PegaWorld iNspire 2023: Panel - The Value of Patient Navigation at HCA

HCA Healthcare is committed to being the provider of choice for patients and physicians by leveraging the scale and capabilities of the system in the local markets. Why Care Navigation? Operational Excellence – optimizing navigator efficiency while improving quality of service and navigator experience. Maximizing reusability reduces operational costs, increases standardization, improves quality, and accelerates time to market and growth. Better care coordination – improving patient outcomes and experiences.

Transcript:

- Welcome you guys. Thank you for joining us today. I feel like we have a tough time 'cause most people are still probably at lunch so we may have some people trailing in afterwards. So we're gonna go through, our session is the value of patient navigation at HCA healthcare. Can we get the screen up? Great, thank you. All right, so I am Barbara Coughlin, I'm the vice President for navigation care, navigation operations at HCA and the panel to my left here, we have Meredith and Sonya, which are both directors on the care and navigation team, and then Jesse Jawanda is our senior director on the care management on our IT front. So we're gonna go through kind of what our journey has been over the past four plus years as we are building out a navigation and enterprise solution for HCA. Our agenda is really gonna be to, first of all, I know probably most people in this session probably are healthcare or around the healthcare space, but just in case you are not around the healthcare space, Meredith is gonna go over who we are, HCA Healthcare, in case you are not familiar with our organization and giving you kind of an idea of the breadth, and scope, and depth of navigation that we do within HCA. Jesse will go in a little bit more on the technical side around our enterprise care navigation solution and how we have developed it, partnering with Pega over the past four and a half years. And then Sonya will bring up the end and we'll go through kind of the outcomes that we have seen. We are definitely on a marathon, not a sprint. So even though we've been working on this for over four years from a technical development perspective, we still have many years ahead of us to finish building out all the navigation that we wanna bring onto our enterprise solutions, so we still have several years ahead of us. So with that I'm gonna turn it over to Meredith and she's gonna go over HCA.

- Thank you, Barbara, and thank you, Pega for having us this week. When we set out on this journey to create a standardized navigation platform, we knew we had to stay true to our mission. Above all else, we are committed to the care and improvement of human life. Dr. Thomas Frist, Sr. and Jack Massey made that commitment 55 years ago, and it still remains at the forefront of everything we do today. For those not familiar with HCA Healthcare and our services, we wanna take the opportunity to share them with you today. We are one of the leading providers of healthcare services with over 180 hospitals, and 2300 ambulatory services across the United States and United Kingdom. Las Vegas is actually home to three of our facilities at Sunrise, MountainView, and Southern Hills. You probably have an HCA facility near your hometown as well. Our facilities, corporate offices, and numerous affiliated businesses employ over 300,000 colleagues across the country and within the United Kingdom, which also includes 45,000 physicians, and over 90,000 registered nurses. In 2022 alone, we had over 37 million patient encounters, including 9 million emergency room visits and over 200,000 deliveries. We're not just here to talk about HCA Healthcare as a company, we're here to talk about our care navigation journey that started eight years ago and how Pega is helping us to bring our vision for standardized navigation to a reality. Back in 2015, our service line leaders identified a need for standardized navigation and leveraged external consulting services to evaluate our siloed navigation programs to determine how we could consolidate them onto one technology solution. As a result of these engagements, we found that none of these systems had the capability to expand and support our existing programs. So in 2017 we set out to find a platform that could and sent out an RFP to 24 eligible vendors to participate. After several rounds of demos and a detailed proof of concept, our care navigation executive committee selected Pega as the vendor to partner with. We developed and piloted the new Pega navigation platform within our high risk perinatal navigation program since they did not currently have a system. After success in our first division, we quickly deployed across our enterprise, and even pulled up pediatric navigation by the end of 2021. After establishing a navigation foundation to build upon and receiving approval to expand, we set out to move our Oncology and multi-specialty navigation programs onto the platform and sunset their existing systems. In 2022, we piloted these programs in our Denver division. Since then, we have brought these programs live in two additional divisions and are actively working on deploying them out to our remaining divisions across the enterprise. Throughout this development journey, we've taken the opportunity to define what our primary objectives are for the navigator, as well as the application itself, regardless of the service line. As a navigator, our main focus will always be to remove any barriers of care that a patient has to improve their quality of life by expediting their diagnosis and treatment, connecting them with additional HCA services as needed, and always working to expand the navigation growth. As an application, we want to reach more patients, improve navigation efficiency, accelerate development opportunities, and improve communications between our care teams. To date, we've seen tremendous success within our care navigation programs using the Pega application. To highlight a few of our stats, we have four navigation programs live with an additional 14 and counting that have already requested to move over to the application. 123 out of 420 navigators across our enterprise are currently live on the system in 55 facilities. Navigator productivity has increased from 12 to 35% based on the specific service line program. For Oncology alone, we've been able to eliminate over 56% of our documentation. Since going live, we've navigated over 40,000 patients, we've scheduled over 3000 appointments and sent over 16,000 digital messages, all from the Pega application. We've also been able to integrate with seven other technology systems to pull in patient EMR data and even send out additional information as needed. Throughout these transformational operation changes, we've partnered with our IT team to translate our needs into a technology solution that can support our existing navigation programs and scale for the future. I'll hand it over to Jesse now to share how we've been able to use Pega to do just that.

