stating, “I leave work an hour earlier every day and have a very fulfilling relationship with my team…We’re having fun” (Sinsky et al., 2013).

Health Coaching

Massachusetts General Hospital in Boston strives to put the patient at the center of a collaborative team, which focuses on wellness and prevention. A key aspect of their strategy lies with setting personal wellness goals and utilizing health coaches to enable meaningful patient participation and continued motivation (Sherman et al., 2013).

In their approach, the health coach uses the following technique: (Sherman et al., 2013)

• Initial health coaching intake

  • Orientation to health coaching provided to the patient

  • A vision is created of where the patient would like to be within a year

  • Three-month goals are established

  • Two-week goals are established

• Phone based visits

  • Review short term goals, assess the challenges

  • Set new short term goals

  • Utilize motivational interviewing and problem-solving techniques to promote behavior activation

• Follow-up office visits

  • Three-month goals reviewed

  • New three month goals established and strategies to achieve success are reaffirmed

When this strategy was applied over a 9-month period for a patient with obesity, there was a 23% decrease in body weight, a 10% reduction is waist size, and blood pressure and a heart rate that were within acceptable ranges. The patient stated, “Having sessions with a coach helped me come up with ideas on how to reach my goals, and the follow-up sessions gave me pressure to stay on track” (Sherman et al., 2013).

In several examples, medical assistants and even people without formal training in health care have been successful health coaches. Effective communication, rather than medical knowledge appears to be most important factor for success and patients with higher level needs can be referred to staff with that higher level of training as needed.

This health coaching strategy in primary care has the potential for substantial cost savings because promoting healthy living and weight loss now is more cost-effective than paying for care related to diabetes and other chronic illnesses later.

VII: Training for Health Coaching and Scribing

Training for the health coaching aspect of the HA role center on VHA National Center for Health Promotion and Disease Prevention (NCP) approved communication and coaching skills training.

In addition, the training for the scribe portion of the HA role is customized to meet the specific needs of each clinic and PCP. The HAs complete a national training module on the fundamentals of scribing in a medical setting, and then additional training is provided at the facility level with the PCP and other facility experts as indicated.

VIII: Health Advocate Proof of Concept Pilot Project

The Office of Primary Care Services (10P4F) and the Office of Nursing Services (10A1) have co-led the Health Advocate Proof of Concept Pilot Project. The aim of this small primary care pilot is to assess the feasibility of medical scribing and evaluate the inclusion of health coaching into this role. Additional objectives are to explore the operations, efficiencies, and implementation barriers of the health advocate role.

Specific details for the Health Advocate Proof of Concept Pilot Project are below:

• Teams must be fully staffed to meet the 3:1 ratio

• Sites must provide sufficient space to house the health advocates and associated team members

• Daily Operation Requirements

  • Before the scheduled appointment with the PCP the Health Advocate is responsible for:

    • Encouraging and supporting the completion and linking of appropriate health assessment tools into the Veteran’s personal health plan.

    • Hearing and capturing the patient’s story

    • Establishing the patient’s reason for the visit

    • Introducing patients to the Proactive Components of Health and Well-Being

    • Taking vital signs

    • Performing health screens, surveys, and clinical reminders

    • Participating in medication reconciliation and reviewing the personal health plan

Note: some of these steps may be accomplished during pre-visit phone calls

• During the scheduled appointment the Health Advocate will be responsible for:

  • Recording the history, physical exam and assessment as stated by the provider

  • Interjecting key patient-driven goals, priorities or additional information which may be otherwise overlooked

  • Entering in the plan of care, limited orders and follow-up visits

• After the scheduled appointment the Health Advocate is responsible for:

  • Summarizing the PCP recommendations and instructions

  • Reinforcing medication changes

  • Providing written documentation and information for the patient

  • Organizing next steps

  • Verifying patient understanding; encouraging and answering questions

  • Exploring patient interest in health behavior change, using MI and TEACH skills as needed.

  • Assisting interested patients in setting health behavior goals.

  • Arranging follow-up for health behavior goals.

