At the end of the day, healthcare is all about bringing systems together to provide the best care possible for patients. However, coordinating this is not without its challenges. Often, it takes great leadership to pull off a high-performance care network. In this episode, we have a guest who has figured this out. Mary Pat Olson has more than 30 years of experience in healthcare across Nursing, Care Management, and Healthcare Associations. She is currently working at Loyola University Health System. With her expertise, she shares with us how we can create and manage high-performance and clinically-integrated networks built around the patient. Mary also discusses how they navigated through the challenges brought on by COVID and the issues of staffing in the industry. Full of wisdom and insights, this conversation will enlighten you on how to really support your patients. Tune in and learn more on providing access to the right care in the right place.
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Listen to the podcast here
Creating And Managing A High-Performance, Clinically-Integrated Care Network With Mary Pat Olson
Ben, we had a very interesting conversation. It went so fast. Mary Pat Olson is a Nurse Leader at Loyola University Health System, my former system. I was there for a bit. I didn’t even know this was going on. This was quite a while ago. I’m so excited about what she shared with us because it’s so practical.
Thank goodness there are leaders like Mary Pat that have hung in there and created the bridge from pre-COVID to post and supported the caregivers throughout. In this role, she showcased how important the care coordination role is and what the essentials are of access, the right patient, and the right location. She is making sure that the care coordination team is supported in a way that they can execute without a whole bunch of frustrations.
I’m sure that physicians and patients alike love this program. I’ll bet that they hung on to a lot of their patients in the midst of turmoil. It was fascinating. I encourage our readers to read this. Thank you so much. Enjoy this interesting conversation, reading our conversation with Mary Pat Olson.
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I am joined, as always, by my cohost and dear friend, Ben Sawyer. How are you doing, Ben?
Good, Rog. Great to be here with you and Mary Pat. I think this is going to be a great conversation.
It is. To our readers, we have with us Mary Pat Olson, who is a former colleague of mine. It was a large organization, and we didn’t have much interaction. Mary Pat works at Loyola University Health System in Chicago, and she has an incredible background in nursing. I want to ask her about this. It says in the information here that she got her LPN and licensure while in high school. She’s a nursing prodigy, Ben. I’m going to do a little bit more formal introduction, but welcome. I’m glad you could join us.
Thanks for inviting me. This is like the first show for me, so I’m very excited.
We’ll do our best to make your first experience a great one. We’ve got a great audience who’s interested in hearing not from Ben and me so much but from you. We’ll do our best to ask you the questions that our audience is looking forward to reading. I’m going to do a little bit more formal introduction of you, Mary Pat, if you allow me to do that.
For more than 30 years, you have been working all across healthcare in nursing, care management, and healthcare associations. You’ve worked for a couple of major health systems in the Chicago area, the University of Chicago Health System as well as Loyola. You also worked for a while with the Illinois Hospital Association, which is a great organization. I’ve had some impact or some contact with them as well. The thing that excites me the most is that you have had such a broad range of experiences within healthcare.
Mary Pat has worked in the emergency department and EMS. She has worked in these major health systems. She’s worked in care transition and management programs, grants, addressing workforce development, and nursing licensure, fully aware of what nurses are capable of doing and ways to upscale them.
A lot of systems talk about creating systems of care around the patient. It’s very popular to talk that way, but it sounds to me that you’ve figured out how to do that. Our topic is creating and managing high-performance, clinically integrated networks. The fact that it’s built absolutely around the patient and you have RNs, social workers, pharmacists, and other healthcare professionals gathering around the patient to ensure that their experience is an excellent one and that they get the proper care, the proper time. You create value as a health system.
I’m super excited about talking to you, Mary Pat, you’ve met a boots-on-the-ground nurse and you’ve done all these things. It’s not theoretical with you, but you’ve done it. We’re excited to talk to you about this. Thanks again for joining us. To start out, you can tell us what, from your perspective, is a care network.