- So as Meredith had alluded to, this was not only just a technology collaboration itself, but it really was a transformational change that needed to occur kind of across our enterprise. So we leveraged that consulting service and I think through that engagement, there was three or four major principles or tenets that we were going after. I think the first one was to really look at the patient holistically across their care navigation journeys, being able to kind of allow our clinical navigators to work at the top of their license, and be able to ensure that we can offset those nonclinical tasks to ancillary team members such as contact center agents. The other thing was for us to be able to have power in numbers, right? We needed to be able to have the technology unlock our teams to be able to do more, and to do it across multiple service lines and that's what we call kind of multi-specialty. And then the last thing is just to make sure that we meet the patient where they would like to be engaged, which could be digital, or it could be that face-to-face, or that phone contact. So when we think about those core principles that you see up there, workflow standardization was key for us to be able to implement really the desired outcomes that we were looking for, to ensure that every patient got the same equity in terms of their care delivery. Reusability was a core tenant for us. We wanted to make sure that we had reusable components, features, functions and being able to access a lot of our enterprise integrations that we do have. And then lastly, as you can imagine, healthcare is very dynamic. It is very personal and we wanted to make sure that we had within our technology the ability to be flexible to meet our service line needs and be able to meet the patient's needs. And then lastly, as we talked about engagement, being able to do more with the same amount of resources or be able to do it more efficiently is very important to us. But being able to now have a technology and a platform that allows us to do digital first engagement depending on the criticality of that condition, and then being able to break it down into separate workflows. So in our use cases we have here as episodic where we're basically able to shepherd that patient to their next point in their care journey, as well as then in the longitudinal space where we're able to manage a patient over a multitude of months, and be able to have multiple contacts with that patient for an extended duration. That could be Oncology, it could be high risk Women's in terms of that service line. So when we think about applying that into the Pega architectural layer, and as we talked about that exhaustive RFP that we did, there was aspects of this that was really important for us, just due to the size, scale, and complexity of our enterprise. There was really no out-of-the-box solution that we could find that really met our needs, right? And so our goal was to really kind of build an accelerator to allow for that care management application to be built more quickly and more efficiently to meet the business need as well as be nimble to the transformational changes that occur on a day-to-day basis. So when you think about what you see here in the architectural layers, and of course, we heard today about the layer cake and the importance here, it's how did we apply that in our use case, right? And so as you go to the the left there of our brain and our transaction management, a lot of that is patient identification and ensuring that we really understand how do we get those patients to the right level of engagement, qualifying them that they are eligible for navigation, and then being able to start that engagement itself. When we think about our situational layer cake at that core base of Pega Care Management was really some of the out of the box functions that we needed to leverage, which were a lot of our workflow templates, a lot of the data models that were existing already. But then being able to build upon that and that really leads us, to the HCA care management foundation that's our agnostic base layer of features, functions and integrations that are common between all of our programs. So being able to kind of build those tools within our toolbox, allows to drive towards that repeatability and reusability. And then lastly, ensuring that we have that care model are those workflow standard features that we were then able to implement, which are our longitudinal and episodic ones that we were discussing earlier. And then lastly, the programmatic piece. So as we think about the service lines and the navigators that are serving our patients, there are nuances in terms of managing your cardiovascular patient versus an orthopedic patient, and how do we layer in standardization but at the same time be nimble enough to meet those very specific needs at the service line level? And really bringing this vision to life, this is just a great example of what we did in oncology navigation. So we had some key principles and we really needed to kind of take this model and see if it could work for us. And so as you can see here, we leveraged our core workflow and building out our longitudinal use case for oncology. And the first one that we did it for was our breast tumor type. We were very intentional in the workflow configuration to accommodate for the nuances that are necessary. And you can see that in the blue and orange shades of where exactly we had put some nuances that would be necessary at the tumor type level. So as we incorporated additional tumor types, it was a much lighter lift. So as you see in that bottom quadrant there, our first build took about 20 weeks to kind of build the full-on application and that breast tumor type. But then the subsequent tumor types that you do see on the left side, were all built basically within one sprint. And so this drastically improved our efficiency in terms of introducing these new tumor types. As new opportunities came to navigate more patients, we're able to kind of build that on, and become a little bit more nimble in terms of their needs. Next, we're gonna have Sonya review the early results being recognized from our transformational changes, and we're super excited about that.

