UH Authors 'Design for Value' to Improve Patient and Physician Experience for Referrals

CLEVELAND – 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, PhD, FCCM, 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.”