Health care providers are on the frontlines of care, and they’re working furiously to meet an overwhelming demand for services. Nowhere is this more true than in the health care safety net.

For safety net providers, challenges are magnified by financial pressures, lack of resources, and an ever-shifting political landscape. The type of health care inventions we see there are a far cry from the glamorous world of “think-tank” and “start-up” innovation. Instead, people have to come up with new and better ways of doing things just to get through the day.

These mission-driven organizations need to find creative, low-cost innovations to better serve disadvantaged populations. As a result, safety net professionals have learned to think outside the box. For example, one CCI Technology Hub has explored new ideas simply by having staff members write ideas down on sticky notes and leave them on posters pinned to the wall in a hallway. People jot down their ideas and others respond, saying why they thought the idea would or would not work.

Such an approach has resulted in bold, scrappy ideas that take on some of health care’s most pressing problems. Out of these ideas came Raven, a breakthrough approach to connecting providers with solution partners.  

Here are four snapshots of Raven in action:

Medication Adherence at San Francisco General

Consider the challenge of medication adherence — that is, ensuring patients use their medications as agreed upon with the provider. It’s a problem which, if solved, could save the healthcare industry between $100 and $300 billion in costs annually, according to an article published in the Journal of Risk Management and Healthcare Policy.

Nowhere is this problem more acutely felt than in the country’s safety net facilities, where patient populations have low health literacy and may speak English as a second language or not at all, leaving them dependent on family and friends to help navigate a complicated health care system. These factors exacerbate an already trying challenge.

“We see a lot of indigent people, people who don’t speak English as their primary language, and those who may not be legal citizens,” said David Smith, PharmD, from San Francisco General Hospital, in an article that ran in HealthIT Analytics. “So, it’s difficult to do a lot of consistent patient outreach once they leave the hospital, and it’s not easy trying to empower them to manage their own health.

“We have large numbers of Mandarin, Cantonese, and Spanish-speaking patients,” Smith added. “We also have Tagalog-speaking patients and a number of other populations. In general, it’s difficult for them to understand all their medications.”

The traditional approach to dealing with this challenge is to use human interpreters and rely on family members to assist the provider by painstakingly inscribing simplified instructions by hand into the patient’s native language. But what would happen if we could automate the process by which patients received simplified medication information to deliver it in their native language, at a literacy level they would be able to understand? Such an innovation, while simple, could make a world of difference.

Raven had the opportunity to test out this type of innovation by partnering with San Francisco General Hospital.  The project examined the impact of automating the translation of medication instructions in a pilot project involving Meducation, a program developed by Polyglot Systems. Meducation offers ethnically appropriate drug information that can be understood by people at all reading comprehension levels.

What Raven learned

Here are some findings from Raven and the team piloting this solution at San Francisco General Hospital:

  • Providers and staff improved the education process with patients, which resulted in a reduction in the amount of staff time devoted to medication adherence education.
  • Patients immediately recognized and appreciated receiving the information in plain language. Adherence improved.
  • For a cohort of high-risk inpatients, the readmission rate was reduced from 26% to 8%.

Those are the type of results that everyone who works at safety net facilities truly values: Results that make a real difference in the care delivered to some very deserving patients.


Health Coaching for Employees and Patients

Risks like high blood pressure, high blood sugar, high blood fats, and obesity can lead to costly chronic health conditions. Lowering these risks often requires changes in behaviors such as physical activity and cooking, but developing good habits can be difficult. It’s often not enough to just tell patients the changes that they need to make. Patients may backslide, forget, or not fully adopt new habits. Real outcome improvements need discipline, but even programs like Weight Watchers don’t always provide the right structure to achieve this. Every patient is different and may require different forms of support and motivation.

Raven reviewed a health coaching program developed by Omada that offered individualized instruction. It was first tested with an employee group: Participating employees who met eligibility criteria were connected to the program through their health center. They signed up and were matched with a coach and support group based on their health aims. The 16-week program, which was later extended to patient groups, included:

Goal-setting. After measuring their risk factors for heart disease and type 2 diabetes, participants were given a goal. These goals are usually percentage-based, allowing group members to share and compete no matter what point they are starting from.

Tracking devices. Omada sent participants a wireless digital scale, a pedometer, exercise bands, and other peripherals. The connected devices were already synched up to the participant’s Omada account.

Daily weighing. Participants were asked to step on the scale every day. The scale automatically sent the information to Omada to update the participant’s progress. Participants also entered the food they ate every day, as well as tracking their steps and other physical activity.

Health education. Omada provided a health education curriculum that participants could access online to learn more about the best ways to make better health choices and build better health habits.

Individual coaching and weekly emails. Over the course of the 16-week program, participants received two individual calls with their coach to get personalized health advice. They also received weekly emails and exchanged messages with their support group.

Goal measurement. As participants made their way through the program, their progress was tracked in a small bar field on the Omada interface. If they reached their goal, they were given a new one — for instance, losing another 7 percent of their bodyweight.

What Raven learned

  • For some patients, signing up is the hardest part. Such patients may require some extra encouragement and handholding.
  • When rolling out Omada, providers should take cues from their patients. Some employees, for example, were interested in being in a group with their coworkers, while others preferred to share health goals with strangers.
  • Omada is most beneficial for individuals or groups that can’t meet regularly and instead need to receive their health coaching remotely.
  • In the areas of weight loss and fitness, employees who used all parts of the platform had the greatest success.