- All right, thank you, Jesse, for highlighting the framework development that really allows for rapid implementation. Now I'm gonna put on my operations hat for here for a minute. I've been a nurse for almost 20 years, and I can tell you the healthcare industry has a lot of very unique challenges. I'm assuming if you're in this session, you might understand that a little bit. One of the biggest, of course, is the labor shortage, which was certainly gotten a little bit worse, maybe through Covid, and over the last few years. In an effort to really make our team more efficient and allow for them to really reach more patients every day, we had to do something a little bit different here, and we had to look at our challenges in a unique way. The integrated systems, as we look at that program integrations, really looks at what are the nurses currently doing. How many screens do they have open at one time? How many additional programs are they opening just to be able to navigate one patient? And this is where we realized, man, we had a great opportunity to just integrate those systems directly into our Pega platform. Looking at standard workflows. So how many people here struggle to get every staff member to do the same thing every day? Like this is not a unique challenge, right? So at the same time, nurses are no different, and trying to get them to walk through and do the same process every single time on the same patient, man that is a little bit challenging. And so as we looked at this system, we developed a system where we can have improved workflow, standardized processes, standardized documentation that really just walks them through, one step at a time, and then equally prevents people from doing things a little bit different day in and day out, which of course is challenging from a leadership standpoint. And so one way that we did that, is really through our automated tasks, and I'm gonna go into a little bit more detail about that,. That really just prompts the nurses on each step along the way, what needs to happen with that patient journey. Also here, as we look at our step-by-step structure data fields, that's huge, because now it allows for us to have really accurate reporting of what's happening with these patients, looking at the timeliness for that patient journey. So that was also pretty instrumental for us. I do wanna go through a couple screenshots of our application, just to really set the stage here for how we actually implemented this with the nurses. And so as we look at efficient documentation, we have now, kind of, a quick speedy checkbox approach for documenting the patient's past medical history. Lot of reasons for this, one of which is making it very personalized for the patient. So if we have a cardiac patient, we wanna look at their cardiac history, we wanna look at their cardiac surgical history, and that can certainly change by our different patient populations. The other thing I'll mention with this is documentation with different abbreviations can be challenging. And so this really spells out everything but still makes it very efficient for the navigators. It also pre-populates with each admission. So if the patient is coming back a second time or a year from now, we have a pretty good head start from a documentation standpoint. Improved workflow. We have... As I mentioned there, we have the automated tasks, we also have additional tasks here where they can say, hey, next Friday, I'm gonna call this patient, or I'm gonna ask about something specific. And then every day when they log into the application, it has what I call their daily to-do task. So this is telling them, hey, I need to reach out to these five people, this is what I'm gonna talk about, and really kind of drives that clinical pathway. Back to that documentation. Can't emphasize this one enough. So this is where, as we look at different barriers for patients to follow up. Again, we know the healthcare system can be challenging and there's a lot of different factors here that can make it a little bit more difficult for patients. And so we wanted a really quick way to document that they may have transportation issues, they may have financial concerns, a lot of different ways here that we may need