Aligning provider buy-in, leadership priorities, and patient-centered strategies is key to closing the ACO engagement gap. We talk with Illinois Rural Community Care Organization (IRCCO) to learn how thoughtful provider engagement, leadership support, and innovative partnerships can close the engagement gap and transform ACO success!
In this episode of the Outcomes Rocket Podcast, hosted by Saul Marquez, Dr. Lauren Fore, Chief Medical Officer at IRCCO, shares how provider engagement is key to motivating patients to follow through with preventive care and wellness visits. Todd Searls, Executive Director of IRCCO ACO, underscores the role of leadership in setting priorities, addressing burnout, and supporting care teams to sustain patient engagement. Kathryn Anderton, Vice President of Clinical Services at ThoroughCare, highlights the importance of care management, motivational interviewing, and trust-building through consistent monthly touchpoints. Together, they discuss the unique challenges of rural communities, the power of partnerships, and the value of combining digital tools with human connection for sustainable outcomes.
About the participants
Dr. Lauren Fore is a family practice physician who has worked in critical access hospitals for her entire career. She works in the clinical setting as a primary care physician and also works with the IRCCO to help facilitate provider engagement.
Todd Searls began working with accountable care organizations in 2018 and has worked in the rural critical access hospital space for many years.
Kathryn Anderton's background is in nursing and care management. At ThoroughCare, her clinical team helps empower clinicians to establish care management programs, streamline operations, and improve patient outcomes.
Key podcast highlights:
Why do so many ACOs struggle to keep patients engaged long term?
Lauren: I like to really dive back to our provider engagement. I think if we think about our ACO initiatives and even a lot of the metrics that CMS is putting out there, they are very much provider driven, whether that's the provider putting in a specific order or having a certain conversation with our patients or documenting something appropriately. We need our providers to really buy into these processes, to help us then have those conversations with patients and to engage them. I've had different opportunities to talk with the clinic administrators or even with schedulers, and sometimes they have difficulty having the patients buy in to these different initiatives if they aren't using the provider's leverage. So if they're calling and saying, "Hey, you need this Medicare wellness visit," and they're like, "Yeah, I'm okay." But if we're having them call with a certain script, saying "Your provider, Doctor Fore, they want you to schedule this Medicare wellness," or I'm sitting and talking with the patient and I say, "Oh, I see your due for your Medicare wellness. Let's get that scheduled." We're going to have a lot more buy in and engagement from our patients when our providers are also engaged.
Todd: And I would add to that from the executive side. So it's also been very easy, I think, on the provider side to wonder if after a year or 2 or 3 of doing that, is this still a priority? So on the executive side of the fence, the C-suite really needs to be proactive, I think. We lose a lot of patient engagement because we do in health care tend to put out there all these burning fires. We know that there's going to be changes in Medicaid and things like that coming down, and so all those conversations happen at one time. I really like to look to the executive suite to outline what are the priorities. How are we going to get paid under these value based care programs that we're holding our providers, their care teams, and even the patients accountable for going and getting their mammograms and things like that. So I love it. If the providers are engaged with that sort of support, then they need to have a partner from the C-suite who then is willing to champion, and also being willing to be proactive about identifying that providers are burned out, that every provider wants to take care of every patient that they've been assigned. I think that's just inherent in the providers who I work with, Dr. Fore especially, and all of her colleagues. But at the end of the day, are we really getting to 100% of those patients? And so we tend to lose engagement, I think, because the highest risk, highest priority patients may bubble to the top like they should, but we can't lose sight of those who are starting to improve and perhaps fall down the call list just due to the number of staff we have, the hours in the day, the number of exam rooms. So again, I think the C-suite has a big hand in making sure that things are prioritized right, but then also ensuring that patients remain engaged in these programs through education of the care teams and everybody else.
Kathryn: I would also say I really appreciate that we're leading with the provider and the leadership buy in because oftentimes if that organization doesn't have that already established and clearly defined, then when it gets down to the care manager, they're not going to be able to really express that value to the patient with that kind of confidence to then have the patient want to opt in to do an elective program. We know it's beneficial, but that alone doesn't create patients' motivation for them to participate in the program. You really have to have their own personal buy in. So I really loved hearing that we're going to strengthen that provider and then the leadership and then roll it out to the patients, because I think that's how you end up seeing positive results as well.
What makes sustained engagement in rural communities uniquely hard and how have you worked around it?
