Use Clinical Identity to Reshape the Future

Origin of Clinical Identity

A clinician is expected to know many things.

• I knew that the adjoined eye clinic would let me use their slit-lamp so I could save my patient from another hand-off.

• I knew which closet had the iodoform wick for more complicated incision & drainage (I & Ds) and so I could save my patient a trip to the ED.

• I knew to get an ambulatory sat with a little incline and the number for the radiology reading-room so I could save my patient a hospital stay.

I felt (or knew) my clinician identity when I knew what my patient needed AND how to get all done within one clinical "touch." I felt (or knew) my clinician identify the most when the person who was the patient needed to hear, "I don't know the full answer and that's ok. You're not alone. Here's what we can do." It was humanizing for both the person who was the patient and myself. When I felt like a clinician I was comfortable and I could extend comfort to the person who was my patient.

Conflict of Clinical Identity

I've never felt more like an impostor to a clinician when I didn't know the events unfolding that would lead to an undesired situation for my patients. Maybe the person missed a regular medication refill or they missed a rescheduled follow up visit and then worsened clinically. Afterwards, I might say, "Oh he didn't show to his follow up visit that the front desk rescheduled. I meant to reach out to him again" - i.e the opportunity was "fleeting" and those words felt hollow.

It was simultaneously true that

1. I wish I had known

2. I was aware that knowing was unrealistic, much less intervening.

There wasn't a second system to proactively track patients who were upstream, not in front of me, and on a path to an undesired situation. Therefore, the person who was my patient and I could never be effective "co-owners" of that person's outcomes - we were both reactive and we both bore the cost. Looking back, I think the forced acceptance of failure of "judgement, experience, skill" despite desire to do good led to an accumulation of moral injury in myself (likely not unique among clinicians).

Power of Clinical Identity

As I journeyed through the provider, payer, care management/coordination settings in the US healthcare system I worked with teams that combined clinicians from many disciplines: nurses, advanced practice clinicians, social workers, pharmacists, physicians, community outreach workers. Regardless of setting, we all worked in earnest for the benefit of the person who was the patient or member.

Over time, I noticed that initiatives or technology produced the most benefit when reinforcing a desired upstream clinical identity, even when we couldn't explicitly articulate the clinical identity. In other words, things got better when it aligned with "how ought a good clinician act" if they were present upstream with the patient/member.

Acute Care/Facility Usage

Here I share an example related to acute care and/or facility utilization, a very common topic, in hopes that non-clinicians (e.g. technologists) will find this experience useful (I think other clinicians will find this example familiar). All the clinicians at the organization (somehow) had the same sense of everyday end-to-end "clinical identity" related to stable vs acute/facility care:

• Every clinician

  • Owns the the outcomes of their patients

  • Continually learns what actions improve their patients’ lives

• Therefore, every clinician

  • anticipates and meet their patients’ needs before those needs escalate to acute/crisis care

  • accelerates our patients’ recovery from every episode of acute/crisis care

This clinical identity was "on all the time" and could intrinsically power an initiative to reduce acute care regardless of benchmarks, KPIs, leadership focus BUT only if the initiative was linked in context of the full end-to-end identity and NOT identified as a separate distinct effort.

Impact of Clinical Identity

For example, an initiative to minimize unnecessary skilled nursing facility (SNF) days performed well when merged into the everyday clinical identity. The initiative to reduce unnecessary SNF days was matched to any upstream decision moment (known or unknown to the initiative) during the patient's hospital stay that influenced SNF utilization. Maybe for a particular patient the solution to avoid a SNF stay was durable medical equipment (DME), maybe for another patient the answer was a temporary home health aide. This didn't require creation of new services nor drastically different services for the same patient day-to-day. Across the population of patients where was a variety of needs and a variety of services; but it was relatively simple and stable for each patient.

This led to complete avoidance of a SNF stay and markedly reduce human cost and financial cost. There was much less benefit to facility utilization and the patient if the focus was "get patients out of SNF sooner" i.e. wait to intervene until the patient is "in-front of you" instead of upstream intervention (see figure below).

Taking a step back, the intrinsic clinical identity allowed all clinicians ("nurses, attendants, and externals") to focus on the combination of needs inherent to each person who was the patient at that moment in time and meet those needs (as best as possible) with available combinations of services. This lead to a decrease in facility utilization even if the "SNF initiative" never even knew the patient existed in the first place. In other words, NOT identifying the initiative as special or distinct led to more successful end-to-end (and bottom-line) outcomes because of a change in upstream decision moments.

In hindsight, a restricted decision "use SNF = yes/no" lead to more complicated downstream actions (e.g. SNF care is more complex than home with DME). However, allowing bounded variety increased the complexity of the decision but produced MUCH LESS complicated downstream actions.

Opportunities for Upstream Action Based on Clinical Identity

Below I share a collection of expected vs observed scenarios for clinicians to proactively identify patients or members who benefit from upstream intervention. This is mainly for non-clinicians (e.g. technologists) in hopes that some will find this experience useful and make possible upstream interventions for patients wherever possible (I think other clinicians will find these examples familiar).

Of note:

• Upstream intervention will take on even more importance as Centers for Medicare and Medicaid (CMS) continues the expansion of direct contracting, now named ACO-REACH.

• The concept of upstream intervention and avoidance of downstream events was described in the 1980s by Deming's System of Profound Knowledge

• LTSS - long term social support services

• HCBS - home and community based services