to step in and help the patient. And so with this, quick sliders, as I'm calling it, this stays on the patient level. And so if they were to come back for any other navigation program, everything stays in here for that patient. It also means that when we resolve a problem, like maybe we connected them to a great transportation company and they're good going forward, we can use the little slider and change that and say, okay, that barrier's been resolved for the patient. With any of these changes, it also highlights to the nurse with different color cues and icons in different areas, which I think has been very helpful as well. We know everyone loves feedback. This is what I refer to as the daily ticker. And so as the nurse navigator is calling patients and maybe making appointments on their behalf, or going through their tasks, each step along the way, every day, they are getting that daily ticker that goes up. I'm sure some of us would love this in our more professional life with Outlook, and how many emails did I respond to today, and check some of those meetings off the list. This is kind of like that, but for the nurses. All right, and looking at our outcomes. This is probably the most exciting part here. So starting off with the patient experience, I will say what was so exciting to me the first week that we launched this. Literally the first week. We had so many positive comments from patients, and they would say, oh yeah, I got your text message you sent. They didn't say, I got your voicemail, now they looked at the new ways that we were reaching them, which was pretty exciting. So just a lot of really positive comments as it relates to our digital communication. The operational excellence. Again, not to beat a dead horse here, but I do wanna really highlight that, a standardized workflow that we put in place, and what a big difference that made for the nurses. So a lot of positive comments, again, just the first week of training where everyone really said, oh my gosh, we needed this, this whole time, it really walks us through step by step. The communication between healthcare teams. This is where we have different ways of now communicating back to physicians in the hospital. We could highlight that patients are actively being navigated. We have ways now to communicate between different navigation programs, so we're not all working in our individual silo, and we know, somebody else may be managing a patient for cancer, and by the way, now they have a heart problem, and all the teams can really communicate together. The time to market. As Jesse mentioned, this is really where it comes into place that we are able to go from, hey I have a good idea, to, okay now we're live, like it is now in place. So that's really what I think is so exciting about this, is we are going from that, kind of, idea to launch very quickly, and that has historically been a little bit of a challenge. The operational efficiency. This is where we saw that improvement of at least 12 to 35% on the navigator level, and being able to reach patients and appropriately navigate the right patient populations. The enhanced reporting. The structured fields, now that we have in place have really opened up the doors to have a really nice patient story. And so we can look at that entire treatment pathway for patients, we can look at a lot more information than what we had before. So really very exciting. I will say we've had a lot of really quick wins with just implementing this over the last year. I am very excited to to really see how this goes over the next year and what some of our new metrics look like now that we've had a little bit more time to peel back the onion and continue to develop all of this. So at this time I'm gonna open it up for questions and I will also just leave it on this screen for our contact information. So if there is something that kind of sparked an idea or you may not wanna ask it right now, but think about it on your plane ride home, please start at the top with Barbara Coughlin and direct all questions to her. I'm just kidding, I'm just kidding, anyone on here is fine. But all right, so we're gonna go ahead and open it up to questions. We have a couple mics in the room here, don't be shy.

