Shifting Gears the Day Florida’s Economy Reopened
Editor’s Note: This article is part of Oliver Wyman's ongoing series about the evolving novel coronavirus (COVID-19) pandemic.
The US state of Florida recently surpassed 650,000 confirmed COVID-19 cases. To learn more about the specific challenges healthcare leaders caring for patients in Florida are facing, Oliver Wyman interviewed Bill Lamoreaux, Chief Executive Officer of IMC Health Medical Centers, a population health-based primary care group in South Florida. Their patient demographic – with over 10,000 Medicare and 22,000 Medicaid at risk lives and about 8,000 Affordable Care Act lives – is primarily Hispanic, African American, and Caribbean American.
Oliver Wyman: COVID-19 is worrying and confusing for many. What was IMC Health’s initial game plan when South Florida became a hotspot for confirmed cases?
Bill: South Florida was initially a blip on the radar regarding pandemic media coverage. But that changed quickly between March and April. Once the government announced “stay in place” requirements, fear elevated substantially. That's when our patients began to worry and seek our advice as their primary care provider on what to do.
Our initial goal was straightforward: Get as many people out as fast as you can and find alternate ways to service them. We never closed but we only took care of about 10 percent of our patient population onsite through the crisis. This is because this cohort of patients has many comorbidities and required a trained eye.
Within three weeks, we were back to our normal visit volume. The volume was normal, but we had adjusted the mode of care delivery - now, ninety percent of visits were done telephonically or via telemedicine.
Oliver Wyman: What were some early realizations as you navigated the pandemic?
Bill: We realized early that our staff who performed site-specific roles when we were a brick and mortar center was a key group. So we thought about how people can perform different functions. We repurposed about 65 positions – roughly 12 percent of our workforce – to expand our original outreach capabilities. Those original outreach calls were to ensure medication adherence and assist with refills. In those calls, we immediately heard about patient fears such as loneliness, support for activities of daily living, and concern about access to food and nutrition.
Since mid-April, those 65 staff members have been conducting two main tasks. The first is making companionship phone calls where we use preset times with patients to discuss their medical needs and how they’re staying active, keeping their mind active, and what day-to-day activities we can help them with. On average, we are talking to over 4,000 patients each week.
Often, a call that used to take a minute or two was now taking five to seven minutes. Patients wanted to stay on the line to talk to somebody, get advice, and express their fears. We knew we needed to address companionship and loneliness.
The second activity is providing food and nutritional support. We established a catering supply chain that provides us hot, fresh food daily. Our staff fills individual portions and we then deliver those portions to the patient’s homes. Since late March, we have been delivering over 1,200 meals daily.
Oliver Wyman: It sounds like you’ve taken a proactive outreach approach. What was needed to transition towards those types of calls?
Bill: We had a lot of the core capability in place – for example, deep pre-existing relationships with our members. With staff, we trained around the new companionship model and on empathy. We didn't want to disenfranchise the patient because the companion had to move on to the next call, so we didn’t place any limits on how long calls needed to be. We encouraged people to keep conversations going so patients felt heard and valued.
We repurposed part of our electronic medical record to capture notes, report findings, and facilitate feedback loops. So from a systemic point of view, we could collect learnings, and then adjust our outreach scripts, other outreach programs, and the support we were sending to their homes. We trained staff on the system once reconfigured to capture that information. And we set up weekly debriefs with small groups so we weren’t just relying on the system to give us answers but could hear directly from staff about at-risk patients. We’ve also used those outreach resources to convert onsite visits to telephonic visits to telemedicine visits.
Oliver Wyman: What did you learn from these feedback loops?
Bill: As mentioned earlier, loneliness and nutritional needs were the first things we heard about. As time went on and the newsreels intensified, fear and anxiety were really high. This manifested in patients requesting masks. This was when masks were hard to come by. We found a supplier willing to work with us to get all members a mask in that timeframe. And we sent them instructions about using the mask. There’s obviously an ongoing debate around masks, but just the fact that we provided them gave people peace of mind. Now, we’re doing the same with hand sanitizers.
Oliver Wyman: What do you wish you could be doing more of?
