HEALTH INFORMATION TECHNOLOGY
Reducing patient no-shows Hitching a ride BY CHIP TRUWIT, MD, FACR, AND CHRIS MERRITT
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edicaid spends $5 billion on non-emergency medical transportation (NEMT) every year, but 3.5 million patients still miss medical appointments. Patients who do not receive timely care may experience health crises that require expensive emergency department visits and potential inpatient admissions. Moreover, estimates show that no-show appointments cost U.S. health care systems $150 billion each year in lost revenue and unproductive staff time. The National Institutes of Health says that patient no-shows significantly affect not just care delivery, but also cost of care and resource planning. Patient access to reliable transportation represents one of the most persistent barriers to health care in the U.S. Published data report that lack of transportation is responsible for 25 percent of all medical appointment no-shows. This is particularly true for our under-served populations, whose health is significantly constrained by social determinants, including access to food, housing, employment, and transportation. For this population, transportation is effectively “medicine.” Paradoxically, this transportation barrier exists at a time when the number of transportation options is unprecedented. Traditional taxis, clinic shuttles, public transportation, and ride share services like Lyft and Uber provide ride options. Moreover, the sheer number of these ride services alone provides exceptional coverage. So, why do patients still miss appointments due to lack of reliable transportation?
Treating the symptoms If you think about it in terms of medical care, the system is treating the symptom of transportation, not the disease. There have been multiple ride options for quite some time, yet no-shows persist. Some heath systems offered an incremental change, replacing taxis with Lyft and Uber, although their process itself changed little. In fact, a JAMA publication earlier this year reported that such programs have had very little impact on no-shows. However, such programs and the JAMA publication both fail to acknowledge that it’s actually the process that impacts patient engagement and participation in ride programs, not necessarily the make and model of the vehicle. Upstream Health Innovations (Upstream) and its first commercial venture, Hitch Health, witnessed this first hand at Hennepin Healthcare and set out to uncover why this was happening. It’s important to understand the “why” before you provide a solution to a problem, particularly one that is influenced by social determinants of health. Upstream’s human-centered health care design team met with hundreds of patients, families, and health care professionals to understand the problem and uncover a solution. Medicaid patients told us they need to call their health plan three days in advance of an appointment to request transportation. They are often put
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AUGUST 2018 MINNESOTA PHYSICIAN
on hold and can spend 30–45 minutes on the phone, wasting their time and mobile phone minutes just to get a ride to the doctor. The coordination of return rides home is equally painful for both the patient and the clinic staff, with long wait times that often exceed 2–3 hours.
Jump starting the system Patients told us they do not want to call to schedule a ride, be placed on hold, download an app, or provide a credit card for either the traditional or new ride service options offered to them. Collaborating with Upstream and Hennepin Healthcare, Hitch Health has developed human-centered design software to improve patient access to transportation and care. The proprietary technology software (patent pending) sits between an appointment system—tied to electronic health records (EHRs) or practice management systems (PMS)—and a ride service such as Lyft. Importantly, Hitch Health is agnostic to both the health record and the ride service (ride share or taxi). Patient appointment data flows electronically to Hitch Health, whose software filters the appointment data to determine which patients will receive a ride offer. Hitch Health then automatically sends patients a ride offer through basic SMS texts delivered to their cell phones. The process is completely automated and controlled by the patient. When the appointment is over and it’s time to go home, the patient simply texts “ready,” and a ride will pick them up within minutes. The software was designed with simplicity and security in mind. Because the software sits in between an appointment system and a ride service, it communicates directly with the patient, removing the middleman. Hitch Health obviates the need for a phone call, app, or credit card to access the transportation service. Front-line staff can also track the patient’s ride locations through a dashboard, which increases coordination, efficiency, and customer service. Thus, Hitch Health is quite different from other “startup” solutions that simply exchange taxis for Lyft and Uber services, yet maintain the current process of engaging call centers to schedule rides. Hitch Health is an innovative logistics solution that automates both the front and back ends, providing a human-centered experience and increasing patient satisfaction.
Driving up the numbers The results are drawing attention. Hitch Health began a pilot with Hennepin Healthcare, a large safety-net hospital in Minneapolis with more than 650,000 annual appointments and a relentlessly persistent 19 percent no-show rate. Hitch Health has been deployed at five Hennepin Healthcare clinics, and has provided more than 8,000 rides to Medicaid patients in the metro area. Remarkably, 80 percent of these patients had six or more missed appointments in the previous 12-month period. Data suggests a reduction in no-shows of greater than 8 percentage points in those clinics deploying Hitch Health. Patients are showing up to their appointments and reporting