- [Audience Member 1] Hi, you mentioned... One of the slides showed integration with doctor's offices for scheduling. My question was, are those all doctors employed by HCA, and did you have control over what scheduling system they were using, and did they all use the same one? In what system was it you integrated with?

- Yeah, yeah definitely. So, today the way that we have been set up, is that we have the integration with our contact center agents that then work with those physicians to be able to find that appointment availability. So a lot of them are our employed offices and those providers. We are looking at different APIs and interfaces that will allow us to do that with that extended team that are out there in the community as well. That is definitely a major initiative for HCA's being able to cast that wide net and be able to build those APIs that allow us to get appointment availability, not only at the provider, but also the practice level. So if one provider is not available, what is the next available option? And timeliness to care is super important for a lot of our clinical conditions that we're treating. So I think that's a, a very imperative initiative, but it goes beyond. To your point, just our HCA employee group.

- I do wanna mention maybe just one thing as it relates to integrations. So that is one thing that we've built out through the Pega system. Now, previously a nurse navigator might have that application open while they were talking to the patient, and they're actively looking up the patient name, and trying to find out when is their next appointment with Dr. Jones. Now, we've integrated that system into the platform and it already shows up there right in front of the navigator, so they can say, oh yes, Dr. Jones, in this case relates to our employed physicians. We can reinforce that with the patient right there while we're on the phone, and all of that is integrated.

- Yeah.

- So that's another factor.

- I think you asked about the application itself. So the EMR that they do use on the outpatient side is eClinicalWorks.

- For our employee physician, the only thing I would add is that one of the big initiatives when we were doing this project is that it has to be a transformational change project. And so we really drove the service lines that already had applications to not just rebuild their application. Like how can we do it smarter, better, faster? And so previously a lot of our nurse navigators were scheduling appointments. Well, that is not a good use of a nurse navigator's time. Like I don't need a nurse scheduling a primary care appointment. So we are integrated over with our contact center, and so we send appointment requests that need to be scheduled, over to them, and then they have a very Stark-compliant physician referral process, and it does schedule appointments with either our employed or affiliated providers. It goes through this whole algorithm that's approved from a Stark compliance perspective. So, it was a great question. Anybody else?

- [Audience Member 2] Kinda tying on that integration question, was there a lot of hesitation on removing this work, and this documentation, and this engagement from the EHR? I would assume working with other provider organizations, they would say no, everything stays in the HR, that is the system of record, that's where the patient's information lies. And that would be a big hurdle to overcome with something like this.

- Yeah, so our navigation notes are not included as part of the legal medical record. Our navigation notes have never been included in our EMRs, our electronic medical records. So we handle our navigation as a supportive mechanism with our patients to help them through their journey, but our nurses are not part of the core care team that's providing care to the patients. So we're really meant to be more of an adjunct services where we're helping them either get from the hospital to their next appointment. Or if they're on their oncology journey, which could be longer, or high risk perinatal, or helping them to facilitate conversations with the physicians and helping them go to their different appointments and get to the right services. But we're not making those medical decision-making. Now, with that being said, we have a couple of integrations with our EMR. So for example, we connect all of our patients into our hospital EMRs, so that if one of our navigated patients shows up in the hospital, they're flagged as a navigated patient. And then on the flip side, we send all of our navigation notes over to an HIE viewer, so that if a provider in the hospital sees a patient that has a navigated flag, they can go over into HIE and see any navigation notes on that patient. So we give the information to the providers but we don't include it in the actual medical record.

- [Audience Member 2] Yeah.

- But I think that goes to some of the Pega advantages, right? We don't want to duplicate the source system, we wanna allow that source system to be called upon and be looked at and reviewed by a clinical navigator, but we don't have to dual document, right? And so that's really a key thing with the API strategies that we do have. It allows us to have access to those enterprise assets, bring those, that information in, enrich that information for the navigator and really just help with that patient's navigation.

- Thank you.

- Sorry.

- [Audience Member 3] Gosh, every time I look at your slides, I think about what a great job you guys have done and how the Pega team just loves that layer cake. But I was wondering if you yet have any information about the impact of this new system on training new employees. You mentioned the transformation, you know, flipping over the system, but how do new employees, nurses who have worked elsewhere with stickies and multiple screens, how are they taking to it?

- Sonya and Meredith, you wanna take that?

- I'll take that a little bit from an episodic side. So the biggest comment I hear when we train new staff, an early part of that is the conversion over from our legacy system, is there's just so many comments of, this is so easy. Because it does, it just directs them from one section to the next, and you can't move on to page two unless you've reached the patient and did X, Y and Z, and there's no chance then for people to get confused and start wandering over to a different area or start kind of going down rabbit holes. It is truly just a step-by-step kinda directed care, and that's why I think it's been so easy to train people, compared to our legacy systems.

