This article is brought to you by MatrixCare. The article is based on a live Q&A session with Navin Gupta, SVP, Home & Hospice, MatrixCare; Chris Pugliese, Senior Product Manager, MatrixCare; and Laurel Thomas, Associate VP of Quality Home Health & Hospice, Covenant Care, that took place at the HSPN ELEVATE conference in Chicago held on October 21, 2021. The discussion has been edited for clarity.

Navin Gupta: Good afternoon, everyone. My name is Navin Gupta. I lead the Home and Hospice Business at MatrixCare. We’re going to be spending some time talking about patient engagement. If you look at the key trends within a hospice, the first is around labor and resources, and that itself is a challenge many are facing within the hospice space.

The second is access to patients and patient engagement. Forty percent of hospice care is delivered within skilled nursing facilities and [assisted living]. In the last 18 months, it’s been a challenge to access them. We’ll look at what patient engagement is and where you will benefit from our panelists. Let me introduce Laurel Thomas. She is the Associate VP of Quality Home Health and Hospice at Covenant Care. Covenant is a large national not-for-profit organization in Southern Alabama and 80-plus counties in and around the U.S. They provide a range of services that include hospice and palliative care. Thank you all for joining us.

Christopher Pugliese is the Senior Product Manager for MatrixCare. He has been very influential in not only the shaping of interoperability with the MatrixCare, but also in post-acute care at large. He is involved in the Common Health Alliance. He is involved in several of the standard bodies shaping interoperability as well. It seems like he’s been doing that for the last 20 years. He started when he was six [chuckles]. We’re really grateful to have him as well.

Let’s start with palliative care in particular, and the increasing number of family plans providing some palliative care reimbursement. With one-third of hospices providing palliative care as well, we are seeing inconsistent revenue models and less frequent direct patient interactions. Laurel, how has Covenant really explored this area of patient engagement when it comes to palliative care? How did you all get started?

Laurel Thomas: I’m a nurse, so if I start speaking like a nurse, there you have it. But I have been in hospice for 26 years and I can’t even name all of the roles. Right now, I’m working in the quality sector to figure out how we can improve the care.

I came to Covenant and, all of a sudden, I needed to start palliative care and remote patient monitoring. We bought a few machines. I thought, “This looks like a good idea,” then boom, COVID hits. The hospitals were coming to us and saying, “What can we do? We’ve got patients who have COVID but don’t need to be hospitalized. We need to get them home so we can put critical patients in these beds. What are you going to do for us, Covenant?”

We said, “We’ve got these RPM machines. Let’s see what we can do with those.” We were duly launching palliative, which was still not at the level where a payment model could do anything, but we were going to be left in the dust if we neglected that in moving toward hospice and moving toward that industry. You’ve got palliative and you’ve got the RPM that we’re utilizing at that point for those patients.

It certainly had some growing pains. We’ll go through how to start a remote patient monitoring program right when it’s needed immediately. But overall, patients were really engaged. They actually loved it.

They told my nurse, Angela, and I, if their blood pressure isn’t what it should be, because they would take their blood pressure. If they don’t answer the simple yes or no questions correctly, Angela’s there immediately to talk to them. They felt connected— even the elderly patients. They love feeling that someone was there for them, especially in the beginning of COVID when nurses couldn’t go into the home.

I was also struggling with how to get PPE.That was before vaccinations. That was when I had them putting their N95 masks in brown bags every 72 hours, and we were on Amazon trying to find stuff. That’s when we saw the benefit of palliative and that connection. If the patient said, “Something’s wrong,” it immediately went to their nurse. I’ve got CHF patients. They take their weight, and if their weight’s really up, we know they’ve got swelling. They’re possibly going to be rehospitalized, and that is not what the hospital wants. We certainly have a payment model that they don’t want, but they also have a problem with capacity. We’ll talk a little bit later about the nursing shortage and COVID.

Gupta: That’s great, Laurel. I know you’re engaging patients earlier and helping manage their chronic conditions or serious illnesses. Patient engagement for palliative looks slightly different than hospice, right? How do you tailor patient engagement solutions from a hospice?

Thomas: I’m an old hospice nurse. My millennial children would tell you that I’m not very good at technology, but I’m better than they think. I’m used to “right now” technology and that it is not a distraction, but you will see some of your nurses say, “Oh, the tablet. I can’t chart at the bedside.” If I had a dime for every time I heard that, I probably could retire.

They will say that that’s a disconnection. All that a hospice is about is connection. It’s about that care, that empathy, that, “I’m there for you,” but it doesn’t have to be that disconnection. It can still be a connection to people because they feel like the caregivers are actually there for them, responding to things that are going on.