I pretty much helped build this department when I started here. It’s changed a little bit as a provider and especially as a nurse. It’s very patient-focused. Here’s one thing that I learned along the way. Like you said, we all have great ideas on quality of care and how to deliver quality care. There are a couple of other players in the equation. One is the providers, your doctors and mid-level providers that have to coordinate at a very high level around whatever the disease is that the patient is managing with or their WellCare. They get left out of the equation a little bit because it’s like there are a lot of things to do.
The list is usually very long of quality indicators to help guide them. When we think about it, they might have 1 or 2 interactions a year with their patients. They’re usually not that long, and there might be a lot of great information shared with them on how to manage your blood pressure and, “Here’s your medication, and then we’ll see you back in 6 or 12 months.”
There is not a lot of capacity for anybody, either at the doctor level or even in the primary care practice offices to be following up with the patient. We’ve done a lot of things with the patient where there is that actual point where there will be a support of the patient once they’re in the place that they are 99% of the time, which is living their life out in the community
Practically speaking, unless they have an escort with them, some other person listening, taking notes or they’re taking notes themselves, one minute after the provider leaves, they’ve said, “What did they tell me about this? What am I supposed to do about that?” They’re on their own for maybe six months.
Yes. It’s pretty hard to say how you get people to manage their blood pressure. We give them medications, we’ve talked about diet, we told them to exercise, stress, whatever it is that we’ve “prescribed.” Where is that point where somebody can support the patient when they have to do these things? Honestly, most people don’t have a Mary Pat, Roger, or Ben who is a little bit familiar with healthcare and what things they may or may not need.
The learning for me was where is that point where we truly are supporting the patient and being patient-centered. I’ll tell you, in all of my experience, starting back when I was in the emergency department, working nights, patients need more support than what they are getting at home. The issue is where does that come from and who can be responsible for it?
A lot of it is very resource intense. If you don’t have the staffing that you need in your office, where does it come from? Who are you going to call? I think of us as the Ghostbusters of the patient care continuum. What does it look like to be clinically integrated? That’s a great question because it starts at primary care and then builds things around it. We have employee physicians at Loyola, but we also have affiliates.
How does everybody know what everybody else is doing? Where can you put a patient into a system where they can get pretty much everything they need? It’s like the cruise line. There’s a bed, a place to eat, and someone to tell you to do your aerobics. Where is that place that patients can go that could be easy? They don’t have to make a million phone calls or try to coordinate their care with their providers.
Sometimes, the biggest thing is this doctor said this, that doctor said that. The patient’s like, “I don’t know. You know what to do.” Clinically integrated is having a place where you can offer all the services either through Loyola, which would be great, but we do depend on some affiliated things, services that we don’t offer at Loyola. We may have to go on the outside, but the beauty of an academic medical center being in the middle of it is we pretty much have everything.
Now you need that care coordination who can help you manage through every different appointment and understanding all the things and then working backwards to your provider to also be that voice between the patient and the provider. Our staff, the nurses, social workers, and pharmacists work very closely with providers. We’re in constant communication on the daily about that other thing.
The patients appreciate that because they’re like, “I don’t know what to tell my doctor. I know I need to ask them about this or that.” We can be in between both to support the provider to not have to figure things out like, “How do I order a wheelchair for a patient because they obviously need one?” The patient who’s like, “I don’t even know what to tell my doctor. They want to know what they should order, and I don’t even know.”
Do you coach them in terms of having a conversation with their provider?
We do. That’s one of the big things that we do. One piece of advice is that when we’re educating our staff on how you interact with patients is to always tell them not to bring paper and pen with them. Before you go to visit, sit down and write 1 or 2 things that you want to talk about. No matter what it is, whether it’s a question, this or that, or, “I see these commercials on TV.” Write it down because that is a good starter for the provider-patient conversation as well.
It gives the docs, APRNs, and PAs like, “Here’s what your patient’s thinking about.” It makes it more interactive for the patient, so they know that they’ve got some skin in the game like, “We’re here to help you, so tell us what you need or what you’re thinking.” The thing being in a place like the Loyola Health system is we do offer a lot of services here so we don’t have to send them here and go there for this or this and that. We have an integrated electronic medical record.