- Meredith, anything you wanna add?

- Yeah, I'll add to that. So as I mentioned, we started out with our high-risk perinatal navigation program. They were not currently on a system so they were using any sort of office product they could use to track their patients. So, to say that the change was very well received is an understatement. But since then, we have taken the opportunity to even refine the training that we do just for their teams that we've then been able to move over to our larger navigation programs for multi-specialty and oncology. So we do use HealthStream videos that we use, as well as take the opportunity now. We're in the process of making more foundational training. So regardless of the service line, every navigator at HCA will have the same foundation, so that they understand, really what is an HCA navigator, what are those core components, and then go into more service-line-specific areas. But I think it's an area that we continue to refine as we bring on new service lines. Great question.

- And I think the one thing is that you'll find that the system, the way that we've designed it with the Pega functionality, it is very easy for the navigators to learn. But we also are building reporting to make sure that... I'm a nurse by background as well, so I can say this honestly, we will find alternative ways to do something if we think it's gonna be easier, right? So, like you're used to doing that on a clinical perspective, and so we have reporting tools now where we can identify if people are kinda deviating off the path or whatever, so that we can pull 'em back in, and making sure that we're documenting the same way consistently. But I will say it's not super easy to deviate off the path. There's not a lot of other paths you can take in the system, which does make it a little bit easier to keep that standardization that we're trying to drive towards, especially between the different service lines. So between an easy application for the nurse to navigate in and also being able to monitor and track it easy has been very successful. We're eventually gonna have around probably between five and 600 nurse navigators on the system when we're completely done building. So we had to have those productivity standards in place as we started or we're gonna lose it before we get out to the final version.

- [Audience Member 2] That's a great story. And so my other question, kinda unrelated, is, you mentioned patient experience, you mentioned impact on your staff, but I'm kinda curious how your other clinical partners at HCA have been able to recognize how much better things are in the care navigation space. Wondering if you have any feedback from them.

- Well, so I'll start that and then let others answer to that. So navigation is seen as a huge support for our service line growth. So oncology, it is the backbone, I will say, of the oncology programs, 'cause we capture clinical pathway information, they collaborate with multidisciplinary meetings, cancer boards. And so navigation is a big portion of an oncology journey, and Jennifer Hasburg who's here with us, senior director on the oncology side can speak more specifically to that. And then on our episodic side, that is how we're getting those patients from the hospital over to the right patient care setting post discharge, which is very confusing. I have an elderly mother, when I get discharged with her from the hospital, I'm like, thank God I know what's going on, 'cause I don't know anybody who could like transition that, especially on the elderly patient population. So that's really helping build those relationships with our ambulatory physicians, you know, cardiovascular, neurology, et cetera, those specialties that we're trying to transition those patients over to. And so we have a lot of engagement with our service lines on how to grow that patient population, and making sure that they stay in our system when it makes the most sense. Women's and Children's is another example on the longitudinal side, similar to oncology, high risk perinatal, a lot of times those mothers have never been in a healthcare setting until they have a high-risk pregnancy. Like a lot of times those are healthy young women and then they have, unfortunately, a very high-risk pregnancy that doesn't always end well, and that's their first engagement a lot of times with the healthcare system. So really navigating them through that very stressful situation, one, develops a lot of patient engagement, hopefully stickiness if you will, with the patient to stay in our system if they have a good experience. But it's also working with those maternal fetal medicines and OB-GYN physicians and pediatricians to really build out that relationship of what we can do with their patients and help them through that journey. So it's a great support for our service lines and a lot of our development is strictly related to, service line asks for support for specific patient populations. Yeah.

- And I'll add one more thing to that. So from the beginning we had a care navigation executive committee that includes service line leaders from across the enterprise. And so regardless of if they have an active navigation program, they've been included as a stakeholder, and they've been brought along this journey since 2015, and they're aware of what we're doing, and to this day there's still some service lines that they're ready to move on. They're very excited to see what we're doing. So it's very well known within the HCA of what and how navigation has grown and I think there are a lot of people excited about the future of it.

