Implementation of a Navigation Center to Improve Patient Access

The Challenge

Nearly 25 million underserved patients each year rely on care provided through 1375 community health centers in the United States.(1) The primary access to care for most patients is through call centers. However, patients seeking care in these settings face significant barriers to accessing care due to long wait times, dropped calls, and staff who are not equipped to manage questions efficiently. With the exception of answering all but the most basic of questions or scheduling appointments, call center staff typically act only as intermediaries, resulting in the need for multiple phone calls to resolve many questions. The net effect is reduced access and a poorer experience of care for patients, inefficiencies for the health centers, and reduced quality of staff experience.

The Goal

East Boston Neighborhood Health Center (EBNHC) created a Navigation Center, designed to improve patient experience, staff experience, and access to care by putting key staff, technologies, and workflows into place. In the first phase, described here, EBNHC aimed to develop a proof of concept model. This laid the groundwork for a second phase in which the team would focus on continuous improvement and sustainability.

The Execution

EBNHC is a community health center with 300,000 patient visits per year in the greater Boston area. The center serves a diverse patient population, nearly 60% of whom have limited English proficiency (LEP) and most of whom are low-income. EBNHC historically managed 70% of its call volume through the Contact Center, which was staffed by customer service representatives (CSRs). The Contact Center was extremely busy, handling as many as 40,000 patient contacts per month. This resulted in average patient call wait time of 14.5 minutes, and a 13% call abandonment rate, well above the industry standard. EBNHC estimated that 40% of incoming calls required a call back from a nurse.

In August 2016, EBNHC launched phase one of the Navigation Center, designed as a proof of concept. The Navigation Center aimed to overcome the existing limitations of the Contact Center by resolving patients’ queries at the initial point of contact and more efficiently escalating calls. The key innovation was to consider incoming and outgoing patient calls as part of the clinical process rather than a basic customer service or business operations exercise. In this model, the Navigation Center staff became part of the clinical team and helped coordinate patient care rather than acting as telephone operators. In effect, the Navigation Center paired nonclinical staff with clinical staff and technology to navigate patients through the continuum of care. Key components of the Navigation Center included an upgraded call management system, development of new workflows, and embedded nurses with nursing triage (Figure 1).

Figure 1. Navigation Center model.

Upgraded Call Management System

EBNHC selected and installed the Zeacom TouchPoint system, allowing data to be tracked starting in August 2016. This system created call queues, which more effectively distributed calls to available CSRs and more efficiently escalated calls that required clinical knowledge to resolve. Calls were routed to appropriate staff via phone trees designed to reduce wait times and abandoned calls. For example, the call system included a priority line tool that prioritizes calls based on department and volume.

A key benefit of the call management system was the capability for both real-time and recorded monitoring of calls and call outcomes. Analysis of call data allowed management to better train new staff, monitor call quality, and resolve quality assurance issues. For example, management was able to use the data to develop an electronic scorecard to evaluate each CSR’s call performance, including measures such as customer service, accuracy of documentation, and knowledge of guidelines; a similar scorecard for nursing is currently under development. The call management system also allowed management to determine the appropriate staffing level of the Navigation Center.

New Workflows

New workflows simplified how CSRs schedule appointments and allowed them to better assist callers with questions about labs and tests, connect patients to insurance enrollment assistance, and perform routine chronic disease management—all directly at the point of contact. Through the new workflows, EBNHC took the first step toward having a Navigation Center that supports population health management. For example, development of standard operating procedures for the Navigation Center included a new protocol that allowed CSRs to relay messages and more comprehensive information to the patient on screening results and screenings that were due. Instead of sending messages to providers, this allowed CSRs to resolve more questions and thus freed up providers to address clinical issues. Second, due to efficiencies from these new workflows, CSR time was available to support population health management activities by performing outreach calls to patients at the request of providers.

Embedded Nurse With Nursing Triage Modules

One inefficiency inherent in most call centers is that CSRs cannot resolve symptom-based calls or provide answers to clinical questions and concerns. In the Navigation Center model, nurses were embedded in the Navigation Center to deal with clinical-level patient queries immediately. This allowed patients to receive quicker resolution, allowed CSRs to move on to other patient calls more quickly, and reduced the call transfer rate to clinical departments.

An indispensable tool for the nurses in the Navigation Center was a nursing triage module interfaced with the electronic health record. A separate nursing call queue directed appropriate calls to the nurses, and the nursing triage system was designed to allow for consistent resolution of higher-priority calls. This allowed higher-level functions to be performed by licensed nurses embedded in the Navigation Center, such as triage and the identification and management of high-risk patients.

