Improving patient engagement in rural America

Like all health organizations, rural practices are increasingly called upon to improve patient engagement. This isn’t surprising, considering patient engagement is linked directly to better health outcomes and lower costs of care.1 It is also credited with minimizing care disparities among patients with challenging social determinants, improving medication compliance and more.

However, guidance on how to “engage” patients properly — to achieve high metrics such as the ones cited in medical studies — is sometimes a little vague. Improving the frequency with which a patient connects to his or her provider and takes ownership of health outcomes raises many questions: Can a provider reap the benefits of engagement by simply buying a portal to send secure messages to a patient (per the Centers for Medicare & Medicaid Services [CMS] Promoting Interoperability guidelines)? Or must a provider connect with patients daily, in and out of the office, to ensure that patients’ health scores improve?

Strategizing to improve engagement can be a source of stress, especially for rural health providers.

Access to high quality healthcare services for rural Americans is dependent upon an adequate supply of physicians. But there are only 39.8 primary care physicians per 100,000 people in rural communities, compared to 53.3 physicians per 100,000 in urban areas.2 In addition, rural practices tend to see older and/or more chronically ill patient populations, such as more frequent occurrences of diabetes and coronary heart disease than non-rural areas.

What good patient engagement looks like

Healthcare stakeholders don’t always agree on the definition of patient engagement. A blanket term encompasses everything from patients being more directly involved in healthcare decision-making to providers communicating with patients on a more regular, off-hours basis between visits. Patient engagement is an ongoing effort between physicians and patients with the singular goal of improving care and outcomes.

Yet engaging rural patient populations in promising new care delivery models has not been a huge success to date. A 2018 report by the U.S. Department of Agriculture found that rural residents are much less likely than their urban counterparts to use telehealth, due in part to the physician shortage issue and less access to broadband internet for such technology.3 However, the U.S. government and major tech companies are focused on expanding rural broadband in the coming years to provide “every rural healthcare facility” with “the speed they need for the newest innovations in telemedicine,” as Federal Communications Commissioner Jessica Rosenworcel said in 2018.4

Rural health providers can learn from medical groups that successfully encouraged patients to take ownership of their health and, as a result, saw a significant boost in health outcomes. 

As one study published in the Annals of Internal Medicine revealed, doctors at UCLA Health and Beth Israel Deaconess Medical Center discovered that patients would benefit if they were invited to co-produce medical notes, called OurNotes, with their doctors rather than merely reading them.5 The report also found that the practice of co-producing medical notes helped doctors by reducing time spent on documentation.

Meanwhile, another healthcare organization, Atrium Health, discovered that one of the best ways to engage its patients was through the use of a mobile app, MyCarolinas Tracker (now called MyAtriumHealth Tracker). The app collects data from Bluetooth-enabled wearable devices and provides clinical context around it, informing patients about the data’s meaning and when they should follow up with their care provider.6

Engagement tools

As these examples illustrate, using the right consumer-oriented tools can foster better engagement. Yet many engagement-boosting tools, such as cloud-based health IT tools and wearable devices, remain largely untapped by rural physicians.

Rural providers should take the time to explore some of these resources and determine which make the most sense for their patient demographic. 

For example: A small medical practice or urgent care center that primarily sees young, healthy patients — perhaps students at a local university — would likely approach engagement differently than a home health agency or orthopedic practice with mostly Medicare patients. Patients in their 20s and 30s have grown up with technology and want to schedule appointments from their phone and use direct messaging to communicate with providers. They are interested in preventive strategies, such as weight management or nutritional guidance, and therefore look to apps that can sync with their Apple Watch, Fitbit or other wearable device.

That’s not to say an older patient demographic — such as those with high blood pressure or chronic illnesses — wouldn’t benefit from some of the above technologies and applications. Wearable devices that share data with physicians are useful in improving disease management. This demographic tends to need more comprehensive care — including multiple tools inside and outside of the office — to manage their higher levels of need.

Chronic care management (CCM) services can be useful for improving frequency of care, and if outsourcing this offering, can also reduce your staff’s workload. Older patients with two or more comorbidities (e.g., congestive heart failure, COPD, diabetes) are also ideal candidates for virtual, on-demand consultations, which enable them to reach a clinician whenever they are experiencing the onset of troubling disease symptoms. An added benefit of both CCM and telehealth is that they offer healthcare providers opportunities to receive additional reimbursement through quality incentive programs.

Recent changes by the federal government suggest this may be a banner year for how rural health is delivered, especially given updates regarding telehealth:

• The CMS Center for Medicare and Medicaid Innovation (CMMI) introduced an update for the value-based insurance design model of care, which opens the door to using telehealth for certain visits for patients on Medicare Advantage Plans.7
• Success stories such as the NICU telehealth program for Intermountain Healthcare further demonstrates to the industry that telehealth platforms for rural providers can boost care outcomes and reduce transfers and spending.8

To achieve these gains in patient engagement, providers in rural America can begin by training their employees to get the most out of these technologies. A recently published Journal of Nursing Education article suggests that quality improvement approaches, such as the Plan-Do-Study-Act cycle, are beneficial to building understanding and confidence in training nurse practitioners who plan to work for rural and underserved populations.9

In addition to considering the most sensible patient engagement technologies available today, rural providers need to keep an open mind toward innovation — the technologies of the future that hold the greatest potential for affecting quality of life. Every day, better technologies emerge that make engagement easier and more fulfilling for patients and providers, promising to offset provider shortages in rural areas. The sooner rural providers can incorporate engagement-centered tools into their workflow, the better off their patients will be.

Notes:

1. James J. “Patient engagement.” Health Affairs Health Policy Brief. Feb. 14, 2013. doi: 10.1377/hpb20130214.898775. Available from: bit.ly/2EynFQW.
2. Hing E, Hsiao C. “State variability in supply of office-based primary care providers: United States, 2012.” NCHS Data Brief, No. 151, May 2014. Available from: bit.ly/2FZ5jgA.
3. Wicklund E. “USDA report highlights challenges to rural telehealth adoption.” mHealth Intelligence. Nov. 7, 2018. Available from: bit.ly/2AR9wPz.
4. Van Wagenen J. “Rural telehealth expands as companies, government seek to close connectivity gaps.” HealthTech. Aug. 24, 2018. Available from: bit.ly/2ojFDAF.
5. Mafi JN, Gerard M, Chimowitz H, Anselmo M, Delbanco T, Walker J. “Patients contributing to their doctors’ notes: Insights from expert interviews.” Ann Intern Med.; 168:302–305. doi: 10.7326/M17-0583.
6. Peterson T. “3 healthcare organizations call on wearables to take patient care to the next level.” HealthTech. Nov. 29, 2017. Available from: bit.ly/2jxTsIX.
7. Wicklund E. “CMS pushes telehealth to replace some in-person visits in MA plans.” mHealth Intelligence. Jan. 18, 2019. Available from: bit.ly/2CsAv3G.
8. Albritton J, Maddox L, Dalto J, Ridout E, Minton S. “The effect of a newborn telehealth program on transfers avoided: A multiple-baseline study.” Health Affairs, Vol. 37, No. 12. Available from: bit.ly/2SaJcKR.
9. List B, Saxon R, Lehman D, Frank C, Toole K. “Improving telehealth knowledge in nurse practitioner training for rural and underserved populations.” J Nurs Educ. 58(1) 57-60. doi: 10.3928/01484834-20190103-10.