- Yeah, we can't move fast enough, quite frankly, on some days. Yeah, what's your question?

- [Lisa] Hi, my name's Lisa. I work for Bupa in Australia. We're a provider and a health insurance arm as well. I was just wondering whether you've had any feedback from your insurance arms about standardizing information capture. We've had some interesting use cases recently where we are trying to follow up with patients on surgeries, and the information we're getting is that every body part is ticked. Clearly that's not the case, and I just wondered whether you've had feedback around how that's accelerated claims and cost reduction in that space.

- Yeah, that's a great question. So in my opinion, I think we have a great opportunity to work with our payers on the navigation that we're doing for our patients, and providing better outcomes, more consistent outcomes and a better kind of experience for the patient. But also, especially if you think about the episodic side, if we're getting the patient from discharge and getting them to the right point of care, that's gonna be the first sort of failure point so that they don't get inappropriately readmitted, right? Like if you get 'em to that next point of care. We have not consistently, I'll say, demonstrated to our payers all of the navigation efforts that we're doing. And I think that there's a large opportunity, honestly, in our organization to do a better job with the payers of explaining all the navigation that we're doing. One of the big steps in doing that though is that we had to get all of our navigations onto one consistent program. So four and a half, five years ago when we first started this journey, you had oncology navigations, and Women's and Children's navigation, and what was called Care Assure, which is the episodic navigation. They all reported stats differently, all counted things different, nothing was consistent. That was one of the big reasons why we're trying to get everything onto one platform. Now that we're finally to the point where we are right now, we can start demonstrating the value across multiple service lines, and sort of making that more generic, if you will, and normalizing the data so that we can see and make comparisons, like, was this really high-risk and did that compare to an oncology from a Women's and Children's? So that is part of the conversations that we're having internally right now in HCA, is, how do we bundle all this up and then demonstrate it back to the payers? The other side of that is that there is some payers who have come to HCA through what's called our PCA, which is our payer and contracting alignment organizations. So they're the ones that negotiate with our payers. There are some payers who want us to take on the navigation of attributed patient populations. And so as soon as we get through, we have to get the enterprise deployed, which is gonna take us through the end of the year for everybody to have what we have currently built right now. 'Cause we're a large organization so we don't... It's not just one implementation. We're having to do 15 different implementations. Once we get that on, starting in 2024, we wanna work with some of the payers, and if they want us to navigate their diabetic patient population,, they could give us an attributed file, we can outline what that navigation would look like and then we can start navigating some of those patients. So there's a lot of opportunity in there, but we had to get where we are right now first before we could start really working with the payers.

- I think enriching that information with like closing our gaps in care, if there's some opportunities there. And then I think lastly, identifying any barriers to care, and then showcasing our ability to close those gaps as well.

- And one thing we didn't mention on here that I'll give you a little bit of a preview is that there's a few other things that we're working on. So one thing that's a really big issue in healthcare is social determinants of health barriers. So transportation, getting meds filled and things like that. So we are working with a partner to identify a solution for those SDOH barriers, and we're integrating that through our Pega, through our care management application. And that's gonna be a huge win, I think, on the payer's space as well, because those barriers are a lot of times why patients won't get care. And so as we go through the next few months with that partner and really integrate that capabilities, we're gonna be able to identify all of those SDOH's and then resolve them across the board for our patient population, which is a huge, huge benefit.

- [Audience Member 3] Hi, first of all, I'd like to thank you guys for presenting today. I'm really excited of what you, you guys are doing in terms of helping drive the health outcomes that we need to see because right now in providers we're overwhelmed with the volume of patients that we're seeing and we can't address it solely by ourselves. So the fact that you've created this program with care navigators to hold the patient's hand through their care continuum through this fragmented system is huge. And so with that I do have some questions more targeted towards your technology. If you had the opportunity to do the implementation again, what would you do differently?

