Fierce Q&A: Outpatient clinics help Lee Memorial curb ED crowding

Earlier this year, Florida's Lee Memorial established clinics to provide primary care at a reduced or free price to patients to ease emergency department overcrowding.

With ED overcrowding growing twice as fast as visits, FierceHealthcare caught up with Dr. Scott Nygaard (pictured), Lee Memorial's Chief Medical Officer for Physician Services, to see whether those clinics have relieved the pressure on strained EDs since opening.

The early results are in, and so far, the clinics have helped the system achieve its main objectives of providing care at the right level in the outpatient setting and offering patients with a regular physician to provide that care, Nygaard said.

The clinics also have hit the marks for allowing Lee Memorial to give the most cost-effective care, at the right place, which preferably was in the outpatient setting. Nygaard noted that simply offering another location to seek care has not only reduced ED utilization but also the admission rate because a visit to the ED is ultimately a hospital admission.

FierceHealthcare: How have the new clinics impacted day-to-day care?

Scott Nygaard: It's a tough population because the first thing we ran into in the community was "Can we trust you to be here?" People have come and gone, and we're trying to say, "We're really here for the long-haul." So like any relationship with a caregiver, it starts with trying to build trust.

We're now going to increase the hours of operations Monday through Thursday from 8 a.m. to 7 p.m. and then Fridays until 5 p.m. The expansion of services in the next month says, "We want to be here to meet your needs."

FH: What barriers did Lee Memorial face when implementing the clinics? How did you overcome those?

SN: The first barrier was people wondered "would anyone be affected, would people actually establish care, could we even change behavior of the patients that sought care." There was a lot of stereotyping of the population, saying "they'll just continue to seek care at the emergency room." Overcoming that involved making a strong commitment, trying to reach out to those patients as they came to us.

The second was getting the financial system set up so we could track the value on the population that we were serving and trying to find out if we could really reduce variables in terms of ED visits and inpatient stays.

The third thing were looking at is quality outcomes. For a population like this, we track outcomes of care. And in the early stage, we've seen some improvement, particularly on diabetes measures, from having a regular care site.

FH: In addition to expanded hours, are there plans for future clinics or other affordable treatment options?

SN: We're looking at that; we haven't yet identified a site.

FH: How will Lee Memorial and the care clinics work together?

SN: They're fully integrated into our electronic medical records. Most physicians and caregivers there are part of or an extension of Lee Physician Group. We wanted our brand to be out there across all of our other locations so there's nothing unique or different about them. So the communication and flow of information if they were to go to another specialist is on our electronic medical records, and they would have access to the information.

We have a need to create specialty referrals that's been another barrier of just trying to create those relationships with other independent physicians.

We understand that not everybody in the population pays, but as part of your relationship with Lee Memorial health system, we formulated what we call a "physician compact," which defines the give and the get between physicians in the community even if you're not employed by us that we would still ask you to be part of the solution to not let these people just fall through the cracks. Because, ultimately, as a safety-net provider, we end up picking up the care for these people.

FH: How have patients been responding to the clinics?

SN: Their general response has been pretty positive. We do still have a higher no-show rate than we'd like to, so we're working on some strategies to improve that and see if we can get people to really understand the importance of keeping their appointments and improving their overall well-being. But that just takes time.

FH: What ROI did you expect from the clinics?

SN: There was a business case for this. Our original business case had a small number of diabetics--about 187 unique patients--and with the downturn in this economy, they have less access to care. To serve their primary care needs, their rate of admission increased at our hospital 232 percent over five years. And on that small population, we were spending $2.8 million for inpatient admissions. So we said for 187 patients, we could provide a lot of primary care access for a lot less than $2.8 million. If could we avoid that cost, it would be part of our business case.

Secondly, we could qualify so that people over time should be eligible for other payment programs like Medicaid. If we could qualify for those people, we could have the opportunity to approach some form of reimbursements to us as a health system.

FH: What best practices can Lee Memorial offer to other organizations looking to ease ED crowding?

SN: What I said to our community was that we'd been thinking differently as an integrated health system about solving this problem than an independent physician practice would, just based on economics and the fact that we're a safety-net provider. But what really got people focused on this was getting them involved in the overall vision of what we're trying to do--for the health system but also for the community and patient care.

I remember when we first opened the clinics, we announced them and went into the community and to a lot of the churches. I had a lot of people come back and say it's so good to get reconnected with the vision of healthcare, and it's reminded me of how we can make a difference in people's lives. 

You have to think outside the box, but you've got to have a compelling vision for people to buy into and say you know this work is valuable work to be done--both for me and for those we serve.

Editor's note: This interview has been edited for length and clarity.