Lean Daily Improvement helps improve chronic care management enrollment at multiple sites

All organizations experience challenges when improving processes and work flows. Those challenges may seem even more problematic when an organization attempts to improve processes across diverse service sites while maintaining program uniformity and quality. HealthLinc, a federally qualified health center (FQHC) that operates multiple health clinics throughout Indiana, wanted to streamline its process of enrolling patients in chronic care management (CCM) and to increase the number of patients served. Leadership knew they would need a plan for process change that would be consistent, yet allow individual clinics to solve problems unique to their locations and patient populations.

Funding through the Great Lakes Practice Transformation Network (GLPTN) made it possible for HealthLinc to work with Purdue Healthcare Advisors’ lean experts to facilitate optimal CCM enrollment at seven of its clinic locations. As the result of Lean Daily Improvement (LDI), a continuous quality improvement strategy that helps healthcare organizations make small, sustainable changes in workflows and processes and integrate those changes into daily routines, HealthLinc has grown its monthly billable CCM caseload from eight patients to more than 260.

Changing processes to benefit patients

HealthLinc analyzed its patient population and noted it had a small population of Medicare patients with uncontrolled diabetes, but served a much larger number of patients with chronic diseases such as hypertension and depression. The Centers for Medicare and Medicaid Services (CMS) defines a chronic disease as any condition expected to last 12 months or longer. HealthLinc analyzed its patient population and noted it had a small population of Medicare patients with uncontrolled diabetes – one of the most prevalent chronic diseases nationwide. Instead, HealthLinc served a much larger number of patients with chronic diseases such as hypertension and depression, and, while patients can benefit from CCM services to improve health outcomes, care transitions, and medication management, too few eligible patients receive services. According to HealthLinc’s Quality Improvement Program Manager Aleksandra Papadimitriou, senior leadership had discussed the need to increase CCM enrollment, but had not yet identified a streamlined plan of action. “An organized methodology was definitely beneficial to the success of the program,” she said.

HealthLinc had access to PHA training and resources through the GLPTN, and using PHA’s LDI methodology made improving the CCM enrollment process a reality. Since HealthLinc planned to run the LDI at multiple sites, a group of key staff members first formed a committee to oversee the LDI work and ensure success across the organization. Prior to implementing LDI, HealthLinc also conducted several training sessions at each clinic to promote buy-in from all stakeholders. The goal was to make certain that staff recognized the importance of enrolling patients in CCM and that staff members understood their roles and specific responsibilities throughout the enrollment and service process.

A team effort

HealthLinc’s goal was to have at least 350 patients receiving billable CCM services by the end of calendar year 2018. At each clinic, various team members would be responsible for taking the steps necessary to identify eligible patients, provide prospective patients with information about CCM, collect consent forms, and provide CCM services. Support from leadership and buy-in at all levels of the organization helped build strong LDI teams at each site. All clinic LDI teams included front desk staff, medical assistants, and the clinic manager or assistant manager. At locations that employ a pharmacist, the pharmacist also was part of the LDI team.

Papadimitriou said that having multiple disciplines working together to increase enrollment was key to success. Often, she says the front desk staff were even more instrumental in driving CCM enrollments than clinicians. According to Papadimitriou, “Front desk staff would prompt other team members for what they needed to make the project a success,” and she added, “They felt valued as part of the huddle team.”

LDI teams at each clinic relied on weekly team huddles and visual management boards (run charts of daily metrics, participation check lists, etc.) to monitor their progress and ensure effective communication among team members. Visual management boards made it easier for the LDI teams to identify barriers to success and overcome them and, according to Papadimitriou, seeing daily progress was crucial. “Staff were eager to see progress day over day, but got discouraged when numbers went down,” she said. When teams didn’t meet their goals, HealthLinc implemented corrective measures such as re-training staff to identify eligible patients and reviewing barriers to educating patients about the benefits of CCM and obtaining consent forms.

In addition to team huddles, each LDI team also reported its successes and challenges to the larger committee, which gave HealthLinc the benefit of learning from all LDI teams and sharing information across clinic locations. The seven clinics that participated in the LDI event serve very different population groups and have dissimilar site dynamics, so what worked well at one clinic didn’t necessarily work well elsewhere; however, HealthLinc discovered common obstacles to CCM enrollment and solutions to implement across the organization.

The next phase

Growing patient enrollment was the first step in HealthLinc’s expanded CCM services and efforts to improve quality of life for patients who need help managing chronic diseases. While HealthLinc hasn’t yet reached its goal of 350 enrolled patients, the clinic has seen significant increases in billable CCM services. The number of active, enrolled CCM patients is a moving target. Because CCM is billed to Medicare on a month-to-month basis and requires providers to spend a minimum of 20 minutes per month talking with patients, keeping patients engaged is critical. Patients may come on and off the service as needed, or patient availability may prohibit staff from obtaining the minimum required contact time for billing.

Providing service to a growing number of patients with chronic diseases has brought new challenges to HealthLinc, so the organization is once again using LDI tools to refine its processes. HealthLinc is concluding a second LDI event designed to help staff identify barriers to scheduling the monthly phone calls and successfully reaching patients. Across the organization, clinic staff continue to use the strong team approach and problem-solving techniques they developed during the first LDI event to provide exceptional patient care.