Building a Better Network in Ohio

Published on Friday January 3, 2020

Pioneer Physicians Network, an independent physician group in Northeast Ohio, has used PCMH recognition and participation in CPC+ to develop a more structured and disciplined approach to care. As a result, the network realized the value of opening after-hour clinics to serve patients who would otherwise continue to go to local emergency departments. The network is now improving ED utilization, controlling costs, and better understanding the urgent care needs of their patients.

“We realized there was an opportunity to collect data from that call and educate our patient at the same time. So, we developed a structured data template to guide our nurses in making that transitional care management call.”

Leanne Knight, Director of Health Informatics, Pioneer Physicians Network, Ohio


Topics From This Episode

healow Open Access®

healow Open Access® for online appointment booking helps providers reduce no-shows, keep schedules full, and reduce administrative burdens on staff, while offering patients the convenience of requesting and/or booking their own appointments. Improve your practice’s online visibility and improve patient satisfaction while remaining in complete control of your providers’ schedules.

eClinicalWorks Business Optimizer® (eBO)

eClinicalWorks Business Optimizer® (eBO) offers eClinicalWorks clients a full suite of canned reports and metadata, a newly redesigned portal for easier access, and administrative dashboards featuring the financial visibility and insight their practice needs for success.

Patient-Centered Medical Home

The Patient-Centered Medical Home (PCMH) model is a self-guided, operational excellence program that puts primary care at the center of healthcare reform, helping private practices, hospital groups, ACOs, and health centers use analytics to assess and manage Population Health and coordinate care efforts as they seek to improve outcomes and lower costs.

Comprehensive Primary Care Plus (CPC+)

CMS’ Comprehensive Primary Care Plus (CPC+) initiative aims to transform practices by implementing best practices in access, care management and coordination, Patient Engagement, and the management of Population Health. Whether your practice is in Track 1 or Track 2, eClinicalWorks has the tools and experience to help you navigate payment reforms and the transformation of care.

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Adam Siladi: Good morning and welcome to this live edition of the eClinicalWorks Podcast. I’m Adam Siladi, and thank you so much for being here with us this morning at our National Conference in Orlando, Florida. You know, the healthcare industry is changing rapidly, and care delivery models are adjusting as a result, along with reimbursement models, but there’s never been more opportunities for growth in the industry as we have today. Of course, technology has to play its role, and eClinicalWorks is no different. And here to speak with us about how they’re leveraging the eClinicalWorks technologies to change their models and their deliveries to improve patient care are representatives here from Pioneer Physicians Network. We have Kathleen Kostelnick, who is the Practice Administrator and Director of Business Operations, and we have Leanne Knight, who is the Director of Health Informatics. Thank you so much for being here this morning.

Kathleen Kostelnick: Thank you, Adam.

Leanne Knight: Thanks, Adam, for having us.

Adam: So, the first thing we’d like to do is learn a little bit about yourselves and your organization.

Kathleen: Great, thank you. Thanks so much for having us today. So, Pioneer Physicians Network is an independent physician group. We’re one of the fewest ones left up in the Northeast Ohio area. We have over 60 providers with mid-levels and primary care physicians. We’re located in 18 locations across three counties, with a centralized office to support all of our primary care offices. We’ve been focused on quality measures and working in many strategic programs with CMS, HEDIS® Quality Star measures. We’re a Patient-Centered Medical Home — we’ve done that since 2012, Level 3. And, we’re also participating in the CMS Track 2 CPC+ program.

Adam: Well, those two programs I think — PCMH, like you said, and CPC+ — both advanced models of primary care, so it’s great to know that you guys are working on those. Now, one question that I have is when we were talking before you actually mentioned that you did something to lay kind of the foundation for all of these things that you’re doing with the HEDIS and all of that stuff. What was it that you think really gave you that strong base to do what you’re doing today?

Kathleen: Right. So, moving from fee-for-service to value-based, we really had to be very intentional about our processes and strategically leverage technology and data analytics. Leanne, who’s our health informatics director, has led this, our group, in all of that, and I’d really like to turn it over to her to address some of the exact things that we have done. But it really was laying a foundation, and by participating with the Patient-Centered Medical Home program and the CPC+ programs, that’s what really helped us build and move to that strategy.

Adam: Do you think that your participation in the PCMH and CPC+ was a result of your structured, disciplined approach to care? Or did those programs help you to become more structured and disciplined as well?

Kathleen: It was very much structure and strategy that put those together, for sure, wouldn’t you say, Leanne?

Leanne: I agree, thank you.

Adam: Great. So, Leanne, let’s hear a little bit about your participation in some of those programs. What are some of the things that Pioneer is doing today to drive better outcomes?