The Team

EBNHC convened the Navigation Center Workgroup, with representatives from each of the eight service lines, supported by a project manager and executive sponsor. Because each department had different workflows for how to manage inquiries, the goal of the workgroup was to launch standard operating procedures (SOPs) for management of calls across service lines. The workgroup developed SOPs for a range of topics, including preoperative appointment booking and timeframe, nurse visits and pre-appointment advice, internal language line availability, referrals workflow, specialty scheduling, medication refill workflow, appointment cancellations, emergency symptom call list, symptom call transfer, results messaging, addendums, and hospital follow-up booking and timeframe. The Institute for Community Health was the external evaluator for the grant program that funded this work, and worked with the project manager and executive sponsor to define evaluation metrics.

Outcomes

Access to Care

After implementation of the Navigation Center, call abandonment rates decreased from 13% to 3% without a significant increase in staff or decrease in call volume (Figure 2). During the same timeframe, one-call resolution rates increased from 70% to 84%, the proportion of calls answered within 60 seconds increased from 61% to 73%, the proportion of calls being transferred to practice nurses decreased from 86% to 47%, and the target service level (80% of calls being answered within 60 seconds) achievement rate increased from 35% to 74%.

Figure 2. Impact of Navigation Center on call metrics.

Staff Experience

Eighty-six percent of CSRs reported that their work was more enjoyable after implementation of the Navigation Center (Figure 3). Staff experience outside of the Navigation Center also improved—86% of primary care nurses reported they had more time to spend with patients, and 100% reported that their work was more enjoyable since the Navigation Center was established.

Figure 3. Impact of Navigation Center on staff experience.

Patient Experience of Care

Patient-reported phone attendant courtesy and helpfulness mean score increased from 88.2 to 90.3. This increase was seen in five of seven service lines.

Efficiency

At the same time that access to care increased, EBNHC efficiency also increased. The number of patients served per full-time equivalent practitioner assigned to phones (inclusive of Navigation Center and departmental nurses assigned to phones) increased slightly, from 272 to 276. The number of encounters in the nursing in-baskets was reduced—for example, in one department, messages in the nursing in-basket decreased from an average of 90 daily to about 15 daily. Qualitative feedback indicated that staff were now able to spend more time working with high-risk patients over the phone.

Challenges and Lessons

In this first phase of the Navigation Center, EBNHC demonstrated improved access to care, patient experience of care, staff experience, and efficiency with this model. In addition to learning about the impact on these outcomes, staff at EBNHC learned several valuable implementation lessons. First, they learned about the critical role of the interdepartmental workgroup in guiding collaborations across departments. This workgroup serves as a model for other workgroups as EBNHC turns its attention to focusing on integration of care across departments. Second, EBNHC learned about the potential role that Navigation Centers may play in population health management. The Navigation Center’s focus on the one-call resolution rate has led to increased recognition across the institution of the opportunity to maximally utilize incoming calls to achieve multiple goals. As the center continues to develop its population health management strategy, the Navigation Center has been a natural part of the solution. The center currently is examining mechanisms to leverage the Navigation Center to support population health management goals.

In its second phase, EBNHC will focus on continuous improvement and sustainability, guided by lessons learned from the first phase. Specifically, the first phase highlighted that continued success of the Navigation Center requires ongoing attention to the processes and structures that support the center’s work. For example, the ability of a call center to improve patient access to care depends in part on having available appointments to triage patients into. In addition, a more complete picture of sustainability of the Navigation Center requires understanding its impact on quality and safety, and turnover of staff. Finally, community health centers, which operate with thin operational margins, are experiencing rapid change to maintain solvency. In this rapidly changing healthcare environment, continuing to prioritize Navigation Center work requires alignment at the organization-wide level and with other evolving initiatives.

Reference

1. Rosenbaum S, Paradise J, Markus A, et al. Community health centers: recent growth and the role of the ACA. January 2017. Kaiser Family Foundation. http://files.kff.org/attachment/Issue-Brief-Community-Health-Centers-Recent-Growth-and-the-Role-of-the-ACA .

Where to Start

• Identify opportunities for improvement. Consider how a Navigation Center could improve operational efficiencies, patient access, patient experience of care, and staff experience of care, and support population health management goals.

• Convene a project team. Ensure you have a buy-in from executive leadership, strong project management, and operational knowledge.

• Convene a cross-departmental group of leaders. Cross-departmental cooperation creates alignment across the organization and a platform for interdepartmental work.