It’s patient experience week here in the United States, and we have asked CHESS President Dr. Yates Lennon to share his story about how, as a practicing provider, he took the time to listen to feedback from his patients and implement changes which not only led to better patient experience scores but shed new light on the importance of value-based care.

Doctor Lennon, welcome to the Move to Value Podcast. Would you share your story about being a provider and how you came to realize the importance of the patient experience in health care?

So, my name is Yates Lennon and I am an ObGyn by training, practice, private practice, obstetrics and gynecology from 1993 to 1998 in Hot Springs, Arkansas and then in 1998 moved back to North Carolina, which was home, to practice in a small private practice in Asheboro, North Carolina. From 98 until 2008, we were a small independent group for physicians at at most. And in 2008, our group really saw the early, phases of value-based care coming. We saw, the landscape of regulatory requirements, changing quickly and, and understood that keeping up with that was going to be a significant challenge. We were one of the first ObGyn practices as a small group to go on to, electronic health records. So, we did that, and actually we did that in 2002, I believe. But then in 2008, as we really sort of started seeing the handwriting on the wall, we felt like we needed to join forces with a larger organization that could really help us keep up, stay abreast of what was happening while we continued to focus on delivering care to our patients.

So in 2008, we merged our practice into what was then Cornerstone Health Care, based in High Point, as we merged in and became a part of that organization around 2011, I had expressed an interest to the leadership at that time of becoming more involved in an administrative capacity of some sort, did not have a particular path in mind, but but knew that I had always enjoyed the administrative side of medicine and, and running a small practice. So, I was asked at that time if I would consider taking on an overhaul of the patient experience for the Cornerstone Group. So, we formed a multidisciplinary team, included, physicians, advanced practice providers, CMAs, nurse assistants, nurses, office managers, front desk staff. The throughout the whole organization, through all levels of the organization came together and formed a group, that later was named peak, patient expectations are key. And in the course of that, I really began to see, how important patient experience really was. And, and even though I had practiced for a long time, I never really thought that much about the patient experience of care. Fast forward another year or two. Cornerstone had begun the their first efforts at a patient experience survey, which was done online.

Prior to that, it was a paper survey, and it was handed out at the desk to patients. So not incredibly random. We employ a employed, a large provider that, did these online surveys. And I was actually very excited to see my first survey. I had a large patient panel, had a good reputation in the community, and was excited to see these first results. Unbeknownst to me, when they came in, our office manager took it upon herself to post them at the back door, and I came in and saw my scores and they were by far the worst of anyone in our practice, and I was devastated. I went through all of Kubler-Ross stages of grief in the span of about 15 minutes. But following that, I decided, you know what? There's a message here. So, what is that message? What What are my patients trying to tell me? are kind enough to fill out the surveys, tell me how I'm doing. I need to be wise enough to listen. So, I started assessing what a visit in my office actually looked like. I thought the the highest standard was efficiency, that if I was efficient and always on time, that that would be what made everyone happy. come to find out, that was not the most important thing. So as I talked to my nurse about what was happening, I changed the whole way I saw patients, I went in and spoke to them first, make sure I had a social connection before I just walked straight into the office and to the exam room and said, what can I do for you today? Tried to make a social connection. I allowed them to gown after the interview as opposed to before. Again, I'd always been aiming towards efficiency and as I made these subtle changes, in the way my workflow went, I saw my scores come up.

And so at that point in time, I became a believer that there is a message here. You just have to find it. It's not always well received by physicians. Well, following that experience, I relayed that to the leadership at Cornerstone and following that experience, was asked if I would take on the role of leader for a large multidisciplinary group that would address the patient experience throughout Cornerstone.

I think our scores, our overall patient satisfaction scores were somewhere around the upper 60s, maybe low 70s, percent the percentile. So we form this large group, representation from all different roles in the organization and really began to tackle some, some challenging issues, talked to physicians, identified other physician champions, and really began to push this out into the group. And we saw scores rise up into the high 70s and low 80s over the over a period of about 6 to 12 months. I found that very rewarding. And it was sort of my first foray into physician leadership, trying to provide education, support, encouragement to other physicians as they tackled improving the patient experience. Needless to say, there were skeptics along the way. But, I think we did a good work, and it really helped me focus, even though I've been practicing for decades, helped me focus on the patient.

So, from that, my interest grew. And then in 2015, I stopped obstetrics and moved more into the realm of quality for what was still Cornerstone Healthcare. So I focused on working with providers to make sure we were identifying and capturing quality measures in the EMR, able to report those out, able to give providers feedback on how they were performing in their quality measures, so that we could have unblinded comparisons. And again, with those with that data going back to physicians and having conversations about how they're performing, we saw, quality scores dramatically improve across our whole, the whole practice, but particularly in primary care, where so many of these quality measures are captured. As I did that work, became more involved with the contracting side and interested in how the Value-Based contracts were, negotiated and oriented. And, along that same period of time, Cornerstone had founded CHESS. So, 2011, 2012, Cornerstone founded CHESS. So I worked closely with the CHESS teams throughout those years, from its inception until 2016, when I became the chief quality officer for, the Wake Forest, what became the Wake Forest Health Network and 2016, when Cornerstone was acquired by Wake Forest. I stayed in that role, continuing to support physicians in their quality improvement efforts, as well as, performance and quality in the value based agreements really pushing for physician reimbursement to be impacted by quality. So, looking up compensation models and how do we incentivize physicians to do the right thing? How do we make it easy in the EMR to do the right thing Was really sort of our philosophy. And then in 2018, I had an opportunity to come over to CHESS as the chief transformation officer. One of the things I really enjoy and, is interacting with, people and physicians and, being a champion for value based care, so the chief transformation officer role allowed me the opportunity to work not only closely with business development as, we were engaging potential value partners but then taking the handoff from business development as we signed new value partners, bring them into the family on our value based agreements, and then working with those physicians within those health systems to bring them on board as, as if to their understanding of value based care, how to implement that in their office adjust their workflows.