Capturing Patient Stories Changes Perspectives

For all the value of data and metrics, personal stories have a unique power to inspire, motivate, or teach us to be more compassionate and understanding.

Because doctors and nurses see people at their most vulnerable or most relieved, they often hear patients speak about struggles and triumphs. A new project at West County Health Centers trains clinic providers and staff to record videos of patients telling their stories — with permission — during these moments of insight. West County hopes sharing these videos in exam rooms will help build empathy and trust among staff, patients, and the community.

At the West Valley, providers and staff are equipped with iPads. Along with accessing electronic health records, these tablet computers have cameras that can record video. They also have release forms for patients to sign if they agree to tell their stories, which should be about their health or wellness journey or about their care at the clinic.

For West Valley to date, sharing stories has humanized the often stressful and convoluted process of getting healthcare. According to providers there, hearing from patients who struggled with difficult health issues or who received care that made their lives better can put other patients at ease, keep staff motivated, and help organizations improve their practices. Hearing stories from staff and volunteers can also help build trust in the community.

What Raven learned

To determine if a patient story is worth sharing, clinics should look at four criteria:

  • The story should be about the patient’s health, their wellness journey, or the care they received at that clinic.
  • The story should be emotionally compelling.
  • It should be a story that others could benefit from hearing, particularly if it can inspire them to make good decisions about their own health.
  • Recorded stories should be less than five minutes long.

Experimenting with E-Consults

Health reform changed the landscape not only for payers and primary care providers, but for specialty care. The Affordable Care Act saw Medicaid enrollment double in two years, giving access to specialty care to millions who had previously been left out of that system. Primary care providers are dealing with more complex care issues, so need to send patients to specialists with increasing frequency. With such an influx, many patients are forced to wait weeks for an appointment with a specialist.

For safety net provider organizations, interacting with specialists can be difficult. Safety net patients’ difficult lives and lack of experience with the health system mean they are often less likely to show up for specialty appointments. And since many community health centers are also hiring physicians and advanced practice providers right out of training, some of them may not have the experience to write good consult questions, resulting in higher costs and frustration for specialty providers as well as less effective care for patients.

After hearing complaints from specialists, the Community Health Center Network (CHCN), which serves underprivileged patients in the East Bay of San Francisco, revamped its practices. It sought a way to change the way it did specialty referrals that would be good for patients, primary providers, and good for specialists, as well as strengthening their relationship with its partner, Alameda Health System. They needed a “quadfecta.” The solution they found? Digital “curbside consults” through a platform by health tech company RubiconMD.

 “Curbside consult” refers to a physician asking the opinion of another provider without getting them officially involved in a patient’s case. With questions for specialty domains, providers may call up a specialist they are friendly with for advice on whether a patient’s case warrants a specialty visit or how to best frame a clinical question for a specialist.

Such consults make specialty visits more effective and efficient, but unfortunately, they are rarely formalized. Instead, they are born out of social relationships between doctors in their community — relationships that many new physicians hired by safety net clinics have not yet cultivated. RubiconMD offers curbside consults as a digital service, allowing providers to get advice on their cases from specialists across the country.

How it works: A primary care provider using RubiconMD sees a patient who has a complex case. The provider is unsure if the case warrants an appointment with a specialist or would like some help crafting a good clinical question with which to send the patient to a specialist. Or perhaps the provider needs suggestions on further testing to run before their patient is seen by a specialist.

Here’s what happens:

  • The provider uploads the case into RubiconMD’s web-based platform. The platform may be connected directly to an EHR or offers fields to input the case details that mirrors an EHR. Usually the provider can copy and past the information directly from their chart notes.
  • Using a RubiconMD phone app, the provider can upload pictures of the patient’s relevant body parts, skin lesions, and other relevant images. They may also take pictures of computer screens to more quickly enter information about lab reports or patient charts.
  • RubiconMD will prompt the provider to ask a specific question for their case as well as their current plan of treatment, which helps both the RubiconMD specialists and the primary care provider better understand the case.
  • The patient information is anonymized to protect patient privacy and comply with HIPPA regulations. Then the case is assigned to specialist on RubiconMD’s network of specialists relevant to the primary provider’s question.
  • A specialist on that network will look at the case and submit an answer, which is sent back to the primary provider. If they do, the specialist gets paid by RubiconMD. (Much like an in-person curbside consult, the e-consult is not official and not legally binding.)
  • The answers are sent back to the submitting primary provider, who uses the consult to inform decisions about whether and how to send a patient on to a specialist appointment.
  • The primary provider can rate the quality of the consult. RubiconMD assigns more consults to specialists that receive high ratings.

What Raven learned

  • EHR integration with a system like RubiconMD sounds easy, but it can be a challenge to implement.
  • While useful, e-consults are not a golden bullet to create efficient provider workflow. This is a tech intervention, and as such, it’s not always easy for less tech-savvy providers.
  • It’s important to consider the ecosystem of your local specialists. Specialists in urban areas are more likely to be overburdened with demand and appreciate a system that makes visits more efficient and takes off some of that strain. In rural areas with less demand, it is important to be careful about interventions that might alienate local specialists.