That’s the other beauty of all this because I was a care manager for a large insurance company and all we could look at was claims which basically told you nothing and then you’re trying to dig things out. This is being at the center of the information about the patient as well as at the center, hopefully, with your primary care provider. They know, “I can go to Mary Pat when Roger’s blood pressure still doesn’t seem like it’s going anywhere. Can you dig in a little bit about this? By the way, can you ask the pharmacist to take a look? Are there any recommendations on do we need to tweak the medication plan?” You start thinking about all the different things that come into play from one fifteen-minute visit. It could be at least an hour’s work on the back end of things. Our CF can be getting in there and help out.
Ben wants to jump in there with a question. Go ahead, Ben.
My question is you’ve established well that the care manager and that team are representing the voice of the customer. They’re the link to make sure that the patient’s getting what they need and are able to communicate with their providers. How was that impacted during COVID, particularly if family members couldn’t come in? How have you adjusted afterward with staffing challenges, etc., to re-establish that optimal interaction that you’re describing?
COVID, I never thought I’d ever lived through anything like that. My vice president, who you know, Keith, and I remember had a conversation where we were like, “You didn’t even know what you didn’t know or what you were going to need to know or something like this.” The positive part about our experience with COVID is we had already set up telecommunication. We were embedded in clinics. You’re the nurse, social worker, or pharmacist at very different times embedded in the clinic. You could see patients while they were there and talk to the doc right there.
We also do a lot of transitional care. You’ve been in the hospital, and you got discharged. “You’re Dr. Spellman’s patient. I’m going to call you and see how did everything go.” Fifty percent of our work was done by phone with the other 50% being done in person. We lost the in-person part of it, but we already had the skillsets built up. We were able to pretty quickly scale up for video appointments, helping get patients scheduled for video appointments with docs.
All this was so new and then became like secondhand communication. I feel like at the beginning of COVID, because we knew no one was coming in, we were able to use our analytics to identify some of our higher chronic illnesses or more fragile patients. We started proactively doing calls out to talk about how you are doing and what you think you’ll need at home. We did follow-up calls all throughout COVID because there was a lot of isolation. There were a lot of patients that would not come in. We could be that in-between person for that.
We managed well through COVID because we already had some good skills in place. I feel like we did a great job with COVID. We’re all skilled practitioners too. When the vaccines came out, we were doing COVID clinics. When COVID first started, they started a hotline for COVID questions and our staff staffed it for the first month and a half because there was nobody else that could do it. We took shifts on the phone.
We dug in in the beginning. I feel like we’re bumping along on the sand now with up and down a little bit. How do you re-establish? You’re right, the workforce issues are real. Having worked a lot in the workforce a decade or so ago, you can’t underestimate enough how much that does affect patient care on a lot of different levels, especially on the acute side.
You almost feel like the role has become even more important because there’re staffing shortages in the clinics. There’re staffing shortages in the hospital. There are staffing shortages at the pharmacy. There are immediate care centers. Nobody has staff. We’ve put ourselves back in the middle of if you have these care questions or you need to follow up and nobody can answer the phone, we’re calling out and we’ve got our number out there on the street for people to call into us.
We haven’t struggled as much with staffing. We’re pretty much right where we need to be. We probably have a couple of positions that we could fill, but we’re trying to get through it all now too. What’s the new reality? Roger, you and I talked a little bit about the new reality, what patients feel about accessing healthcare, where they want to access it, and what that means to all of us.
You run a hospital, usually on heads and beds. You run an academic medical center on we want to have that tertiary and quaternary care patients. What do you do at the secondary level of people show up? They’re not quite primary care and they’re not quite tertiary care. Now what? That’s what we’re seeing a lot of the surge in the EDs. These things are possibly primary care. If you have a robust primary care system, are there ways that we can start maybe shifting a little bit more into immediate primary care versus planned scheduled primary care? How do your beds open at your academic so that these people who need to come in for their advanced illnesses for higher-level management, we can keep the doors open for that?
