The Forum

The 3-step framework for managing your waiting list

by Paul Trigonoplos

If long wait lists were a problem before Covid-19, then they've become a full-blown disaster amid the novel coronavirus pandemic.

How Covid-19 will impact population health management

Background

Cancelled elective procedures from March through May added thousands of patients to every health system's wait list worldwide, and new infection control policies now limit the capacity any provider can use to catch up. As one hospital strategy director from the United Kingdom recently told me:

'While we are up to our necks with elective wait lists, the world feels like Covid-19 has gone away. Peoples' tolerance for a hospital underperforming is growing tired. But we have no ability to recover our position because our new ceiling is at best 70% of our total capacity. The wait lists just might break the system.'

The issue has begun to draw government-led responses. British Columbia's government is taking a supply-driven approach: hiring additional surgeons, opening more spaces, tapping private providers to conduct procedures, and expediting clinician training.

Other jurisdictions are going so far as to change incentives. England's National Health Service (NHS) published guidance outlining a new incentive model to push systems to see at least 80 to 90% of last year's elective volumes in September and October.

Regardless of whether there's a national policy or not, providers are often left asking the same question: How do I prioritise patients on my wait list while making best use of my scarce resources at hand?

Apply a population health management framework to manage your wait list 

We conducted a global review of how providers are managing their wait lists successfully. Exemplary organisations are applying a population health management methodology to their wait lists. These leading providers—including organisations in England, Canada, and Scandinavia—first segment patients based on the patient's risk of deterioration and then map treatment strategies to each segment to give patients the right level of care as soon as possible.

The graphic below shows a modified risk pyramid, representing how the best organisations segment and treat wait list patients.

The timelines on the left side of the graphic are based on guidance from NHS for surgery and outpatient wait listed patients. It's worth noting that these timelines vary based on a provider's immediate population needs and will likely be longer for outpatient waits. But these are good benchmarks, and providers in other markets have shared similar timeframes with us.

The NHS is one of many jurisdictions segmenting its wait list by risk of deterioration and further bucketing patients based on if they are surgical or medical, inpatient or outpatient, new or follow-up. Organisations also often segment by service line (note that most exclude oncology patients from this approach and fast-track them instead).

Providers then rally around each segment of the wait list in a targeted way. The patients with the most urgent needs are fast-tracked for care. The most insightful guidance, though, comes further down the pyramid, where care strategies centre on keeping people safe at home or substituting alternatives in place of the procedures or visits that were slated for a patient. Systems are employing three treatment strategies for 'non-urgent' patients:

  1. For patients at high-to-moderate risk of deterioration, providers use analytics to identify those in need of 'shielding,' and then deploy mobile care teams and remote tools to monitor and stabilise them.

  2. For patients at moderate-to-low risk of deterioration, providers substitute care alternatives where possible to remove patients from the wait list entirely. Some common substitutions we've heard from the membership:
    • In-person cardiac rehab → virtual rehab;

    • Orthopaedic surgery → physical therapy (sometimes virtual);

    • In-hospital stroke care → mobile stroke assessment units;

    • Spinal surgery → back pain clinic;

    • Inpatient surgery → palliative or end-of-life care;

    • Pacemaker checks → drive-through cardiology clinics;

    • Post-acute care → remote monitoring, virtual support; and

    • Chronic disease management visits à self-management enabled by patient activation.
  3. To guard against any additional influx of unnecessary referrals that will grow the wait list further, systems are ensuring GPs and their patients have rapid access to specialist advice and social care. The most common specialist advice tool is a simple phone line, and for social care, we are seeing an uptick in social prescribing models around the world.

As you make progress on your backlog, consider whether further segmentation and care model mapping is possible. But keep in mind that with any approach like this, it is absolutely is critical for clinicians to own decisions around treatment strategies, to safeguard their buy-in and build a strong relationship as a foundation for future partnerships.

How Covid-19 will impact population health management

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