We are seeing connection with RPM as well. In the olden days, you would see family members focus on obscure details because they can’t focus on the fact that they’re losing a loved one. Well, guess what? You put RPM in there, and they now have something to focus on and connect with, and you can start to work with them. Again, you’ve got to look at lengthening the time we have with chronic illnesses too. My dad was on hospice this year and people are like, “Why is your dad on hospice?” Because he’s eligible for it, and he’s going to get the benefit when he’s eligible for it, but you still can’t come to grips with the reality of what that means.

We can use technology to our benefit and it’s not a detriment. I think we have to stop looking at it in black and white just because it’s not the way it used to be in a hospice.

Well, we’re not the way we used to be in hospice. We have not remained a static area of health care. We have to get caring for people and holding them in our hands, and we can use technology, RPM, et cetera, in order to elevate that.

Gupta: Laurel, I want to pick your brain to better understand the evolution of patient engagement. And Chris, we can share a little bit about the technology components that drive patient engagement.

Christopher Pugliese: Yes, absolutely. We’re actually perpetrators of this too, of using this broad term to describe a series of interactions that are all different tracks. RPM is certainly one of them, right? That’s the real-time collection of clinical data to support clinical operation. We’ve got communication tools to help us reach out, engage and respond when it’s needed.

Then you’ve got the trend of workforce and operational automation, where you’re engaging with your patients, or you’re using these patient engagement tools to drive efficiencies in your operation. With labor shortages, however, [what] level of automation is being driven off.

In the marketplace, there’s a large number of tools claiming to be patient engagement tools, but they’re covering a wide array of different solutions under the patient engagement umbrella.

Organizations need to start looking for a platform that provides tools that fit their population, staff and specific patient needs on a day-to-day basis. It’s a difficult question right now because there are so many platforms rising to the occasion. And as we talked about before, COVID changed the way people interact with their providers and buyers. It opened opportunities and accelerated the need for these kinds of tools across the different categories of patient engagement.

Gupta: It goes through a broad range of categories, simply RPM and telehealth. Even if you looked at pre-COVID to COVID, it’s almost a 10X increase in the number of virtual visits. From the current state, Laurel, if you were to reimagine what patient engagement looks like in the future, what does that future look like? What does the evolution of patient engagement mean for Covenant?

Thomas: First of all, you’ve got to look at your different entities and how they communicate with each other. You’ve got to look at yourself. There needs to be some inward reflection on communication within the different entities of the health care continuum.

My mother lives here in Chicago. I live in Alabama. Well, how do I connect with her doctor? I click the app, and I can see all of her lab results. I can see all of the notes they put in. I can see all of this technology. Why wouldn’t we head that way with hospice? I think that sometimes we can look at it and say, “Well, what are we saying in these notes?”

It could be concerning to a family member if they’re out of state or out of town, but they can talk to the doctor. They either call or use the messaging system, and it’s all kept completely HIPAA-protected. Why aren’t we heading that way with something that is going to be so connected? How can we communicate better with each other? Well, that’s through your platform. If we’re all sharing the same medical records and communication notes, we can see everything that’s going on. I see more streamlining, but we’re better now than we were at the beginning when we were shoved into it.

I’ve always said COVID jolted us into a realm probably 5 to 10 years sooner than we were ready. We need to adapt to that, but it’s not a bad thing. It’s going to be better for patient care, overall.

Gupta: Yes, Laurel. I think you talked about patient engagement as the experience the patient is having. Below that are the transitions of care and the tech coordination. A lot of that is done through interoperability. We can look at the communication piece, but if the clinical documentation is not there and its real-time information is not accessible, we can’t give the patient the right experience. From your perspective, what role does interoperability play?

Pugliese: I’ll answer that one twofold. First off, what you would expect to see is more tightly integrated apps. There are going to be a lot more players trying to solve these problems in this space. We know there’s a need for this because 96% of patients in the Porter Research study said they would switch providers to one that could communicate in real-time with them.

Furthermore, the same study also found that patients are much more likely to get an immediate response in a dedicated app. Phone calls are a pile of air. They go into a big pile with all of your other daily life activities and your work activities. When something comes out of a dedicated app, you’re more likely to see it.

Then, if you throw interoperability into that evolving marketplace of apps, the level of access to data is going to keep rising. These patient engagement tools and apps are likely going to rise right along with that to get access to that data.

That mandate applies to all providers. It named certified EMRs as another actor. Certified EMRs had their own specific requirements as part of the blocking rules rolled out in April of this year. Providers also have requirements even if their EMR is not certified to make this information available.

We can expect to see those apps starting to collect patient information from multiple sources, allowing patients to different providers who all have more access to it. You can expect there are going to be more apps. Apple’s made it very clear what their intentions are.

Gupta: What are some of the considerations for providers who want to lean into patient engagement and family engagement, and how do they get started with this?

