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Last week, Awell Co-Founder and CEO Thomas Vande Casteele hosted a panel discussion together with Dr. Ali Khan (CMO, Oak Street Health), Wayne Li (VP Care Operations, Headspace Health), Dhruv Vasishtha (SVP Product, Firsthand), David Lerman (CTO Boulder) and Mariza Hardin (Co-Founder & COO, ZĂłcalo Health) to discuss the tools and practices they use to deliver high-quality care. You can watch the full panel discussion here.
If you are already familiar with the terms CareOps and care flow, skip this section and feel free to go straight to the key takeaways.
CareOps is a set of practices and tools to build, operate and improve software-enabled care flows. It applies principles from agile software development, quality improvement and design thinking to healthcare processes.
CareOps brings people from clinical, operations, product, data and compliance teams together, overseen by strong clinical leadership. Ultimately, CareOps increases a provider organization’s ability to deliver higher quality care at lower cost and drive improvement cycles more frequently than its peers.
For more context on CareOps, read What is CareOps and why do we need it?
Clinical operations or clinops is a function that helps making sure care is getting delivered.
CareOps is a cross-functional practice to design, implement and optimize software-enabled care flows that power clinical operations.
The central concept of CareOps is the “care flow”. At different care providers different terms are in use for this term, such as care program, care pathway, care plan, patient flow, patient journey, care journey, clinical protocol, care process, (clinical) service line, care process model, clinical workflow or even digital therapeutic.
In essence they’re all sequences of activities completed by a care team and/or patient to maintain or achieve a desired health status for that patient.
Care flows are often defined at the medical condition / population level: a care flow for “Anxiety”, “Type 2 diabetes”, “Total joint replacement with obesity for 65+”, “Menopause”, “Sexual health for LGBTQ+”, “Discharge after surgery”, etc. and can be patient facing only, care team facing only or include activities for care team and patient.
We’ve used “care flow“ as an umbrella term in the panel discussion.
To provide a view on the practices and tools of care provider organizations (virtual, traditional or hybrid) use to build, operate and optimize software-powered care flows, Health Tech Nerds and CareOps launched the "State of CareOps" survey. In total we surveyed 147 healthcare professionals active in clinical operations in the period of July & August 2022. We were able to cover a broad range of care providers from the early startups seeing a handful patients per month to companies with 100,000+ patients that have been operating for more than 15 years.
In total, we extracted 15Â insights from the "State of CareOps" report. Together with our panel we discussed four leading insights.
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Thomas Vande Casteele: Our results show that there is "no standard" team to design care flows. So what roles are involved in designing, validating and improving these care flows at your care organization?
Dr. Ali Khan: At Oak Street Health we evolved our thinking around this question over time as we became more aligned around an agile infrastructure. In the beginning, most care organizations define cross-functionality as either engineering plus operations and business or engineering and clinical without realising that the full suite of stakeholders is crucial when you want to implement a specific change into clinical practice. The people that will actually use the feature need to be involved in the product development from day one. And at times, pulling in the patient experience can be crucial towards making sure we are designing for the full suite of needs. A feature that may appear simple from a clinical perspective, can be actually quite complex from a product or engineering perspective. So that's why we need the full suite of roles to engage, and engage meaningfully when it comes to product development and ongoing iterations.
David Lerman: There is always a tension between the speed of iterations and the number of stakeholders involved. If you want to bring people together from clinical, legal, product and engineering your ability to make small changes quickly goes down. At Boulder, we solve this with what we call a service design role. This person wears a product manager hat but is mostly responsible for deciding what stakeholders to include and knowing enough to know who will care. So rather than saying that legal and clinical need to be involved in every decision, the service designer is empowered to say "I have relationships with all those roles, and I know that if we are just changing this one question only these two people are going to care". This helps us cut corners and avoid having a 10-person meeting every week to discuss small changes.