- You wanna take that first, Jesse?

- Yeah, yeah, most definitely. I think, when we first kind of landed with Pega and we looked at the foundation what Pega had in healthcare, a lot of it due to Susan's great work is really with the payer's side, right? And so looking at the patient through that lens, versus the actual provider's side, is a little bit different. It's got data nuances. They call on the payer side a member, versus in healthcare we, of course, are managing that patient. And so a lot of the data information that's really kind of embedded there, really needed to be reconciled, right? So I think some of those fields and libraries and being able to get a better structure around that, that would be something that we would probably look at more holistically. I still do think though, however, that the core aspects of Pega Care Management, a lot of the workflow templates, a lot of the data tables, everything that's set up is still very applicable, and it was something that we were able to build upon. Barbara.

- The only thing I would add is, when you get to the... I would say we're at the middle of the journey, not even at the end, 'cause we still have a lot to develop out. And as a transformational project, transformational change project where the groups are today is vastly different than where they were four, four and a half years ago. Where they're comfortable from a change perspective and where they'll be in four years is still gonna be even different. So when we first started this journey, there was a lot of resistance to digital engagement with our patients. Like, oh no, a nurse has gotta talk to that patient, and we all feel very strongly about that. Now where we are, we're transitioning some of those conversations into more digital engagement. If I have a heart failure patient that's stable that hasn't had any new meds added, they haven't been a readmitted patient in the past two years, this is a one-time admission, they probably don't need a nurse navigator calling. We can reach out digitally and say, hey, are you okay? We see you have an appointment, do you need anything else? And then by exception, have a nurse get engaged with that patient. Versus one who's had six readmissions, never gets their meds filled, devs would never go to their appointments, that probably needs somebody really getting involved and finding out what those barriers are. And even on the oncology side, they have come a long way in the last four, four and a half years of what comfort level they have with having some digital engagement. If you have a breast cancer patient, if you get them what I call settled, and they're really good and don't have a lot of questions, maybe we transition 'em over to a hybrid model where we do digital engagement for a while. So that would be the one thing. But I don't think we could have done that four years ago, 'cause we really had to go through that journey for the past four years. If we could've started that would've been better, 'cause we're gonna have to do some rework now to kinda pull some things back and move them over onto the digital side. But that's a journey you just have to go through sometimes when you're doing transformational change.

- [Audience Member 3] Makes sense. And to your point, Jesse, I've got another question.

- Sure.

- What percentage, of your work was out-of-the-box, had out-of-the-box functionality?

- So, like I said, I think a lot of our core workflow templates, and some of the data model behind it itself was utilized and kind of leveraged for configuration at that point in time. So I would say a good 20 to 30% is something that we went right out of the box and were able to kind of leverage. But then as a entity such as HCA, as Meredith had shown, just our footprint, there was a lot of nuances that we had to kind of bring in, just from a enterprise architecture perspective as well as then really kind of building out these programs that we needed. I would like to say that this was more than just a collaboration. I think it's a partnership with Pega. And being one of the first in the healthcare provider side. I take it as a great compliment for us to be able to kind of work together and build out this space.

- [Audience Member 3] And what I see, and I'll wrap it up, I'll leave it for everybody else. But what I see that's gonna happen with your organization is you're going down the trajectory of this care navigation, you're gonna shift the mindset of medicine from reactive to proactive. And the reason I see that is because this engagement with patients is crucial and the engagement that you're able to elucidate to drive improvements in health literacy so that they can understand the medications, they can understand their medical comorbidities. I understand that you're not gonna provide diagnosis, you're not gonna provide clinical advice per se, but that wealth and that knowledge is key for them to start gaining some empowerment over their health. So I'm so excited again, at what you guys are doing. So thank you.

- Great.

- Thank you.

- Thank you for the opportunity.

- Any other questions? So we will be here for a few minutes afterwards. And seriously, Sonya mentioned it and Steph, if anybody has any other questions or you want us to set up a WebEx call or anything, we're happy to talk about our journey, what we're doing and stuff. So our email addresses are up there. Thank you guys so much for attending.

- Thank you.

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