Authors ‘design for value’ to improve patient and physician experience for referrals

A new paper in the June issue of New England Journal of Medicine Catalyst Innovations in Care Delivery describes how the University Hospitals (UH) system applied design-based thinking in a re-imagined process for referrals of patients from primary care physicians to psychiatrists in a value-based, high-reliability model.

“Referrals from primary care to specialty care represent a critical pathway in the patient journey to wellness. As we move toward value-based payment models, high-reliability referral pathways will be of increasing importance in achieving better outcomes at lower cost,” said Patrick Runnels, MD, Chief Medical Officer of Population Health and Behavioral Health at UH, Vice Chair of Psychiatry at Case Western Reserve University and lead author of the paper.

From data tracked during a one-year period from March 1, 2019, to March 1, 2020, the authors found satisfaction from patients, primary care physicians and psychiatrists. Patients strongly identified the rapid access as the biggest benefit (some patients were scheduled and seen within mere hours of the referral) and were often willing to travel significantly farther than if they had had to wait for several weeks.

Primary care providers reported the referral process was incredibly simple, which led to quick adoption and consistent use. Furthermore, they reported being highly satisfied with three salient features: (1) rapid access; (2) a communication process that was simple and informative without overburdening their clinic day; and (3) clear algorithms and instructions that were easy to follow.

The participating psychiatric providers—both residents and faculty attendings—reported being highly satisfied with the model. They enjoyed, more than they had expected, the opportunity to see a variety of cases, the time-limited course of treatment, and the partnership with primary care.

The authors used the new model as a demonstration of how to eliminate what they term “wicked problems.”

“Such widespread and visible defects in care require a wholesale reimagination of the entire experience for specialty referrals as opposed to a patchwork of minor improvements. However, a review of the literature turned up no instances in which design thinking was applied to the specialty referral process,” said Peter Pronovost. MD, Ph.D., Chief Quality and Transformation Officer at UH and senior author of the paper.

The consequences of wickedness are dire, said Dr. Pronovost. “Defects in health care cost more than $1.3 trillion annually. Current efforts at eliminating defects often focus on resolving the most pressing issues or helping the patients who have the most pressing needs. To truly eliminate defects and transform health care, however, requires us to design holistic, barrier-free care and avoid creating opportunities to introduce defects that we must later correct.”

“Health care systems must design exceptional health care experiences in order to be truly transformative. The combination of design thinking and value-based care creates a process we call ‘designing for value.’ “

The design framework involves five key phases: 1. Empathize with the users of a process; 2. Define the users’ needs, problems, and your own insights around them; 3. Ideate by challenging assumptions and generating ideas for innovative solutions; 4. Prototype rapidly to start creating solutions; 5. Test those solutions to illuminate how best to configure them.

They tested their design, at first, with 10, then later 25 primary care providers in partnership with primary care leadership who were open to sharing crew with psychiatry. By March 1, 2019, referrals increased to routinely fill at least 75 percent of the available slots. Among the findings during the reporting period (March 1, 2019 to March 1, 2020): No patient who wanted a referral within 7 days was unable to get an appointment within that time frame. A total of 676 referrals were made during the tracking period, resulting in 397 unique individuals seen, representing an average of 7.7 evaluations per week. The connection rate—from being referred to being scheduled to be seen in the clinic—was just under 60 percent. Care retention—defined as the percentage of individuals receiving psychiatric care from a system psychiatrist—increased from 61 percent to 65 percent.

Dr. Pronovost said, “Extrapolating from the data we collected, we calculated that we could expand this model to cover the entire population of primary care providers with less than 2.5 FTEs of psychiatric provider time, representing about 5 percent of our total psychiatric workforce as currently constructed. While this may change as our screening process improves, the ability to manage such a large population with such a minimal investment of time came as a huge relief to us, and we believe it will be exciting to other systems struggling with access issues.”

The authors also see the potential for this model expanding to other subspecialties. They write, “All specialties struggle with inefficient referral pathways that delay care and frustrate patients and providers alike. All specialties struggle with poor back-and-forth communication that increases the risk of errors. … Leveraging design thinking to place patients’ needs at the center of the referral process, as demonstrated by our work here, can translate well to other areas.”