Why this value based care matter? What does it matter to the physician? What does it matter to the patient? how do we help them be successful in these contracts so that their organizations can continue to support the work, that they need to do as our reimbursement models change.

Why is the patient experience metric and other quality scores so important? Why does value based care even exist? I mean, what is the great need.

So, value based care exists today because our current reimbursement system is flawed if not broken. If you think about the way health care has always been reimbursed, it is somewhat of a perverted system in my mind. We have been paid not really to keep you well, but to allow you, in some ways to stay sick. We don't focus enough on wellness and prevention, and we're paid in a service model. In other words, you pay me for delivering a service so that the incentives are aligned around a transaction. You come to see me, I deliver a service, I am paid either by you or your insurance payer or the government, whoever it happens to be, reimbursing the physician. And that model doesn't incentivize me to do a whole lot other than to continue to deliver services, at least financially. I would hope that all physicians still remember their Hippocratic Oath, and they're out to do good. But at the same time, the reality is we have to keep the lights on, we have to pay our help and our staff, and the way to drive revenue in a fee for service model is to see people for encounters.

In a fee for value world, we would move away from that. We would get paid for outcomes. We would get paid for keeping you well, get paid for the work that is required to keep you out of the hospital as often as possible, or to prevent you from being readmitted to the hospital. So, it changes our focus. It can still provide enough revenue for physicians and their offices and health systems to stay alive, but it just realigns how we think about delivering the care. It also allows for other paraprofessional health care providers to deliver some of that care. It doesn't all have to be delivered by the physician. There are times when it may be more appropriate to have a social worker, a nutritionist, a dietitian, a nurse to see a patient instead of the physician. But the way our system today is structured, for the most part, we're only paid when there's a physician encounter or an advanced practice provider encounter. So moving away from that and paying us for outcomes, paying physicians for outcomes, is what the whole transition from fee for service to fee for value is trying to accomplish. And the need to do so is why value based care exists today.

Well, Doctor Lennon, do you have any patient stories that you could share?

As I became exposed to a wider variety or a larger, I guess, view of value based care through my involvement with CHESS and exposure to CHESS, one of the things that really struck me was actually pretty personal. Our pharmacist run a, I think they call it a DOAC report, is a report that will look at labs drawn yesterday for patients who are on blood thinners and, when that is when that happens, then they can identify patients who may need to have their oral anticoagulant dose adjusted because they have renal disease. So if their kidneys are not clearing that drug, well, then they might need a renal dose adjustment. Drop the dose down so that they don't get toxic levels of the anticoagulant in their system and be at risk for bleeding. That happens, they fall, they hit their head, they have a bleed in their head, or they could bleed spontaneously. So that's a dangerous thing. Well, my dad at the time happened to be on one of those oral anticoagulants, and my mom was calling me and saying, your dad's waking up with blood in the corners of his mouth. And I knew he had some cardiovascular disease. And so, I reached out to our pharmacy team here and said, hey, this sounds kind of fishy to me. He's not in a value based care arrangement at all where he lives in North Carolina. What should I do? So, I reached out to his provider, had him get some labs checked, and lo and behold, he needed, he actually needed to be on a different medication because of his renal disease. And then I thought, you know, not everybody has a physician for a son who can think about this or identify this.

And so it really convinced me at that point that the work that gets done in value based care and the way the payment structure is, is established, allows us to do some of these things for patients, which we as busy physicians in the office, often forget. Or we get busy and we see a lab two days after we saw the patient, we're not thinking to go back and check the last, serum creatinine or BUN and determine what stage kidney disease this patient may have, or do they need a renal dose adjustment. So, automating some of that behind the scenes. So the practicing physicians not having to think about that all the time, it provides them with the support they need so it makes it easier to do the right thing. So that for me, at that point, I really became a believer. And what is happening here as, you know, as we continue to do the type of things I just described, as well as many others, that's just one report that, really hit home for me personally. And as I go out and talk to other health systems, and particularly I talk to providers about what's happening, that's my favorite story to share. It tends to resonate pretty well with them.

Well, on the subject of speaking to other providers, would you explain how CHESS supports each of them and their patients to improve the overall experience for both?

If you think about an ordinary patient's interaction with a physician over the course of a year, and let's even take someone who has a chronic condition, they might, if they're in good shape and doing well with their condition, they might see the physician for four visits a year, at best that's an hour time with the physician in the course of a year.

The wraparound services we provide are going to touch that patient much more frequently between those encounters in the provider's office. That's where we connect with patients. That's where we find opportunities to improve the quality of their life and the quality of their care. So often, one of the areas that we focus on in those wraparound services, is a transition of care from the hospital setting to home, or from the skilled nursing facility to home in particular. And it is a time of great danger for patients as they make that transition from one setting to the next. Our care coordination teams and our pharmacy teams work very closely with patients in that transition to ensure that they have the right medications, they have the right dosages of those medications. They're actually able to acquire the medications and afford them. They discover and find situations in the home that would impede the patient's progress, or possibly even cause a setback.

Those are the kinds of things we do that the providers or physicians are just not able, in their busy schedules in the course of a day, to tend to. And so, by providing nurses and pharmacists who can reach out and connect with patients, we're able to extend the reach of a physician and help them to touch patients in a time, and in a way which they would not otherwise have been able to do.

Awesome. Doctor Lennon, thank you for joining us today on the Move to Value podcast.

Thomas. Thank you. It's been my pleasure.