Todd: The biggest thing is that especially when rural facilities join an Accountable Care Organization, there's a lot of pressure, right? Because there's a lot of money that's on the table to get back to them, which they desperately need. And so there's an expectation out of the gate that they have to hit every goal immediately. But success in these sort of programs, especially when you're engaging a very rural community who has been very reactionary to their health in the past, right. "I'm only going to come in after I'm coughing up blood? Prior to that. I'm fine. But after that, all right, maybe I'll go to the doctor," sort of thing. Now we have this shift to proactive care. Those metrics are not going to hit 100% overnight. So I think the biggest thing in terms of sustaining care is that understand that every single care community is slightly different. We have some that are suburban rural, they've got access to staff because people want to live on an acreage outside of the big city in the country. We've got traditional rural, maybe around college town, small college towns and things like that. But then we have the frontier rule, who doesn't have the staff, they operate in the red or close to the red every single year. But that's where the breadbasket is, right? That's where the farming, agriculture, ranching and things like that are occurring, and they are the number one employer in the community, but it doesn't mean that that community is healthcare educated, right? So we have to, as times change, I think groups like ACOs have to take it upon themselves to be the educators of those staff and really get them trained and have them understand all the requirements that it takes to sustain these initiatives. Partners are great because again, the extension of what we can't do in rural, we have to outsource. But it doesn't even have to be outside of the community. I think we talk about pharmacies, we talk about community health workers, we talk about third party vendors who are able to come in and truly drive, under value-based care especially, truly drive patients to get the care they need when they need it. But without partners to extend the reach of this, value-based care fails. I remember back in the day when I was director at a regional extension center, and even back then we teamed up with pharmacies, team up, pressure down, I think it was, so that the clinics partnered with the pharmacists so the pharmacists could help deliver the education on blood pressure medication. And that's not going away. Blood pressure is still a huge thing, hypertension strokes is still huge, and without having that extender, as it were, into the clinic space, it's very difficult to drive any sort of positive outcomes, I think.
Kathryn: I always think about that phrase of it takes a village, and obviously that's pertaining to child or raising children, but I think that goes to managing health. It takes a village. You need the provider, you need the pharmacist to then stop and provide that medication, education, you need a care management team or remote patient monitoring. You need all of these tools to really help the patient be successful. It does take a village. It's hard.
Todd: And honestly, our vendors and our partners, they are experts in their own domain. So I can read 3,000 pages of federal legislation and call myself an expert every single year in terms of the regulatory response, but I'm not an expert in the new tech that perhaps Medicare age patients are able to use and want to use, right? It's convenient for them and the messaging to make that work, so a lot of times you are really trusting those partners to be an extended expert and educator for our clinical teams.
Lauren: One person can't do all of those things, and so like Kathryn mentioned, that's good collaborative care, that's good patient care when everyone is working together with their different expertise to help take care of the whole person. So I think you have to have those resources where everyone's working together. People deserve that.
What makes monthly touchpoints and check-ins meaningful instead of just another task that physicians have to do?
Kathryn: I think so often clinicians, especially care managers or nurses from a hospital setting, you're used to this work list that you check this, off to the next, check this. And I think what's most important about these monthly touchpoints is relationship building. For any change to occur, you need to feel right about it, it need to feel good. So when you can use those opportunities to engage with the patient, have a conversation about their dog and you know, what's happening in the neighborhood, because all of those things are what's going to make the patient answer your call the next month and want to continue to build that rapport and change those behaviors you're wanting to see. So I think it's so important for clinicians to practice things like motivational interviewing, how to conversate, go back to that bedside nursing days where you need to have that rapport. The outcomes will end up speaking for themselves with that.
What's one engagement practice IRCCO's done successfully across all members?
Todd: I think anytime that you can engage with your community as a health care institution, it's very successful. So whether it's in person at, say, a health fair, or even a community celebration that occurs, the 50th anniversary of the founding of the town or things like that, where there's a presence to remind people that we're community members too. We want the best care for ourselves, for our kids, for our grandparents, parents who live in the same town. And I think taking that to the next level, right, the modern times, even though it's been around now for dozens of years, is the internet and social media. We have providers who are going on to Facebook and talking about the importance of Annual Wellness Visits. And in small towns, Facebook's still very big. I know that the TikTok generation are younger. And I think that it speaks to the generations of technology and things, but that's where the population that you're trying to reach lives. Then I think our members are doing a good job and meeting them where they live, both first in person and then also virtually where they go and they share their stories and the pictures about their kids and things like that, or where they talk about their conditions. We do have the HIPAA, but it's amazing to me how many times and how much we're very free when we talk with friends and family about the health care crisises that are going on inside of our families. And if you're in that platform and you just happen to see somebody said something about breast cancer awareness from the local hospital, then you're going to probably click on it and you're going to look at the videos that they posted and the documents. So I think that's one of the key success of our members in rural America, is making sure the community knows that we are members of the community, and that we'll meet you where you are in order to get the message across and try to make it as convenient as possible for you to get in and see us.
What do you think about social media and using it to engage with communities?