Bill: Our average Medicare patient is 74 years old. I wish we could help people more with their daily living activities. We've been trying to address the basics, but there are a lot of unique needs.
My biggest wish is we were better connected. Our patient population is largely unconnected digitally. We do a lot via phone and mail. A minority of our patients have email addresses or have Internet. As COVID-19 hit and then rapidly progressed, we were posting on social media and sending timely routine letters to patients. But I sure wish I had more emails and cell numbers so we could have provided more timely and frequent communications.
As we're trying to convert to video visits, one of the slowest parts of the uptake is giving instructions about getting an email address, finding an Internet provider, or using their phone or mobile device to connect with us.
Connected devices can be a big help, although it’s much harder to introduce those things entirely remotely than if they were in our office where we could have shown them how to use a wireless blood pressure cuff, for example.
Oliver Wyman: If online communication increased for your patients, what’s a key advantage?
Bill: You could send people a cognitive puzzle of the day or offer psychosocial support from professional social service workers acting as navigators. There are emerging companies in that space we could partner with, but patients must be connected first and foremost.
That could be an expensive venture. As a medical group, we're not a technology provider. Providing that technology is a big hurdle.
Oliver Wyman: Will a shift to virtual become a permanent shift with your population? What’s your staff’s general perception of this?
Bill: A year or two ago, many patients would have expressed resistance about a telephonic or telemedicine visit. But with COVID-19, everybody put their ear to the ground. Patients understood they shouldn't leave home. They were grateful just to be able to talk to their clinicians because they had been hearing from friends that other practices had completely shut down. And the clinicians – making most of these phone calls from their homes – felt protected as a result.
As we move into telemedicine and the video side of care, clinicians like it. They say they still want to see some patients with multiple comorbidities routinely face-to-face, but that frequency varies by patient.
As a population health company, we had explicit expectations about how frequently we would bring patients in based upon their comorbid conditions. We worked hard to get them in at the frequency we modeled out. Clinicians are realizing some percentage of that can be done via video versus transporting a patient into a center.
"The 'perfect' plan we thought would work almost immediately had to be tossed aside."
Oliver Wyman: As some economies begin their re-opening efforts, what are you learning?
Bill: We thought as the economy opened up, we would also open up our doors and bring in another 10 or 15 percent of the population – those whose primary care provider thought they needed to see face-to-face. We went through every primary care physician's panel and hand-selected patients we wanted to bring in.
Then, on the day they announced South Florida’s economy had opened, we had 200 people walking in daily to our facilities. They weren't necessarily walking in for an appointment but were walking in to say, “I heard the economy's open. I want to set up an appointment in the next couple of weeks,” or “I want to make sure I have a referral to my specialist.”
This was driven by the government’s messages, but also by the marketing efforts of the specialist, hospital, and ancillary community to re-stimulate their businesses.
We've had to adapt our facilities to accommodate walk-in volume – something we did not anticipate. In short, the “perfect” plan we thought would work almost immediately had to be tossed aside and, a plan B implemented where we’d instead see as many patients as possible within a facility while maintaining a COVID-19 responsible operation.
Oliver Wyman: How did you accommodate this sudden influx?
Bill: We re-purposed other space to expand the waiting room so people could spread apart. We've spread out our appointments and we made appointments longer so we know there's going to be plenty of time to get that patient out before the next patient comes in. We've engineered the process so there's as little overlap in the building as possible at any point in time. For some of our buildings that can't take the degree of walk-in volume they're getting, we've asked people to stay in their car or set up some chairs on the sidewalk, so we remained COVID-19-responsible. We had to shift gears the very first day the economy opened.
Oliver Wyman: What advice would you give to other provider organizations on this reopening or continued partial opening journey?
Bill: In my years in healthcare, I've seen too many groups say they do population health, but the activity is superficial – just a front desk person making a few calls.
Develop competency to do the outreach and have dedicated staff to do that. We’re wrestling with a balance between economic recovery and doing the right thing for a public health point of view. We can't rely on snail mail and outbound or inbound phone calls any longer. If there’s any beauty to be had in a pandemic, it’s the mandate to change and be nimble.