Ben and I have been talking a lot at the ACHE Congress. We were there talking with some senior CEOs and COOs from around the nation. Can you believe that it’s been a few years since we had the lockdown? Flatten the curve. Where did those years go? What happened to most health systems is that we shut off the patients. We said, “Stay away.” As I listened to you talk, it occurs to me how much of healthcare is transactional rather than relational. You go to the lab, get your blood drawn, you go do imaging, do the pharmacy, or whatever. It seems very transactional, but there are bright spots in the relationship in the interaction that are very relational. What you do is you’re an answer to the primary care relationship.
Healthcare is transactional rather than relational. Click To TweetI like that. That’s a great way to put it.
It provides stickiness to the health system. Many of our colleagues around the country are complaining about where our volume is. What happened is that people found workarounds. They found other ways to get their healthcare. Telemedicine went from a niche thing to ubiquitous. Online, you can find anything anywhere because you’re stuck in your home.
Let me ask this connect-the-dots question. Roger, what you teed up is great. We started this conversation by talking about what is ideal as a clinically integrated high-performance network and then COVID happened, and staffing happened. What the audience would be interested in reading is if you go out to that ideal, what’s the exemplar model, and then come back to where it is right now, and what are some of the key things that leaders need to be thinking about to move from wherever they’re at now given all of the histories here to an exemplar model. What are those things they should be focused on and how do they approach that? Is that a fair question?
That’s a great question and I’ve got a lot of thoughts on that. The first is access to care. Are the access points open and are they in the right places? What I said a little earlier is it’s almost like you’re thinking about how you can do enhanced primary care. You don’t want to send everybody to the ER, but you have fifteen-minute slots in your primary care practice that are not going to be enough to work through some symptom management with somebody.
Maybe patients don’t feel well and they can’t get up and come and see you. What do you do about that? There are the access points, what services are available, and if they are high-quality services. I get approached all the time by various groups that are out there trying to build a business for things. You worry a little bit about the quality.
The second thing I think is having that relationship with your provider or your provider group. Everybody will tell you that they are not satisfied when they try to make an appointment with Dr. Spoelman and he can’t take them. They try to get him in to see Dr. Sawyer, who then doesn’t know anything about him, so they feel the visit wasn’t even worth it.
You’re right. You got to dial them in and hold him close and say, “This is the relationship.” If Dr. Spoelman couldn’t see the patient that day, could they call their care coordinator Mary Pat and say, “Could you reach out to this person,” or is it home health? Can we get home health out there? We started a little process where we call our SWAT team so we can get home health out, even if they haven’t started home health yet on anybody that we feel is a little bit tippy. Those are access and the right care, and honestly, the right care in the right place.
The third thing I would be thinking about is what are the things that your staff feels is purposeful to themselves feeling like, “This is a job that I want to do.” We’re hearing about everybody leaving the hospital. People are running away or jumping from here to there. What that is is whether are they able to do the work that they thought they were going to be able to do and that they were able to do before COVID.
Now everything’s up in the air and things might have shifted around a little bit. We have to think about how we keep people engaged in the work that they’re doing. I’ve gone through so many times in my career. This is a time that we’re going to go through. What do we want to be like when we get to the end, and then what are those things we need to put in place that can support that?
That was an eye-opener for me because I always think everybody loves their job and the work that they’re doing, and to find out what were some of those satisfiers and what were some of the dissatisfiers. We try to get some of the dissatisfiers out of the way. I talk all the time about we have patients constantly sending me emails or calling or telling our care coordinators, “We could not have done it without having you to keep coming back to or you keep reaching out to us. We honestly couldn’t.” This is colleagues that have had their family members through the system. They themselves are like, “I never knew what it was, but now I know why we need it.”
Those are three, Roger. I’m going to emphasize that for the readers. Those are access, right care and right location, essentially the right provider, and then the connection of the care team with what is meaningful to them to make sure that it all works. You talked briefly about things that are a little dissociative there for them. It sounds like there probably are more logistics now either because of reduced staffing and/or processes that are not quite as organized as they might have been when they were on cruise control pre-pandemic. How big of an issue is that from the standpoint of care manager satisfaction?
