Note: Stanford Medicine's ClickWell Care project was named a semifinalist in the 2016 Healthcare Informatics Innovator Awards Program. Short descriptions of the projects of all of the semifinalists in this year’s program can be seen here.
At the Calif.-based Stanford Medicine, ClickWell Care (CWC), a telemedicine primary care delivery model, was developed and implemented to better address the needs of Stanford Medicine’s current population of accountable care organization (ACO) patients. Indeed, many low and rising-risk patients were not engaging in traditional primary care, choosing emergency services and urgent care instead for acute issues, and not engaging in prevention and health maintenance.
As such, ClickWell Care is a team-based primary care medical home model staffed by physicians, wellness coaches, and medical assistants. According to Sumbul Ahmad Desai, M.D., vice chair of strategy and innovation in the department of medicine at Stanford Medicine, a key to the program is providing end-to-end healthcare, one in which the primary care piece compliments the wellness coaching piece, which is completely virtual. “With many telemedicine programs right now, you see they are not always associated with health systems,” Desai says. “We are trying to do primary care, so when you pick that physician we try to keep you with that same person as much as possible. We try to keep you as scheduled as possible,” she says.
According to Stanford officials, ClickWell Care was created to provide easy and convenient on-demand access to care, while simultaneously allowing patients to engage in traditional primary care relationships, all done through virtual modalities, including email, phone, and videoconferencing. “We are trying to allow patients drive how and when they want to see us. We have increased access hours as well, as we’re open seven days a week, and the patient can choose how he or she wants to be seen,” Desai says. Indeed, the care team provides integrated primary care and wellness services, including preventive, urgent, and chronic care services through such virtual modalities, including video and phone visits and brick-and-mortar interactions when clinically appropriate. Extended office hours on weekdays from 7 a.m. to 9 p.m. and weekend days from 9 a.m. to 5 p.m. allow for same-day primary and urgent care visits.
What’s more, Desai says that the connection from the wellness coaching to healthcare providers is “a key differentiator to any wellness program out there.” She notes, “We are trying to make being healthy easier. So rather than say you need to lose five pounds and send the patient home, we want to come up with a wellness plan. We also partner with organizations for medication delivery to patients and specific food plans for patients on diets. This is all part of end-to-end healthcare,” she says.
The genesis around CWC was built around the ACO populations, so the program was focused most on preventative care, notes Desai. “We have found that works very well. We do have other vehicles too, but we find that in general, the rising risk—and what we define as rising risk to semi-chronic conditions, such as one or two conditions—is served well here. When you’re a little sicker and need more in-person touch points, that’s where we will hand off. We tend to take patients who are comfortable using the technology and are good in person with virtual touch points,” she says.
Lauren Cheung, M.D., medical director, strategic innovations, Stanford Medicine, notes that making sure you have a specific target population when you do something new is an important aspect. “We had a very specific need that we were trying to meet, and we designed a model around that,” she says. “We knew that the younger population of patients wasn’t engaged in primary care the way they should be. We looked at the reasons for why they were having difficulty getting care, what would they need to get overall healthcare experience? The young rising risk population has been key to making this work.”
Specifically, with the ACO at Stanford being started in 2014, physician leaders found there was a high number of younger population patients who didn’t select primary care physicians, but were instead using urgent care centers and the ER more. “So we ran focus groups to figure out what we needed, and they range from ‘It’s not easy to see my doctor’ to ‘I don’t want to drive that far’, and it goes across spectrum of behavioral and life circumstances,” Cheung says.
The CWC program started with four providers with two others being since added on, though most of them are not full-time. One of the providers who works with the program four days week is Tiffany Leung, M.D., clinical assistant professor, clinical instructor, Stanford Medicine, who says that the main emphasis was on the ease of access to care, and going with the method that the patients prefer. “What we do is mesh those components together, the video, phone, and in-person visits, and patients can schedule those visits during clinic areas. That has worked well,” she says. For example, Leung says she might see a patient early in the day virtually about a particular complaint, and if she can resolve it right away, then great, but if not, she can arrange for him or her to come in for an in-person exam. Unlike some telemedicine programs, in-person visits are not required to be prerequisites to virtual ones.
Stanford physician leaders point to some statistics and results that the CWC program has garnered in the first 10 months of implementation, such as 2,391 physician visits, of which 71 percent of new visits were in-person to establish the patient-physician relationship. Among new visits, about 6 percent were video visits and 23 percent were phone visits. However, among return visits, only 39 percent were in-person, with 18 percent video visits and 43 percent phone visits.
What’s more, wellness coaching has engaged more than 220 unique patients empowering patients to achieve popular health goals, including weight management, stress reduction, nutrition education, activity guidance, and hyperlipidemia. Nine months into ClickWell’s implementation, more than 42 percent of patients who met with a wellness coach had met at least one of their health goals, and among patients with a weight loss goal, the average weight lost is five pounds over three-four weeks among 108 patients. In total, more than 430 pounds had been lost by patients who engaged in wellness coaching.
Further, operational efficiencies included reduced labor and supply costs and higher physician virtual visit efficiency compared to in-person visits. Labor and supply costs were reduced to two-thirds of the typical costs of a brick-and-mortar clinical practice. The average face-to-face time for a video or phone visit for a new patient is 24 minutes and 21 minutes, respectively. By comparison, the average face-to-face time for an in-person visit for a new patient is 31 minutes, while for all return visits of any modality, the average time is approximately seven minutes shorter than new patient visits, according to Stanford officials.
All of the physician leaders at CWC note that patients have identified ease of access to the clinic, clinic response time to patient needs, and positive experiences with wellness coaching as desirable features. “There are plenty of patients in our population whose initial contact are virtual,” Leung says. “They might have one need which is something we can manage by video or phone. Then at their convenience, they can come in to continue to build that relationship.”