A System Without Limits

Clinical and financial leaders from Houston Methodist share how digital care advancements are improving patient care, decreasing staff burdens, and maximizing margins in pursuit of their community-first mission.

Telehealth was the topic of the pandemic – or at least first in line after the treatment of COVID patients themselves – leading to a proliferation of new tools and strategies to reach patients outside the Provider’s four walls. It might surprise some readers to know that the roots of the practice go back much further, with an 1879 Lancet article proposing telephone conversations as a way to reduce unnecessary office visits; a 1925 cover of Science and Invention showing a doctor diagnosing a patient by radio; and the use of early videoconferencing by the Nebraska Psychiatric Institute as a way to provide individual and group telepsychiatry to patients in 1959. A more recent entry to those early trailblazers was none other than Houston Methodist, an 8-hospital academic system with its flagship hospital ranked by U.S. News & World Report as the number one hospital in Texas and the 15th best hospital in the nation. It’s there that Heather Chung, their Associate Chief Nursing Officer, helped establish Houston Methodist’s telepsychiatry program in 2015-2016.

“We had a gap in our physician coverage within behavioral health,” Chung explained, providing the impetus for what would be the start of their digital care delivery journey, “And this was before the introduction of things like FaceTime.” It took some searching, but she eventually found a telepsychiatry vendor they could use to establish a program. There was some hesitation internally when the idea was proposed – as Chung recalls, some leaders doubted the willingness of behavioral health patients to meet with physicians and discuss sensitive information virtually – but as luck would have it, they were very willing.

Expediting care

That initial success quickly evolved into greater telepsychiatry opportunities, as Chung became the Director of System Behavioral Health Services and identified a similar gap in their Emergency Departments (EDs). Psych patients would most often enter the system through that department, due in large part to a lack of behavioral health accessibility in the region. The lack of consistent coverage also meant that patients might be boarded for up to two weeks before they could receive the right care.

“Texas is 50th in the country for behavioral health,” explained Chung, “so that ED may be the first and only entry point for some patients to gain access.” By reaching psych patients with telepsychiatrists as they come in, Houston Methodist can initiate the first stages of their long-term treatment plans more quickly and effectively. “We can start them on therapy and medication in the here and now, when the iron’s hot,” clarified Chung, “and we’re also able to stabilize them, discharge them, and direct them to more appropriate outpatient resources, freeing up ED capacity.”

The early success and potential of the modelled to Chung pushing for its application to each ED in the system, which happened just in time. “By 2020, we had more than 5,900 patient visits leveraging telepsychiatry at our main campus, and that number increased by 40% in 2021 because of COVID’s toll. By spreading that success throughout the system,” continued Chung, “we’re also ensuring that patients have much-needed access to this support in our community hospital settings, which often have the least availability.” Additionally, Houston Methodist has staffed their EDs with social workers who can facilitate patient referrals into trusted community outpatient settings, helping focus care progression and starting patients down a cohesive continuum of care.

Achieving collaborative care

Their work with creating a cohesive patient experience led Chung and Houston Methodist to another virtual care resource. Examining their patient outcomes and stated barriers to care continuity indicated that there was a greater need for psychiatric access in their clinics. “Patients would leave the hospital, and we’d connect them in with our PO clinics,” explained Chung, “but those physicians weren’t fully prepared to continue the treatment plans we laid out. They didn’t have the right expertise.” This was concerning to Houston Methodist’s leadership, especially given that their data already showed 20% of patients visiting those offices, regardless of how they entered the system, had mental health problems going unaddressed.

Searching the market for solutions led her to the practice of virtual collaborative care: the use of virtual televisit tools to support the systematic treatment of behavioral health issues in the primary care setting by integrating care managers, consultant psychiatrists, and primary care physicians onto a single team. Rather than treating behavioral health as a series of acute symptoms or discrete episodes, collaborative care respects that these are chronic conditions, requiring regular contact and intervention with the patient’s primary care giver. By introducing virtual care and teleconsult capabilities, that physician can be better supported by care managers and mental health specialists, giving patients access to a full team of professionals through a single touchpoint.

Chung identified a clinic and physician to begin their pilot with, starting small so they could learn the ins and outs of how best the model could  be used. This also gave them an opportunity to better understand reimbursement pathways and billing, ensuring they had those key elements in place before scaling up. After two years of work in the midst of the pandemic, it was finally ready to hand over to their physician organization. Last year, they saw over 200 patients using the model, and it’s now established in 16 clinics. “We’ve also expanded our team of social workers accordingly,” added Chung, “and intend to keep growing the necessary support infrastructure so we can use this model to address the growing behavioral health needs of our patients.”

Caring for the whole patient

These tools dovetail into Houston Methodist’s work to better address Social Determinants of Health (SDoH) in their community. “Just 20% of the patient and their care plan success are reflected by their actual condition,” explained Chung, “while the other 80% is comprised of social determinants – their socioeconomic reality, their physical environment, their healthy lifestyle accessibility. We want to own that 80% once a patient comes through our doors, and we’re able to do that with these tools by maintaining care plan continuity once they leave.”

Chung demonstrated her point with a hypothetical: “Say a patient is diagnosed with congestive heart failure, which is a chronic condition. With our digital tools, we’re able to expand the continuum of care beyond their routine appointments, and have social workers reach out to explore how compliant they are with their care plan. Are they complaint with their diet expectations? How is that coming along? And if that disease state isn’t being managed properly, let’s set up a virtual home visit to therapeutically guide them back onto the right path.” Methodist has steadily curbed their 30-day readmission rate, and according to Chung, that’s in large part because they have the tools to wrap a blanket of care around complex, SDoH-susceptible patients.