Wayne Li: You need to get the right stakeholders at the table at the right time, and this is really a practice of prioritisation. The most important aspect is making sure that everyone is solving the same problem. Because when it comes to early-stage organizations it's easy to move fast and course correct if things go wrong, but as we get bigger there are a lot of opinions involved from different teams. Each change will impact specific teams differently, and you need to make sure that all these perspectives are taken into account.
Dhruv Vasishtha: There's not gonna be one standard set of stakeholders involved in designing care flows anytime soon and for me more importantly is to infuse product culture and thinking into your organization from the beginning. You need to explain to everyone joining your company what product management is, how product thinking works and what the product development lifecycle is. Your team needs to know that you always need to start with problems, then define metrics, then define hypotheses and then define solutions. For me, it's less about who is the person on the team that is involved and more focused on "Who can solve this exact problem?". It's the cross-functional collaboration and the problem definition that really empowers you to truly make the impact that you want to make.
Thomas Vande Casteele: As a young company you have a million things to do, so how are you thinking about prioritizing care flows above other things that might be more important?
Mariza Hardin: When you think about Latino health, and some of the disparities that exist within the community, you can easily become overwhelmed by all of the things you need to do. We need mental health, primary care and much more. So it was incredibly important for us to be very focused on the question "What do we want to achieve when we launch?". In our case, we focused on how to get a member connected to a primary care provider on the same day that they request an appointment. That meant we focused on building trust, great customer experience and having primary care providers ready to see members. We had to drill down on what are those care flows that will allow somebody to get into the health care system and how those flows can encourage people to engage in that same system. We focused on that first mile of enrolling people and building a good patient experience.
"We don't have a big product team or a big tech team. We have a big human team. We hired a lot of community health workers in the early days that played a crucial role in these care flows and workflows. This meant doing a lot of manual work, but it allowed us to see what works, what doesn't work and where we can improve." - Mariza Hardin
Thomas Vande Casteele: In the beginning, there's a lot of value in keeping things manual to be able to iterate and be flexible, but as you scale how do you make sure that what was designed equals what is actually being delivered in terms of care?
Dr. Ali Khan: This comes down to the quality versus quantity debate: having a bunch of care flows versus having a bunch of care flows that actually work are two different things. As a care organization, you can design all sorts of care flows and continue to iterate on them. It can be that you have built a fantastic system for building patient-centred care flows, but if these flows don't shift into the place where your care team actually does the work, nothing is going to happen. Having as much care flows as possible leads to a check-the-box mentality as opposed to going deeper to understand what are you going to do the actually activate and support your care team to get the end results that you want. Having six care flows as a care organization isn't necessarily a problem. I want to know the depth of each care flow. Having five care flows that are tremendously valuable is probably adding more material good than having 35 of them across a huge set of behavioural conditions that all stay superficial.
Wayne Li: At Headspace Health we've been trying to focus on "How can we do more with less?" and this is not about taxing the system but trying to build out the most efficient process possible. We have standardized processes that keep the lights on and additional processes that help contribute to the standardized care processes that we can iterate on. And anytime we want to make a change to one of the processes we always ask: "What are the efficiency gains we are going to get from this?”. We want to understand the ROI. Is it going to improve clinician sustainability or improve member care? This helps us prioritise what to focus on.Â
"Sometimes you don't need care flows, you just need really talented people" - Dhruv Vasishtha
David Lerman: When building care flows you should ask yourself two questions: 1) are people following the care flow and 2) is the care flow solving the problem that it was designed to solve? If you have good clinicians and the care flow is not solving the right problem, they'll find another way to solve the problem.
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As we argued in Metrics for the CareOps Practice, with regards to care flows 4 categories of metrics should be monitored: performance metrics, financial metrics, clinical outcomes and patient-reported outcomes. Each one of these provides a crucial piece of the puzzle. Leaving out one or more pieces means in the best case, care teams cannot extract insights from those categories. In the worst case, it means they’re optimizing for one category of metrics to the detriment of the ones they are not measuring.
We see that 1/3 of all survey respondents only monitor performance metrics and only 10% (n= 12) of all survey respondents monitor metrics from all 4 categories.