Lauren: I think, like Todd mentioned, meeting people where they are. They're on social media. That's where their getting a bulk of their information these days, so I think we need to be present there. They deserve to get factual information from a trusted source. And why can't that be their local health care organization? So I think there's definitely a place for us to be there and I think that patients kind of need us to be there, too.
Todd: Why doesn't the answer come from the local hospital as opposed to some anonymous website somewhere with a testimonial on something that may or may not be verified? So I think that's so important what you said, Doctor Fore.
How do digital tools and nudges help in maintaining a personal, human connection with patients?
Lauren: I think there's definitely a place for digital tools and digital nudges for both providers and for patients. So for me as a provider, in preparing to see a patient, a lot of times and doing a lot of like data extraction, pulling things out of charts and digging around in there, but if there's a digital tool, or my EMR, if it could work for me and give me those digital tools and nudges to facilitate some of those conversations without me having to put in all that legwork, I mean, I'm all for that. And then as far as for patients, I wouldn't want it to take the place of that human connection and those conversations that we're having face-to-face. But I think we can all agree that we need a reminder sometimes to do things, especially things we don't want to do, so I think there's a place for that. When I see a patient, maybe like their mammogram was due last month or something, we'll have a conversation so we'll get it order and they'll get it done. But what if that appointment wasn't for six months down the road? Now that's almost a delay in care. And that's where I think the digital tools and nudges can be really useful, is helping to facilitate that patient's care in between those human interactions, those human face-to-face appointments.
Kathryn: I am so grateful, Doctor Fore, you're reading my mind. We can't replace one for the other. This is two necessary things because maybe one time you're talking with a patient providing that education face-to-face, but then you have to reiterate that information to her daughter, who's the primary caregiver, and she's got a full-time job, so you should just send her a text. There's a lot of different ways that we can use these digital tools to work for us. One, having integrations so it is readily available because you can't be jumping between several different systems as you're also trying to have a conversation with the patient. So that's where having technology work for you, I think is best practice too. And then realizing that nurses, care managers, are great at triaging in life, so some things we can have more of a hands-off approach, but knowing when to have that face-to-face or phone-to-phone interaction is so important. You can never replace that in my experience.
How has care management software, like ThoroughCare, help rollout programs and overcome tech hurdles?
Todd: I can tell you no hospital, be they rural or otherwise, wants to manage a new app on a patient's phone themselves. So having a partner who understands not only the technology, but that is part of their service is to troubleshoot that, to get connected with them, make sure that they can ask questions back and forth, and you've got almost that extra line of support. So from the tech hurdle side of things, I used to be an IT director. The first thing I want to know is this going to be put on my staff to support the communication means, the apps today, or is that something that my partner is going to help with? So I think partners who do that, like ThoroughCare, who have a whole care management suite around them in which they call in and they talk to the patient, they document it, they may send them reminders if they're using some sort of chat app or things like that. That is so important to have because then I, as the executive director or as a CEO in a hospital, I don't have to follow up on that. I know it's being done because they're our partner and they're taking care of it. I also think that it's not just the technological hurdle, it's really the education hurdle. In terms of if I'm partnering with a vendor for my rural facilities, one of the biggest things that I want to be sure of is that that vendor partner of mine is a subject matter expert, like I alluded to earlier. And that the care managers, as Kathryn, you had mentioned, that the motivational interviewing, trying to get to the why behind patients have failed to meet their health care goals in the past, being able to have those conversations. Sometimes staff in rural areas just haven't received that training and it's a lot of triage training, reactionary care, so I truly believe that the vendors truly are trusted partners when it comes to delivering that matter. I would say, lastly, unifying all the conversations, ensuring that's what's happening on the vendor partner side is flowing in some way, shape or form into the practice. The one thing that providers are absolutely correct in wanting to ensure never happens, in my opinion, is that they lose track of all of the care that's occurring outside of the four walls of their clinic. They want a true partner who's going to report back in. Kathryn, as you said, right, they're talking to the patients about their dogs, their family, but then suddenly they hear that they just lost their sister, they just lost their brother in law, their daughter's going through a health care crisis. Well, is this now a person who's going into depression because life has become so overwhelming and they will then flag it to the clinic staff. And so I truly think that all of that extra attention that's being paid to the patient is a benefit if that partner can again support you on both the technical side, the follow up side, the documentation piece, all of that makes implementing a solution like this just so much easier. Basically sign on the bottom line, you true up the patient list, the patients who need to be seen, and that a lot of times is partnership as well, in terms of what's best practice, what have other groups done, care cohorts, things like that, that small practices who are inexperienced in these value-based care programs may not know who to prioritize. And so I do think that , again, it takes a village, and as Doctor Fore said, there's just no way one person or one pod or one team can do everything that needs to be done to deliver exceptional health care. So yeah, I definitely think care management vendors have stepped into a very big need, especially in rural America, where there just isn't enough people and they can't afford the technology if they wanted to implement it themselves outright.
