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    Health systems and physician practices still face rising cancellation rates as patients continue to postpone necessary care. It’s a growing problem in terms of lost revenue, misaligned staffing costs and empty exam rooms, not to mention the downstream effect on patient outcomes.

    In their session at the 2022 Medical Practice Excellence: Leaders Conference, co-presenters Carrie Kozlowski, OT, MBA, chief operations officer and co-founder, Upfront Healthcare, and Maria McGowan, senior vice president, marketing, Duly Health and Care, shared from their combined backgrounds in occupational therapy, technology, digital health and consumerism ways to build a cohesive strategy that improves quality, financial, operational and patient experience outcomes.

    Recognizing consumerism and the patient experience

    The impetus to address patient consumerism was strong just before the COVID-19 pandemic disrupted the healthcare industry, as Amazon, CVS, Walmart and other large corporations began various attempts to build upon their consumer-focused expertise and broadening it into the care delivery arena, Kozlowski said.

    “We need to be prepared, as providers of healthcare, … of how we are going to make sure that patients are getting the care they need,” Kozlowski noted. “There’s a real risk of continued fragmentation, if additional vendors are coming in who are thinking about things differently and are not really focused … on helping patients get the care that they need.”

    Standing out against that new competition requires a careful examination of the patient experience being offered in your practices with an eye toward all the disparate elements that influence patient experience.

    “As we’ve built our operations, as we’ve built our service lines … I think we can acknowledge we do that in silos,” Kozlowski said. “We take a dysfunctional operational system and then we project that on to the patients, and then their experience feels fragmented.”

    Taking action

    In 2019, Duly Health began looking for organizations to expand its digital strategy and patient communication to improve the patient population’s understanding of the Medicare Annual Enrollment Period (AEP) and benefit offerings. As McGowan noted, this is how Duly Health partnered with Upfront Healthcare initially, before expanding the scope in 2020 to include COVID-19 communications.

    “We were able to communicate en masse to all our patients about how they could safely continue to receive care, sharing health information with them, where we had testing available, where they could be treated in clinic,” McGowan said.

    The program evolved to connect patients to telehealth options and then to in-person care later in summer 2020 when stay-at-home orders lifted. The partnership then grew into new areas to address issues such as visit adherence, cancelled appointments, employee engagement, referral management, and targeted outreach for specific care gaps (e.g., hypertension, mammograms, A1c and eye exams for diabetes patients).

    However, these efforts could suffer if done in a piecemeal fashion and not accounting for the breadth of communication types happening for different patients who encounter multiple messengers and varying messaging. For example: A patient with diabetes and heart failure may get separate communications for those specific issues along with another set of messages about preventative screenings from a team focused on quality care gaps.

    Kozlowski recommends bringing cross-functional leaders together when crafting a cohesive enterprise strategy for these patient communications, ensuring that all the back-end technological pieces are as consolidated as possible and ensuring there is someone in each department to support as communications are scaled up to new areas.

    Specific challenges

    Scheduling necessary care

    Prior to the pandemic, studies found that only 8% of patients get all their high-priority, appropriate clinical preventative services,1 and the pandemic only exacerbated the avoidance of necessary care.

    In confronting the challenge of being a trusted source for preventive care, Kozlowski noted that part of the work done with Duly was to ensure patients kept the appointments they made, understood the importance of the visits, and made it easy to reschedule for a more convenient time and then make that appointment slot available for another patient.

    “During COVID, we did see a very large number of patients not come in for their annual physical, seniors for their annual wellness visits (AWVs), or even children for their well-child schedule of appointments,” McGowan said. “Nationally, we have seen patients presenting with advanced disease because screenings were not kept up.”

    An automated, non-human tool now handles this outreach, via phone/text or email, saving personal interactions between staff and patients “for when they’re absolutely necessary,” McGowan added. To make those automated patient health communications effective requires using best practices around patient readiness and motivations, as well as human-centered design to promote the actions that the organization wants the patient to take, Kozlowski said. But it also requires data.

    “We have a rich set of data from the EHR, from payer claims data, that Duly has access to,” Kozlowski said. “That allows us to understand who needs what, so the outreach is relevant to that person,” such as sending updates to patients three weeks before they are due for a mammogram.

    Messaging also might be tailored based on psychographics, or what is understood about each individuals’ motivations: “’I do whatever my doctor says,’ or ‘I want all the research so that I can make a decision,’” Kozlowski shared as examples of patient sentiment. “We need to speak the language that will be personal to the patient.”

    Ensuring visit adherence through personalization

    The burden of missed appointments has been estimated to cost the U.S. healthcare industry about $150 billion,2 and those unused appointment slots compound patient access issues that worsened in recent years, Kozlowski said.

    Previously, Duly was not feeding cancellation information back into the program used for outreach, and there was no way for patients to cancel electronically without a MyChart account, McGowan said. But taking the step to automate reminders to patients has given the organization information on the right number of attempts to remind patients and the timing of those reminders. “It gives us great opportunity to continue to iterate on our communications to patients,” McGowan added. “Our role is to get them to keep the appointments, and this has helped us tremendously.”

    However, the work is not without pain points: The EHR integrations necessary and data lag need to be addressed so that openings can be quickly surfaced and addressed to avoid unfilled time slots. McGowan also noted that personalized messaging was just as important in digital outreach as it is when sending physical mail to a patient (e.g., including a photo of the provider in the communication to build familiarity).

    That personalization also came in handy during the height of COVID-19, as messages to chronic condition patients were tailored beyond broad updates about masking and limits on visitors, so that those patients could be connected to video or phone visits for continuous care amid stay-at-home orders.

    For AEP work, the teams leveraged clinical, geographic and demographic data to tailor messages that encourage patients to sign up for learning sessions about coverage based upon the sessions closest to them in the Chicago area. Those same tactics transferred to COVID-19 vaccine clinic educational outreach to aid Duly as the hub for storing and distributing COVID-19 vaccine doses when they first became available in December 2020.

    “We were able to not only say, ‘It’s your turn’ [for a vaccine], but we were also able to tell people, ‘It’s not your turn, but here’s when your turn is going to be,’” Kozlowski said, given the structured rollout of the vaccine based on frontline worker status, age, and underlying health conditions.

    “The big point is that one size fits all won’t work,” Kozlowski said. “Taking something out of the box that’s standardized, that goes to everybody with the same language … is going to reach a certain percentage of people, because it’s going to hit the people who are motivated by what you happened to put that day, who happened to need [it].”

    Kozlowski added that this approach to patient outreach helps bust some of the myths around patients’ willingness to engage digitally. “Our highest percentage of engagement is with patients above the age of 61,” she noted.


    Patients often are in a vulnerable state when engaging with healthcare providers, even if it just involves the sharing of personal information unrelated to a condition they might have (e.g., social history, behavioral history, employment, finances, insurance). “What Duly has done really well is to say that when patients are going to trust us with that information, we’re going to use it to make their lives easier afterward,” Kozlowski said.

    The processes of identifying appropriate patient data (e.g., demographics, care gap history, upcoming care needs) and then analyzing it to personalize health communications is a key step in establishing the trust with individual patients, Kozlowski said. “That’s where activation is — when patients begin to get care and continue to get the care that they need.”


    1. Borsky A, Zhan C, Miller T, Ngo-Metzer Q, Bierman AS, Meyers D. “Few Americans Receive All High-Priority, Appropriate Clinical Preventive Services.” Health Affairs, 2018 37:6, 925-928.
    2. SCI Solutions/R1 RCM. “Unused Scheduling Capacity Costs More Than You Think.” April 26, 2017. Available from:
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