I’ve always thought it was a big issue. I’ve been a manager on and off, mostly on for a while. Early in my career, I did understand that. You can tell when somebody’s not satisfied with their job. It’s not going to go right. For some people, you can do what you can. This may not be the role for them. They might not ever be satisfied. You figure out what those satisfiers are. We’re working a couple of days a week, and people come to work from home because they like that. It’s a patient-forward position. We’re not in a telephonic role. We never are going to be. How do you work that in? We figure that out. The second thing was it’s the Wild West out there with the staffing stuff.
You’re a body. There are some times that you have to do things that aren’t the normal part of your role, but this is what we need to do to keep things going, to keep the business running, and to keep the care safe for the patient too. Managing expectations is a good thing and reinforcing that, “I feel that this is temporary. I don’t think this is going to be forever and ever,” but some other things are definitely going to need to change outside of my world. Roger, we talked about it, the whole expectation of you going to have as much volume on the in-patient side as you used to have especially when all these value-based models are trying to point toward more care in the community.
The staffing isn’t in the hospital. It’s everywhere you’re trying to get those patients. At least 30% of them or so are in-patients.
When they do get there, they’ve got the same thing.
We’ve got time for a couple more questions. I’m trying to imagine one of our readers out there, several of our readers saying, “This sounds great. This sounds helpful.” The ideal time to start this would’ve been years ago, but we look forward. If somebody wants to start this care network using the model that you use, what’s the first thing to do? What can they do to get this thing going quickly?
I hate to say it, but the first thing to do is you have to find some finance for it because if you try to make up a role and stick it onto some other role that already is occurring like I’ve heard of some places that use their triage nurse to be their care coordinator, if they’re on the phone with somebody, they can’t triage. You can’t say stick more duties on a role that’s already there. Figure out how you could fund maybe 1 or 2 positions and pick the ones you think are the most important. I’m always going to say RN because of the vast clinical knowledge. A social worker and the value of a pharmacist cannot be underthought or underestimated.
Figure out how you could fund maybe one or two positions and pick the ones you think are the most important. Click To TweetA pharmacist can do a lot of things with a lot of patients where maybe the nurses might need to have them focused a little bit more because there’s a little bit heavier of a lift. Look and see what your opportunities are. There are a lot of opportunities with the payers. Some of them will pay for care coordination. Think about some value-based or bonus-type programs that you would then turn around and use some of that money to support the operations. The second thing is there’s a lot of information out there on roles, responsibilities, job descriptions, and all that stuff. Think of what you are wanting to do.
We started off very small when this started. I only had like six staff, and we’re up to 46. None of them were social workers or pharmacists. We started out by saying that the transition from hospital to home is a very tricky, difficult part. It leads to a lot of things like worsening disease and increased readmission rates if they don’t have a doctor’s appointment. That’s where we started.
We picked where we think the most bang for the buck would be. Getting them in to see their doctor and preventing readmission were two big things. You can quantify them easily. We started to see the results. Either they’re going down on one end or they’re going up on the other end. We could track that easily. I’d say that’s the place to start. There’s a lot of network, information, and people out there that you could talk to about it. What’s the value proposition? I helped some pharmacists in North Carolina on what’s the value proposition of having a population health pharmacist. It could be done.
That’s what I was thinking. Forty-six staff is pretty impressive. If somebody wanted to get started with a project and say, “We’re going to try this. We’re going to borrow a pharmacist, a social worker, and a nurse for a limited time and then we’re going to evaluate,” what are the metrics you use to evaluate the effectiveness of your program?
We picked it in the beginning. Like I said, we wanted to look at readmissions because that’s a big thing. Percentage of patients that have a hospital follow-up appointment, high risk, 7 days, lower risk, 14 days. Those are two pretty big metrics. They do a couple of things that hospital follow-up visits are super important for patients to have. As you said, they get out of the hospital, nobody remembers even why they went in much less what were they supposed to be doing. It drives volume for you too. Now you’re making sure your primary care practices have patients to see. That’s a good one.