Thomas Vande Casteele: The vast majority of care providers are flying blind to some extent. So what's the risk of optimizing the wrong things?
Mariza Hardin: As an early-stage company, our goal was to measure everything and making sure everyone on the team was aligned on why we were measuring everything. Data collection is one thing, but what you do with it once you receive it is much more important. As a Chief Operation Officer, I want to know what happened, why it happened, when it happened and if it happened before. And when collecting so much data, you need to make it crystal clear to your team why you're collecting all this information, what you're going to do with it and what kind of insights you got from all this data.
"When you're trying to build financial, operational and socio-cultural arguments the span of data is really critical. But while collecting all this data, you need to guard against measurement fatigue and I think the biggest way to guard against that is by making your data constantly relevant to your team." - Dr. Ali Khan
Wayne Li: It's important to remember that at the end of every care flow there is a human being. It's very easy to fall in the trap of only focusing on business, financial or operational metrics. On the other side of the coin you have care metrics like clinician sustainability, member satisfaction scores or clinician satisfaction scores that are often forgotten.
"Only 19% (n = 21) of all survey respondents use new medical research to drive iterations." - State of CareOps 2022
Thomas: Why do you think it's so difficult to fold medical research into care flows continuously?
Mariza Hardin: It takes years for research to become actual guidelines. Our goal is to gather data, learn from the data, and then adjust the experience accordingly. And the feedback loop with our own data is much shorter. That’s why every care organization should find a balance between using research to drive improvements and using your own data to drive this improvement. You can’t solely base your improvements on clinical research, you need to tailor that research to your own care delivery processes based on the data you’ve collected.
"Where a lot of innovation happens is not finding new medical research but it is applying that clinical research intro your particular care model and patient population." - Dhruv Vasishtha
Unfortunately, not all wisdom can be shared in one panel, that's why we are organizing some Happy Hours in New York, San Francisco, Los Angeles and Las Vegas (during HLTH) to continue the conversation on tools and practices to deliver high-quality care. You can put your name down here if you are interested.
Dr. Ali Khan has been practicing medicine for the majority of his career mainly focused on urban underserved patient populations and diabetes. He was employee number 34 at Iora Health, spent four years at CareMore Health and two years at Anthem’s Medicare programs. Since 2019, he has worked at Oak Street Health, serving as Chief Medical Officer for Value-Based Care Strategy
David Lerman is the Chief Technology Officer at Boulder Care. Boulder Care is an addiction treatment provider seeking to offer high quality evidence-based treatment for opioid and alcohol addiction. They are entirely virtual, mainly focused on providing care to low income and Medicaid populations. Their services ranges from prescribing medication for addiction, to peer support, care advocacy and much more.
Dhruv Vasishtha is SVP Product at Firsthand. Firsthand is a tech enabled patient engagement and navigation business that takes on risk for individuals living with serious mental illness on managed Medicaid. Firsthand builds trusted relationships with their members around their health, works on chronic stabilisation and connects them to existing outpatient primary care and behavioural health providers through a team of peer individuals with a lived experience recovery journey, social workers, and nurse practitioners.
Mariza Hardin is the Co-founder and Chief Operation Officer of ZĂłcalo Health, a virtual healthcare service for Latino patients. Through monthly and annual membership plans, the startup matches patients with a care team made up of physicians, nurses and mental health clinicians, led by a community health worker. Patients can also access same-day or next-day virtual appointments and care coordination services.
Thomas Vande Casteele is the Co-Founder & CEO of Awell. Prior to founding Awell in 2018, Thomas was an entrepreneur in e-commerce and digital marketing where he spent 8 years improving customer journeys for companies like Samsung, Audi and Nestlé before becoming obsessed with value-based healthcare principles. He is passionate about how software can help people perform at the very best of their abilities.
Wayne Li is the VPÂ of Care Operations at Headspace Health. Wayne oversees four direct organizations: clinical operations, coaching operations, product operations and the support team. In his role, he is intimately involved in building out systems, tools and processes to enable the Headspace Health care providers deliver excellent care.