Thomas: We were forced to because of COVID, but it would have happened anyway. You certainly look first at forming a little committee to discuss your pressure points.

In our case, the hospitals were coming in saying, “Hey, I need something better. I need to give you these patients. We’ve got hundreds of patients. What can you do?” They started out with that. We were able to look at different quality measures and evidence-based practice. Then it always comes down to cost.

I said I’m a nurse, but I have also been in operations for a very long time. It comes down to, “Okay. What are we going to look at?” We’ve got RPM machines that we might be purchasing. We’ve got certain visits in palliative care. That’s a terrible payment model, but I think CMS is going to do something. Then you’ve got to look at the conversion rate.

We did a business plan month by month based on our outlook. If I’m going to go to the CEO, I’ve got to be able to say the proof is in the pudding and this is how many more referrals I think we’re going to get, this is what our referral sources are saying. You got to really stretch that out. You’ve got to look at that and put it on paper.

As a little committee, we did that and moved, because if we didn’t, someone else in my area was going to move on it. These were referral sources coming to us with hat in hand saying, “Please help.” We certainly want to help the patient population, but we want to provide quality as well. You have to look at all of these things, but it’s individualized to.That’s the other part. You have to do a huge amount of education for the clinicians. We had to figure out what we were going to do with that data. I don’t have problems with my RPM going right to my clinician. They’re on top of anything alerting them.

That was something we had to change so it goes directly from the RPM to the NP on call. Then, we have to constantly reevaluate it. What is the recidivism? What’s the rehospitalization rate? What is the average length of stay? What is the median length of stay of our patients? Are we getting them on sooner because we have these things and we can see where the decline is going? Are we decreasing the number of visits?

Not that I don’t want nurses or personnel to be spending time with these patients. Of course, I do. That’s hospice. But how can we help to alleviate the fallout from staffing shortages?. We had to look at these other measures and revisit the drawing board before we could say this is the program we want it to be.

Gupta: Chris, I want to turn to you. It’s a similar question on the flip side of that. Now, a provider wants to go down this path as has been the case with Covenant. They’ve got technology partners. They’re working with the EHR vendor. They’re working with other technology vendors. What are some of the considerations? What should providers be thinking about? What questions should they be asking the technology partner in order to roll out a patient engagement solution?

Pugliese: It’s always interesting when you start talking about the technology and platforms that are even brought to bear, because a lot of times providers have an end game. Even vendors themselves have the same problem, where there’s this idea that the EMR has to do everything. We’re moving towards a place where the EMR is no longer the central thing, it’s now a hub.

What’s important about a hub is its connectivity. When you’re assessing, you have to ensure that, number one, your EMR can support the kind of scaling connectivity that you would need to bring on some of these programs, and then go find your vendor and make sure they connect to your EMR. As I mentioned, there are a lot of vendors out here. Not every EMR is going to work for every organization. Vet each vendor very carefully, making sure you’ve got a clear set of use cases and things you’re trying to solve. Laurel talked about this at the beginning of her side too.

If you don’t know what you’re trying to solve, you’re not going to have a good time. It’s not going to work out. You’re going to spend a bunch of money, and it ultimately won’t turn into the kind of program you want it to. It’s all about engaging the people who can give you that technology insight, bringing your EMR into a conversation.

Make sure your partners are completely upfront and honest about what they can deliver and also what is integrated, because to make the sale, they will suggest things that aren’t there. Validate, call them and make sure you cover all your bases and that your EMR becomes the hub for all of the programs you want to bring into your ecosystem.

Gupta: Yes, sales never does that.

Pugliese: [laughs]

Gupta: What is the ROI? How do you measure the effectiveness?

Thomas: That’s my job every month— to measure the success of that but also look at how quality is tied to financial metrics. You’re not going to reach KPI if you do not have the quality, you just are not. The government is screaming that at us in every realm of health care. I look at where we are in terms of quality by scanning surveys, CAHPS and our HQRP.

How has it improved by getting patients? What is my media going to say? How has it improved the number of days they’re on service to improve the ROI? It also improves the quality, and when you improve the quality, you improve the metrics. We have publicly reportable things. Now it’s way delayed, but you still have publicly reportable measures that you are being compared to the other side.

I look at the surveys, the census, the hospice center and the palliative care conversions. All of those things help prove that this was a good route to take. You have to be able to show that because it looks intangible to some.

Gupta: Yes. I think patient engagement is truly becoming a non-negotiable when it comes to compassionate care. Thank you, Laurel. Thank you for sharing your experience and what Covenant is doing. Chris, as always, thank you for your expertise. Thank you all for being here this session.

This article is sponsored by MatrixCare. To learn more about how MatrixCare can help your organization implement its continuous improvement goals, visit MatrixCare.com.