Luis Castillo is president and CEO of Ensocare of Omaha, NE.
Tell me about yourself and the company.
Ensocare is a care coordination platform that helps move patients to the right level of care along the care continuum. We’ve been doing this for about 10 or 11 years and I’ve been there five years.
I’ve been in healthcare IT for a long time. I don’t think I’ll ever go back to big company. I’m having the time of my life running this small company.
What are the benefits and challenges for hospitals in getting discharged patients placed and coordinating their care afterward?
The big EMR push, Meaningful Use, and even ICD-10 took people’s attention away from the post-acute care side. What happens once you leave the hospital? I lost my brother about two years ago and I remember trying to get him placed into hospice. I had to go to our network and ask my team. Who is available Des Moines area? What are their CMS scores? Because the hospital handed me what looked like the cardboard filler that comes in a shirt. It was laminated and had a bunch of numbers on it. Some were scratched out, some were written over.
They said, here you go, it’s up to you. Make some calls and figure out where to put him. There was no automation and no ability to tell me which facilities were better or which ones weren’t. That discharge and placement process is highly fragmented and not very process driven.
We put automation and technology behind this very manual place. Nurses typically stand in front of a fax machine for 5-6 hours a day getting this done, so we let them go back to working at top of license and get them back in front of the patient — case managers, social workers, and so forth. But we also impact length of stay, so if I can decrease it by a quarter-day for patient population, that’s big money over the year.
Hospitals sometimes leave placement decisions to the patient and family to make sure they aren’t accused of playing favorites or being held accountable for placements that don’t work out. Is their challenge in advising patients and families due to lack of knowledge or a reluctance to exert undue influence?
That’s a really tricky question. I still remember when health providers and payers couldn’t even be in the same room together. There was this hatred for each other. But now health plans own hospitals and hospitals create their own health plans. With some of the Medicare Advantage plans, people who are taking on risk can manage and direct patients to places if it’s their own population.
But you bring up a great point. The IMPACT Act says you have to give a patient choice. You have to disclose any financial relationship you have with that home care agency or that behavioral health provider that is affiliated with your IDN.
Our system lets you put all the choices in front of the patient and give them an unbiased score, such as the CMS scores for quality. They can flip through almost a Hotels.com interface on the tablet and look at the places that have a bed available. They can see if they are pet friendly, check which churches are nearby, see a picture of the area.
Hospitals aren’t supposed to direct people or to steer them. They have to manage that closely. Our application helps document that they gave the patient choices.
In the absence of something like a Tripadvisor that includes detailed reviews and scores from individuals, should I as a patient or family member trust the CMS star ratings?
We’ve been asked by our customers to do some kind of independent rating score for post-acute care facilities based on the data that we have, such as readmit ratios and quality scores. But I’ve been hesitant to do that. We offer the post-acute care network a free portal. We don’t charge them to belong to this, although some of our competitors do. We try to get them to be engaged, to answer inquiries within 30 minutes, and to keep their engagement level up.
We have something that is more on the predictive side on our roadmap. Predictive analytics that say, based on what we know of this patient and the performance of organizations in our network, here’s where we think this patient will do best. They need DME, infusion, dialysis, and these levels of care, and these places do really well with that. I don’t want to become a Class II device and make a clinical recommendation, but I will start scoring and show them a predictive model.
How important is it to have access to actual empathetic humans and not just technology and information when making what could be one of the most important decisions in someone’s life?
I remember when Gateway and Dell came into the PC market. Nobody thought they would ever pick a laptop or desktop off a pick list since technology was intimate in some ways. You wanted to see it and touch it. You would never buy it sight unseen. But the paradigm has shifted. We buy online, even for major purchases like cars, and just have it delivered.
You probably won’t pick a provider via technology, but you’ll get a list of 10-12 places that have a place for Aunt Betty. You take a look on the tablet at their quality scores and decide which three to visit because they meet the criteria. You’ll physically go and take a tour to see if it’s the right place.
The predictive modeling will make it more interesting in being able to show outcomes and recommendations. I’m not sure if I’m going to develop a Yelp-like thing, but people want to know what other people felt about their visit there and what it was like.
It’s also true that everybody is not in the same financial situation. We are looking at working with payers to provide an estimated out-of-pocket expense. That is powerful because you may not be able to afford the five-star rated place.
Given that not everyone is willing or able to pay for a Ritz Carlton, can someone with a Motel 6 budget at least look up how satisfied others like them with similar expectations were with a particular facility instead of just comparing absolute satisfaction numbers?
Not today. The closest thing involves discharges, although it’s hard to quantify with so many variables and I can’t say for sure if I’m impacting it. But we’ve seen a big change in HCAHPS scores. On discharge, people afterwards didn’t understand the discharge because it was in the wrong language, she spoke very quickly, they were pushing me out the door, the ambulance was late. They list all these things, but an HCAHPS-type measure does not exist for the post-acute care visit right now. But as you start managing populations, I think it’s coming.
What does a hospital need to do to get started with your program?
They start by listing their favorite facilities in the area, the ones they use frequently and discharge to most often. We build that into a quick list in the system. We reach out to all those post-acute care providers, train them on our portal, and get them to understand that there’s an engagement value here that says you have to answer referrals within 30 minutes. Seventy percent of Ensocare calls are outgoing as we are managing the network. That’s different from some of other solutions that just buy a CMS database, import it into their system, and call it done.
I build my database organically. Every time I do these outbound calls, I know which facilities aren’t responding. Our customer support people and customer experience people call them proactively to say, we notice that you aren’t responding to the referrals we’ve been sending you. Is there a problem? Many times it’s, oh, the lady that had the app on her phone left and we don’t know how to answer any more.
We deal with post-acute care facilities that are very technically advanced and are part of large national chains. But we also work with home care mom-and-pop organizations in rural parts of the country, so it can be challenging. But we actively engage and manage the network to make sure they are responding.
You wrote after HIMSS19 about how smart speakers like those powered by Alexa might be used in healthcare. What do you predict?
The interface is becoming more reliable. Nine times out of 10, Siri or Alexa gets it right. One of the biggest potential uses I see is managing the population after discharge. Once you get a risk score through LACE or some other technology, you know that this patient has two co-morbidities, is high risk, and has a lot of social determinants. The nurse wants to follow up, but they’re going to call you, ask you to enter information into a mobile device on an app. Many patients aren’t all that technology savvy. But if you send them home with a smart speaker, it could automatically populate population health platforms with vital signs. The nurse is now calling only the people who need intervention as opposed to calling everybody every day. That model is unsustainable.
I recently was at a hospital that had a warehouse full of 75 nurse navigators. All they do, all day long, is call people. I’m following up on your primary care visit. Did you pick up your prescriptions? Did you do these things? Tools like the smart speakers are going to begin to invade that space.
Do you have any final thoughts?
I worked for two large companies. Shared Medical Systems taught us how to be close to the customer. Siemens, true to its German engineering background, taught us all about process and engineering. A healthy combination of both of those things is appropriate.
But the one thing that can’t be supplanted, the one thing that you always have to keep at the top of your radar, is high-touch customer service. We have a person at the end of the phone each time. You don’t get routed and automated and have to press two and three to talk to a representative. We have a high-touch customer service that our customers appreciate.