The first step to elicit patients’ trust is to let them know that we care about them. Engaging patients in a way that works best for them is essential, and we at Scripps Health have learned patient engagement lessons that will lead us well beyond the COVID-19 pandemic.
Following stay-at-home orders in mid-March, we experienced a 40 percent decrease in our emergency department (ED) and urgent care volumes, some of which was expected. However, in April, we also began to experience a decrease in our cardiology outpatient visits. This was extremely concerning to us. The urgency of the problem was highlighted by a patient in his fifties who had experienced shortness of breath. Tragically, he waited a few days before presenting to one of our EDs and suffered a large pulmonary embolism and fatal cardiac arrest.
We will never know the answer to the “what if” question: What if he had decided to come in sooner? Perhaps we could have saved his life. Clearly, our patients’ concerns about COVID-19 exposure were palpable and were preventing them from seeking care, so we commenced several initiatives in response.
First, we contacted local media so that I, as Scripps Health’s chief medical officer (CMO), could make a personal plea to our community. I asked people not to delay care and reassured them that our sites were safe: We had put universal masking policies in place, separated respiratory patients from others, and instituted rigorous cleaning protocols. We then sent e-mails to our patients, stressing the safety measures we were undertaking on their behalf. Out of concern for high-risk patients, our outpatient team also initiated a three-pronged approach to their special care needs: phone outreach, telehealth visits, and conversion to in-person visits if warranted. We were able to carry out these initiatives with staff from clinics that we had closed down in anticipation of COVID-19 surge volume.
Before the pandemic, our telehealth program was virtually nonexistent. When we began to experience significant community spread of the disease, we recalled furloughed staff so we could quickly ramp up those efforts between March 19 and March 26. Within the first few months of this program rollout, we saw more than 62,000 patients by video and conducted more than 50,000 telephone consultations (Exhibit 1).
To gauge the efficacy of the initiative, we initiated a telehealth patient experience survey in April through Press Ganey. The results have been encouraging. For the first 5,754 surveys completed, the score was 96 percent on the metric of whether patients would recommend the provider office to others for their telehealth visit.
For high-risk patient outreach, we devised a COVID-19 risk score to identify patients we should prioritize for a phone call from a nurse. As noted in Exhibit 2, of the 5,015 patients called by a nurse, 763 needed an in-person visit following concerns raised by their histories. The high-risk outreach risk factors included congestive heart failure, hypertension, and hospital and ED visits in the past 12 months.
Knowing the isolation that patients feel after receiving a diagnosis of the coronavirus, we also initiated a COVID-19 Care Companion program through our electronic health record system. In the program, patients can track symptoms and our nursing team can conduct daily checkup phone calls with them. In this program’s first few months, 270 of 373 COVID-19 patients who were on our patient portal enrolled, and 100 of them graduated from the 14-day callback program.
Phased Return of Services
After an initial flattening of cases in June, San Diego County began to allow businesses to reopen, earlier than our healthcare systems preferred. We braced for more spikes in COVID-19 cases similar to those we had experienced after the Easter and Mother’s Day holidays, when we saw increases in patients because of congregating.
In anticipation of more spikes, we developed a process to increase, cautiously and in a carefully metered approach, our surgical and procedural supplies. We also keep a reserve of ventilation equipment and perform what we call “time-critical” surgeries. These are cases that may not, on first blush, fit in the category of “essential” but are certainly not just “elective.” Patients who are having increasing difficulty driving because of cataracts and are the sole transportation provider for their families are time-critical cases, as are patients with increasing hip and knee pain. In addition, our specialty care and procedures now include patients who require COVID-19 tests, which use a minimal amount of personal protective equipment (PPE), as explained later.
By demonstrating that we are not rushing to offer services but are returning to them thoughtfully and carefully, we build trust in our patients because they can see we are taking as many precautionary measures as we can to ensure their safety. For example, purposefully decreasing our case load allows more rigorous cleaning between cases; this, in turn, engenders trust. As we increase the number of surgical cases and clinic visits, our cautious approach has resonated well with our patients: Following a June video message to patients from me as CMO describing our approach, visits to the Scripps Health appointment scheduling page increased by 90 percent.
Staff Safety First
You cannot make patients feel safe unless you first make staff feel protected. Scripps Health staff know we are taking this careful approach to patient care to protect them through surges of COVID-19 patients. We are not resuming “business as usual” for financial reasons. This assurance is crucial because when staff feel secure and protected, their positive feelings carry over into their interactions with patients. That is why we worked so diligently to find thicker plastic face shields and order powered air-purifying respirators to supplement the safety of N95 masks.
Perhaps the most creative step we took was the construction of plexiglass booths to protect staff while performing mass COVID-19 testing. Each three-sided booth has only two small openings for hands to fit through to obtain specimens. This structure protects staff from the inadvertent coughing or sneezing by patients after a nasal swab is obtained. (As an additional advantage, the booth requires minimal PPE—a single isolation gown and surgical mask for the shift.)
Restoring and sustaining the trust of patients— and staff—cannot be overemphasized in healthcare’s response to and recovery from the COVID-19 pandemic. As healthcare leaders determine what a new normal will look like, we should learn what is important to our patients. The strides Scripps Health has made in patient experience by providing convenient telehealth options for care is a great example of a rapid adjustment that healthcare teams can make if leadership has the will.
I do believe in silver linings, and in the darkness of this pandemic, we are learning about improvements that we can make to provide truly exceptional patient care.
The author thanks Christopher D. Van Gorder, FACHE, president and CEO at Scripps Health; Shane M. Thielman, FACHE, chief information officer at Scripps Health; Tracy D. Chu, FACHE, chief operations executive at Scripps Health; Melody Stewart, assistant vice president at Scripps Clinic; and Kristy Mendez, senior director of performance outcomes and risk at Scripps Health, for their assistance.