Chung attributes much of their success to their use of motivational interviewing, an evidence based approach to behavioral change that uses collaborative, goal-oriented communication with a particular emphasis on the language of change. It’s designed to strengthen personal motivation for and commitment to individuals’ goals by exploring their deep-seated, personal reasons for change. Whether patients are speaking in person or virtually with staff in the ED, their PCP, or one of the behavioral health specialists included on their collaborative care team, Houston Methodist is able to guide the conversation with a healthy blend of good listening and compassionate advice towards individual empowerment. Motivational interviewing hinges on promoting, retaining, and respecting the autonomy of the interviewee, all of which are reinforced by addressing SDoH, providing self-service tools, and giving patients more frequent digital facetime with their caregivers.

Rising to our reality

Scott Ulrich, Vice President of Finance and Chief Financial Officer for Houston Methodist’s flagship facility, works closely with Chung, and argues that the benefits brought about by their virtual care delivery extend well beyond the obvious improvements to care quality. “First of all, they help us operationally by reducing the length of stay in the ED for behavioral health patients, expanding our capacity and improving throughput.” explained Ulrich, “Secondly, they help decrease our overall risk profile by ensuring patients have the right disposition opportunities, keeping those that may be a danger to themselves or others out of the general ED pool, and making sure patients have access to the complex, multi-level care oversight they need.”

“Heather’s work with both telepsych and virtual collaborative care,” Ulrich continued, “has virtually erased many of the logistical problems we used to face in the ED with behavioral health patients.”

Additionally, Ulrich believes these models better account for the constrained margins and contracted labor force every hospital is dealing with today. “Regardless of cost and how much you can afford to spend, the truth is there isn’t enough labor available in the market. The old model of healthcare was to simply hire more people and throw bodies at the problem, but we need to be more innovative and strategic. We need to reserve people for people dependent problems, and apply technology and automation to all other instances; it should be a force multiplier, maximizing how many patient encounters your now-smaller team can touch. Telepsychiatry and virtual collaborative care are prime examples,” continued Ulrich, “as they were born out of a need caused by labor shortages, and they’re allowing our pool of professionals to do more with less.”

Everybody wins

“Beyond labor, there’s also significant waste in healthcare that we can cut out by leveraging tech to its fullest, like the waste we see from duplicative orders, excessive care, or even the standards of care themselves.” It’s here that Ulrich began to open up about the plans Houston Methodist has to make reality what would have been regarded as science fiction 15 years ago. “We’re installing ambient intelligence in each of our rooms, which will provide a better quality of care to the patient and help us more accurately monitor their stay.” Ambient intelligence (AmI) refers to the use of electronics within environments that are sensitive and responsive to the presence of people, typically through a blend of human interfaces, the Internet of Things (IoT), pervasive computing, and AI. “This intelligence will not only review if patients are ambulating on schedule, but can connect the patient to a virtual nurse to answer any and all questions about their care on-demand.”

This will help remove some of the stress and burden placed on overworked nursing teams by streamlining tasks like discharge instructions and admission interviews, bringing about several improvements simultaneously. It will help reduce nursing burnout, increasing capacity and satisfaction for nurses; those same professionals will also experience less absenteeism, better engagement, and a lower risk of the kinds of mental health challenges that drive up benefits spend. Those factors in tandem will help increase staff retention, avoiding the high costs associated with sourcing and onboarding replacements, as well as the costs associated with using premium labor as a stopgap.

Patients, and by extension Houston Methodist’s bottom line, will also benefit from more continually observant care and more integrous tracking of ambulation and care plan requirements. Houston Methodist will be able to more easily track caregiver hand hygiene; whether or not rounding occurred when it was supposed to; whether pain control was adequately delivered; and all the other elements that go into patient safety and comfort. “We originally wondered if patients would interact well with virtual nurses at the bedside, and were pleasantly surprised to see just how satisfied they were. That telenurse is spending more time with them than our staff ever could, making sure that patients and their families have every possible question answered, and every line of their discharge summary explained in detail.”

“We won’t be eliminating staff,” Ulrich clarified, preempting the typical fear that increased automation may replace human staff members, “but rather, we’ll be making sure that our teams can focus on the tasks that bring the most value to both the patient experience and our operations. We came into this automation journey with the expectation that we’d squeeze 30% of expenses out through things like reduced labor and supply needs, but we found that was too stringent of a test. The real value we’re seeing is that these programs address the reality that staff are at their breaking point. There’s not one more thing we can ask of them, and these programs will help make their lives easier while ensuring a high level of patient care.”

Margin is mission

Much like patients benefiting from a cohesive, integrated virtual care delivery team, Houston Methodist benefits from having clinical and financial leaders working in unison. “It’s critical that you understand the reimbursement aspects of this,” cautioned Chung. “certain investments should be made because they’re the right thing to do, but you need to be mindful.” Ulrich agreed, adding that “Even if your primary target isn’t financial ROI and is instead something like patient experience improvements, you can spend a lot of money needlessly if you don’t keep a close eye on the finances.”

“We’re very fortunate to work in an institution like Houston Methodist,” Ulrich continued, “because there’s a common understanding that no margin means no mission. It’s not a profit motive, it’s a community motive, and if we don’t have the right funds available, we’ve failed our community. The more we can reduce our costs and expand care access through digital tools, the more we can close critical gaps in our community, and the more aligned we become with our core mission.”