The readmission rate, it’s not great on a lot of different levels, but for many payers, there’s a penalty or a missed bonus. Readmissions are not good. Which ones are preventable? We’ve driven our readmission rate. When I started here, we were somewhere in the high twenties and now system-wide we’re at 14%. For our Medicare population, we’re down to 17%. That’s pretty good.
Mary Pat, you’re a nurse, a care coordinator, a leader, and a manager. You’re not a consultant. If some of our readers want to get ahold of you, is that okay?
I’m always happy. Don’t tell my boss, but here and there, I do have a minute or two. Right now, I have a sign on my door that says, “Do not disturb,” because usually, it’s like Grand Central Station in here. We talk a lot about patients and things like that. We got a couple of projects going on with our pharmacist, too, looking at medication utilization. There’s always something going on around here. There are some good resources on the internet. As you know, you’re in the world of consulting. There’s a consultant for everything.
Maybe I can clarify that for the readers. Gina Kidder, who worked very closely with Mary Pat, is now at ABOUT Healthcare. ABOUT Healthcare as a strategic partner of the Baldrige Foundation. We’re a Mac Baldrige society member and we’re all about the patient, like whatever we can do. We’re a technology company primarily. We handle transfer centers, so access and then a post-acute care network and the connection in between. It’s to support people like you, Mary Pat, and the team.
That was one of the reasons why Gina wanted to come over. It’s to be able to have a broader reach. It’s wherever we can provide that support to readers to help them because these are critical issues, and at the heart of it is the patient. At the end of the day, what is their satisfaction? Did they get what they needed? How can we enable them to live healthier lives?
That is high value for our readers. Mary Pat, thank you so much. I want to let you go because I know Keith wants you to get back to your real job, but thank you so much for taking the time to speak with us. It’s been very interesting. I knew it was going to be fascinating. I love the fact that you’ve been boots on the ground. You know this stuff. I’m sure you’ve got many wonderful and great success stories that need to be told about how helpful this has been to patients and physicians as well. A high degree of satisfaction for your 46 colleagues. Wonderful. Thank you so much, Mary Pat.
I’m going to put a plug there because, Ben, you made me think about the post-acute network. We didn’t even talk about that because that’s something that I’m in a chair, but the whole next side of care, post-acute network, skilled level care, all those things, I think that is something that is very hard for people to figure out. That would be a great next topic for you guys.
The transitions of care, as you know, are much more expanded now post-COVID. It used to be a little bit more of an acute care model, but it is diversified. Those transitions of care and making it efficient for the care managers is important so that the patient gains access, the right care, and the right location. It’s done in a way that supports the coordinator to be able to say, “I love that I was able to do that better for the patient than I did before.”
The family too, because when you start talking about that post-acute, there’s usually even more family responsibility and dynamic that comes into it. You have to make sure they’re supported as well. I would say that’s a great topic.
Thank you, Mary Pat. I appreciate it.
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About Mary Pat Olson
Mary Pat Olson is a Registered Nurse with more than 30 years of experience in healthcare nursing across Nursing, Care Management, and Healthcare Associations. Mary Pat brings a unique combination of project management, program implementation, and clinical experience to her role to provide leadership in managed care, value-based care, and ambulatory patient-focused care. She embraces the triple-aim for patient care – right care at the right time in the right place – and works to ensure that strategic plans around this theme are implemented and successful.
Mary Pat will share her perspective and insights on this important theme and topic, providing practical suggestions that can be applied immediately.
Mary Pat became an RN after completing her LPN education and licensure while in high school. After receiving her BSN, she spent her early career working as a nurse in a Chicago area Academic Medical Center in the Emergency Department and Emergency Medical Services. After achieving her master’s in public health (MPH), she transitioned to develop and manage programs and grants addressing healthcare workforce development and nursing licensure issues in healthcare associations. Mary Pat is currently leading a team of RNs, Social Workers, and Pharmacists providing care coordination in the ambulatory setting – the first if its kind in the health system. Mary Pat is also certified in Case Management through CMSA, and an active member of the Chicago area Chapter of CMSA.
