We have used almost all of the same strategies successfully that Brian mentions above. In addition, we have also rented beds in a SNF for our uninsured patients who simply need a place to wait while pursuing Medicaid, guardianship, etc. This has helped free up beds for patients who truly need an acute level of care and has helped throughput.
Our organization has a Care for the Caregiver Program – essentially, a peer support program for any caregiver (direct or indirect) in our organization that experiences an untoward event, near miss, assault, prolonged management of a challenging patient, etc. It is staffed by psychiatric nurses, behavioral health counselors, psychologists, and is led by a physician. One of them is available 24/7 and staff are encouraged to reach out for support following any event that they found stressful or upsetting. There is no charge, it is confidential, and can be done individually or in groups (example: a team debrief after the code and death of a young patient). It has been in place for about 2 years and has fielded over 700 calls with excellent results.
Our organization has deliberately chosen not to incentivize physicians on productivity but rather on outcomes, total cost of care, and patient access. By measuring these 3 domains, we indirectly get to the issue of productivity without the negative consequences you describe above.
We have engaged private practice physicians in almost all aspects of strategic planning, program development, quality improvement, care standardization, and other health system initiatives. By actively engaging them within the health system beyond just direct patient care we have created a shared vision and a common framework for practice and care delivery as well as aligned incentives and outcomes. This degree of transparency has gone a long way to developing trust and enabling a shared value proposition. Our patients and the larger community we serve are better for it. We still have work to do around EMR integration and more fluid communication, but have come a long way from the “we versus they” mentality.
Attached is a link to an MGMA study on decreasing no-show rates that you may find helpful: https://www.mgma.com/data/data-stories/using-multiple-forms-of-communication-to-lower-no
Additionally, do you have a policy regarding discharging patients who are repeated no shows? My organization allows a patient to no-show 3 consecutive times, at which point they are automatically discharged.
I would also consider doing some information gathering regarding why the patients do not show. Is it transportation related? The absence of child care? Something else? This may help you figure out where to aim your efforts at improving your attendance rate if you know the barriers that are causing the no-shows.
We have been quite successful in developing protocols and embedded order sets into our electronic health record that drive the appropriate utilization of physical therapy resources in the acute care setting. This effort has been a combined project that has included physical therapy, discharge planning/case management, physicians (primarily hospitalists), and nursing. We found through a structured Lean Six Sigma project that 38% of PT referrals in the acute care setting were for non-skilled therapy and/or did not contribute meaningfully to the discharge plan. Education was done to physicians and nursing staff using case-based scenarios to help identify appropriate referrals. Care standardization protocols were developed and embedded in the EHR for populations requiring skilled PT (joint replacement, spine, stroke, etc.). These protocols/pathways were monitored for compliance and providers given feedback regarding variance to the protocol. Education was also provided regarding long-standing practices based in urban legend (e.g., “if I don’t get a PT eval and the patient falls at home after discharge I could be sued – the PT eval will prevent that”) It has been a heavy life with more work to do, but we have definitely seen progress in the right direction.
We have found that telemedicine has been successful in population health follow-up scenarios such as monitoring patients with CHF, COPD, diabetes to name a few. We have also used it with mixed success in psychiatry during a significant shortage of providers. We are embarking on expanding its use in primary care, possibly neurology, and the pre and post-care associated with bariatric surgery. We have also used it very successfully with our own employees for urgent care-type visits to avoid ED utilization. A challenge, if you are using your own providers, is the state licensure requirements that come into play if the provider is in one state and the patient is in another at the time of the visit (a challenge for my health system given our geographic location). There is no doubt that this method of care delivery will continue to gain popularity, however, will need the reimbursers to keep up with this change and recognize payment for telemedicine services.