Leanne: Well, you know, we have a strong focus on quality starting in 2012. But as the years have progressed with our value-based contracts, we’ve had to put more of a focus on utilization. And over the past 18 to 24 months, across our value-based contracts, we’ve seen an improvement in our inpatient and ED utilization — about 15% across those contracts. And that doesn’t come easy. As one of our challenges in our community is that we have a very large footprint of ED departments. So, we have to overcome that, as our patients have access to an Emergency Department. So, we’ve done a lot of different strategies to try to re-divert that care to our office.

Adam: Right. I think you actually called your program the ED Diversion Program, which I think gets right to the heart of that.

Leann: That’s correct.

Adam: Now, what is one of the strategies or solutions you have put in place to divert patients from the ED?

Leanne: Well, as you know there is no one solution that’s really going to change utilization. Our most noteworthy project, Adam, would be the opening of our after-hours clinics. Those after-hours clinics are in our physical locations, staffed by our current employees that work at Pioneer. However, we hired some mid-level providers that have experience in ED. We have strategically evaluated those patients that have come to our after-hours clinics by asking them, ‘If we had not been here today, what would you have done?’ And we asked that in a structured data question in eClinicalWorks, which allows us to pull that information. And we found that 13% of those patients presenting at our after-hours clinic told us that they would have went to the ED, and 32% told us they would have went to another urgent care center. I’d like to note, though, eClinicalWorks’ participation in the opening of our after-hours clinic couldn’t have been done without those healow Open Access® appointments. One third of our patients scheduled their appointments through healow Open Access, so we’re very grateful for that feature.

Adam: Well, that’s a huge success rate there, I think with the Open Access, I think that shows the value of that utility. And then, like you also mentioned, you know, eClinicalWorks gives you the flexibility to record just about any kind of information you want and make that reportable. So, you’re using that to make sure that the interactions with your patients are on track and you’re getting some value out of that. Now, you also mentioned before, when we were speaking before, about some other questions that you’re asking once the patients maybe actually do visit the Emergency Department or do wind up in the hospital. Tell us a little bit about some of that interaction, as well.

Leanne: Absolutely. You know, during those transitional care management calls we wanted to understand how our patients are getting to the hospital, why they’re going, and when they’re going. You know, that call is very focused on care management and care coordination, but we realized there was an opportunity to collect data from that call and to educate our patient at the same time. So, we developed a structured data template to guide our nurses in making that transitional care management call. And we’re asking patients ‘Did you call your office first? Did you call the doctor first? Did you go to our after-hours clinic?’ You know, we assume that our patients are calling us first, but we realized through our data that 88% of our patients presenting to the ED were not calling us first. So, that became a strategy for us to better market our ED Diversion program, and obviously using eClinicalWorks Messenger® was a huge help for that, as well.

Kathleen: And from an administrative standpoint, then, looking at all our office and what were the hours of service — were we closing down at lunch? Closing our phones off? Did we have offices that were maybe closing in the afternoon that we needed to come up with a different strategy for daytime calls? All of those things kind of rolled together once we were able to find out why patients were going to the emergency room and for what reasons.

Adam: Absolutely. Very powerful not only to be able to collect that information in your EHR, but also be able to access it when you need it and get the insights that you need for it, as well. Are you doing a lot of that insight-gathering with eBO reports and things like that?

Leanne: Absolutely. Our team builds queries based upon those structured data entries. And those are real time. We don’t have to wait for claims data to show us the prevalence of conditions as why patients went to the ED. In fact, Adam, when we do that follow-up phone call, we ask them ‘Why did you go to the Emergency Department?’ We want to hear it from them, not the diagnosis on the claim. And what we found is we have so many patients presenting with those ambulatory-sensitive conditions. Again, structured data that we’ve built and pull out of eBO. So, that data revealed there was such a prevalence of patients going to the ED for both UTI symptoms and COPD exacerbation. So, we right away collaborated with our clinical teams to develop programs where we can educate patients about self-management at home, and who to call and when, keeping them out of the ED. And again, that’s all from a really good quality TCM follow-up phone call that we’ve educated our nurses to do.

Adam: You know, it almost seems too simple to be effective. You know, just a little bit of education can be all the difference that the patient needs to make the right decision for their health and to help you work a little bit better. But, of course, without the info that you’re gathering, it would just be a shot in the dark, you know, you wouldn’t know where to direct your attentions. And I really like what you said about not being reliant on the claims data. It’s great that you have it, but I think what you’re trying to say is that when the claim gets processed, they put on the diagnosis that is actually been given to the patient, not why the patient thought they needed to go.

Kathleen: Correct

Adam: Which I think is what you’re saying is the whole aspect of the diversion, there. Well, Leanne and Kathleen, thank you so much for your time here today. I think this has been very informative and very informational. I think there’s a lot that people can take back with them to their practices so that they can make use of these tools and these programs as well. We have more eClinicalWorks Podcasts available for you. You can check those out on iTunes, YouTube, and And if you haven’t made it to the National Conference before, make sure you do that next year. For the eClinicalWorks Podcast, I’m Adam Siladi, and thanks for watching.