  • Clarifying the plan of care as needed and informing the PCP or RN care, manager of additional patient questions or needs

During this stage, the pilot sites in White River Junction, VT and Albuquerque, NM are drawing from their varying experience and situations to create a robust health advocate role that can be implemented throughout VHA. The VA in Erie, PA also contributed to lessons learned, although they are no longer participating in the pilot. VAs in Greater Los Angeles, CA, Long Beach, CA, and Loma Linda, CA are in a planning stage to participate in the pilot. This initial pilot has been well received by both Veterans and our primary care teams.

Primary Care Services and the Office of Nursing Services is partnering with the VISN 23 PACT Demonstration Laboratory to provide project oversight and identify potential challenges to the innovation’s success. The lab will also examine to what degree the innovation can help improve Veteran satisfaction with VA care and Veteran timely access to VA services. Specific actions to be taken by the PACT Demonsration Laboratory include:

• Visit innovation teams in person to observe within team-interaction

• Speak with innovative teams one-on-one about their experience

• Speak with Veterans who’ve been seen by the innovation team about their experience

• Participate in all teleconference and training events for the innovation project

• Ask the innovation team members to complete surveys about their work experience

• Ask Veterans to complete surveys about their care experience (pending approval)

The Health Advocate Proof of Concept Pilot Project began at the end of FY14 and is expected to be completed by the end of FY16. At that time, VA will consider expanding the pilot project to additional sites to collect statistically significant data to assess success and viability. The continued expansion of the Health Advocate Pilot Project is contingent on availability of funds.

In addition, Primary Care Services and the Office of Nursing Services has partnered with the Office of Informatics and Analytics (OIA) on the Proof of Concept Pilot Project. The current role of OIA is to assist with the establishment of the required IT infrastructure and processes to make this initiative a success. All offices are eager to explore the possibility of conducting a comparative analysis of various options for scribing, including voice technology and the current health advocate pilot project, subject to the availability of funds.

Before the comparative analysis of voice technology and scribing, Primary Care Services envision a full request for proposal (RFP) to be submitted and responded to nationally. In this RFP sites will have their choice to improve efficiency and productivity in two ways:

1. Add a 5th teamlet member, the health advocate

2. Train the PCP in voice recognition technology, specifically Dragon Speak.

Dragon Speak is software that is currently available throughout VHA and is currently being used by 11,000 providers and staff members. This technology allows for increased efficiency because it is roughly three times faster than typing and is 99% accurate.

Each site involved in the comparative analysis would be encouraged to have at least two providers/teams who are willing to choose between the HA and voice recognition, as well as contribute to data collection to help determine which strategy is the most appropriate for VHA implementation. Ideally, ten sites would be selected first to begin with an education and training phase, and then transition into a head-to-head comparison.

The HA integrates the best aspects of the health coach and scribe into a role that not only increases efficiency, improves workflow and allows for increased panel size, but also increases the quality of care as well. This expansion will allow the VA to further explore viability, practicality, and cost-effectiveness of these approaches to improve our primary care health care delivery model.

IX: Return on Investment

The Health Advocate Initiative comes at a relatively high cost, which is due to the addition of another team member to the already established PACT. In return, there are several benefits that can be attributed to this addition. First of all, there can be significant clinical efficiencies gained by utilizing a health advocate. Similar models in the private section have seen a 25% increase in efficiency, which allows for increased panel sizes and the ability to see more patients. If we assume that 7 PACT teams utilize this model and increase their panel size by 14% we will be able to care for an additional panel of patients without recruiting an additional PACT team.

In addition, several factors not related to cost will improve due to this initiative, which include quality of care, as well as provider and Veteran satisfaction. These advancements are primarily due to three factors:

1. The provider can interact directly with the patient, as opposed to the computer screen

2. The provider can complete medical record documentation promptly during normal business hours

3. The health advocate can provide deep insight into the Veteran’s needs because they accompany the patient during the entire visit.

X: Concluding Comments

Integrating the two missions of providing patient-centered care and lessening the administrative burden on the PCP is critical to prepare for the anticipated increase in utilization of VHA services and primary care, as well as rising healthcare costs. The HA integrates the best aspects of the health coach and scribe into a role that increases efficiency, improves workflow and allows for increased panel size, increases the quality of care, and improves the Veteran experience. VHA has an opportunity to explore the health advocate role to function at the highest level possible within the scope and training and to assess its viability by continuing the pursue this initiative.

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