Why is encouraging multi-program adoption across providers, beyond just Chronic Care Management (CCM), important?
Lauren: It just comes again down to patient-centered care. So we're doing what our patients need and we're approaching them each as an individual person and kind of adjusting what kind of programs would benefit that person the most. So I think, again, back to like the collaboration between the different groups within your organization working together to help take the best care of those patients.
Kathryn: I always look at it almost as these programs all serve a purpose. You have a tool available and considering the holistic patient care we want, you can use a tool for each aspect of this. So you can have Chronic Care Management where you're focusing on the education components, that they understand how to manage their conditions effectively. You have Remote Patient Monitoring to make sure the interventions you're delivering are actually landing and impacting that care. And then you have Transitional Care Management because even when you do all of the things right, sometimes they still go to the hospital, so we want to make sure patients have that support. And then Behavioral Health, BHI, because change is hard. And you want to check in and make sure people can handle that appropriately and are able to navigate the challenges that come with that. So when you can leverage these programs, I think it really does create this whole big patient picture that really enables the care team to effectively manage patient care.
Todd: I'm glad you both started, because then I have to put on my executive director finance hat, right, that says at the end of the day, it's all about the money. And if you're only focused on one thing, just like Kathryn you mentioned, Transitional Care may be missed, right? Because you discharged a patient to a skilled nursing facility, but a lot of times those skilled nursing facilities aren't going to call you back when that patient gets discharged to the home or anything else, and you don't even know it. And then suddenly an issue happens because what they were discharged with from that care facility was bad advice or no advice or something else. And so having someone there who can follow up and recommend the appropriateness of care. Chronic Care Management, where we call patients monthly, doesn't have to be forever. It's the idea that you're checking in with them after an episode, say, sepsis. And we know that after a septic episode, fortunately, if the patient survives, they're still probably going to have some unfortunate health care issues to deal with. And we get them through that and then you graduate from that, but that doesn't mean you're done, because you may want to take them down from Chronic Care Management to the Remote Patient Monitoring for one condition. And so the billing changes on the back end, but if all you're doing is putting one tool in your toolkit, then you're missing out on a ton of good healthcare for the patient. But in my experience, also, you're missing out on revenue for your clinics, and you're also missing out on maximizing the shared savings because it's probably going to lead to a downstream readmission, a new hospitalization, a visit to a specialist instead of the PCP. So to me, that whole suite of care management has to be, if your team can't deliver it, then you need a partner who can help you step in and do that. Otherwise, again, you're leaving money on the table and the patient's just not getting the care that they need.
Saul: That's really great to hear the different perspectives on that from Doctor Fore's listen, understand, and deliver that care that the patient needs most. To the full program picture that Kathryn offered up. And then finally threading the needle through all of the necessary financials to make sure it all makes sense is definitely critical for success.
What advice would you give to ACOs wanting to close this engagement gap?
Lauren: I'm going to fall back on our provider engagement. I'm very passionate about engaging our providers, whether that's within their own organizations or within our ACOs. But I think if we take the time to really educate our providers on what our ACOs are, what they're doing, and then the why behind that, I think that will carry over to our patients. Our providers are talking to patients every day and we will see them start to facilitate some of those conversations. And then we'll get more patient engagement too.
Todd: So I think you can't say that you've always done it this way before, right? You have to be willing to change your processes. And that's very difficult. I think it's very difficult for providers who have been there for 30 years, the same way it's difficult for executives who have been managing their hospitals for 30 years. Value-based care is a new paradigm. And so out of the gate, the very first thing I think you should be thinking about is kind of doing an organizational assessment off attitudes towards change and really figuring out where you're going to need more support to get people to move in this new direction. I think that goes back to what Doctor Fore said, which is communication. You have to sit down and explain this to everybody that you're not doing it just to check a box, just to avoid a financial penalty, this is truly better care for the patients, but it may come with some pain while you work through those things. But here's what I'm going to do as an executive to support those pain points. If you fail to have that conversation before you even begin, you're ten steps behind your peers who did have that conversation.
Kathryn: One piece of advice I would give to ACOs to close this engagement gap is to really invest in the care managers and their ability to communicate. That soft skill of motivational interviewing really goes a long way to strengthen that engagement long term, and to have patients coming back for other things, too. And so I really I see a lot of patients fall off of that care management program because that engagement wasn't there, they're not feeling super cared for or understood, or maybe they're feeling like they're being talked to or talked at. So, I would really, really strengthen that motivational interviewing skill.
Saul: I really appreciate everybody leaving us with your ideas and recommendations on how to increase success with how this engagement gap could be closed. It's going to take more than tools. There's nudges there strategy. But ultimately I think what you guys shared today will help us get closer to that.
