How Automated Care Helps Northwell Health Stay in Touch With Patients at Home

The New York-based health system is closing care gaps and improving clinical outcomes through a platform that offers multiple opportunities to connect with patients in between medical visits.

A lot happens to patients in between medical appointments, and healthcare organizations are starting to take that into account. From automated messaging programs all the way up to remote patient monitoring and home health visits, they're developing an understanding that healthcare is a continuous journey, rather than a series of isolated incidents.

At Northwell Health, those interactions are handled in an automated care program. Zenobia Brown, MD, senior vice president and associate chief medical officer at the New York-based health system, recently sat down—virtually—with HealthLeaders to talk about how health systems can identify the best opportunities for in-between visit care within larger health strategies, and how they ensure those opportunities drive impact.

Q. Can you give us an overview of Northwell Health's automated care program strategy?

Brown: Northwell’s approach to in-between visit technologies has been ‘What can help us as we try to achieve something that aligns with our organizational need?’ An example of that is that for the past six years we have worked very successfully on our readmission rates. If someone leaves the hospital and then comes back, especially within 30 days, in some cases that represents a clinical failure. We don’t want that for patients. We want patients to be well when they leave our buildings and not need to come back, especially for things that are preventable. So we took a look at how are we interfacing with patients before and after they are in our care. Then we took a look at how we could do that at scale across our 21 hospitals. 

Zenobia Brown, MD, senior vice president and associate chief medical officer at Northwell Health. Photo courtesy Northwell Health.

One phrase I love is ‘You can fix any problem with enough money.’ If you have a nurse physically follow every discharged patient home for 30 days, that will work. That will probably keep people out of the hospital. Of course, that is not feasible, and that’s where the technology comes in. That is the disciplined approach that Northwell has taken. We ask ourselves, ‘What are we trying to do clinically? Where is the gap? Can technology help us with this gap?’

Q. How do you measure success with these programs?

Brown: Ultimately what you need is for providers to behave differently, and for patients to behave differently. You need an infrastructure that can respond to the needs of those two parties. If I can’t engage with the patient when and how it is convenient to them, then I have no hope of changing their behavior or what happens to them. But when you are mindful of the patient’s needs and they feel that you will be there for them any time they need it, then the trust is built and then behavior changes.

We want our patients to call us at the first sign that they are having trouble, but we must be asking the questions. We need to be engaged and asking the questions and asking them often.  And that’s where the technology comes in. Asking questions multiple times in different ways and at different times when it’s convenient to the patient is what sticks. This creates an infrastructure and provides really good information coming right from the patient. This patient-generated data then comes back to the providers, who can then adjudicate that information. 

Q, How many of these programs has Northwell deployed, and how have they helped to reshape in-person care?

Brown: It really spans the gamut of everything from pre-operative, postoperative pain, test results, cancer treatment, COVID-19, etc. It was huge, the ability to do some of this automation during the pandemic. So when you’re looking at big populations and straightforward things that patients don’t want to get tied up on the phone for, it can just be a chat. It lends itself to a lot of use cases.

We talked about patient-generated data and how that extra information is helping us build, reframe, and retool our different programs. For example, a really important issue is the maternal mortality crisis. How do we end that cycle of maternal mortality, particularly amongst Black and Brown women. So we’ve established the Center for Maternal Health and are using automated care programs to stay connected to these women. How are we hearing them? How are we asking them the right questions at the right times when it’s convenient to them? I can now tell you the top reason that moms are escalating back to us through these chats is due to high blood pressure. Based on that information, we can build additional programming to address that specific issue. Post-visit chats that are creating escalations also help us change our behavior during the visit to proactively address some of issues. It’s about enhancing how we deploy our clinical programs as a whole.

Q. Can you provide an example of how an automated care program is improving patient care?

Brown:  I’ll give you an example from that high-risk moms program. We talk about patients needing to be approached with the questions in multiple different ways, in ways that are convenient to them. We had a patient who, in her in-person encounter, did not reveal that she was having behavioral health symptoms consistent with severe depression, with suicidal ideation. She revealed that in the chat. When the stakes got lower and she was home and she could just put it in her phone, she revealed that. She already had the appointment, so standard care would’ve meant no further intervention for this mom until her next appointment. But we were able to have another interaction with her that then surfaced this issue, and then we were able to respond to that. That builds trust.

Q. How do your care providers feel about these programs?

Brown: I think it’s been invigorating for the team. In cases where the patient needs it, the team has actually interacted more with the patient. There is always a concern with automation that it is replacing a person, but we don’t see it that way. It helps with scaling, it helps with efficiency, and we actually see additional interactions, but they’re happening when the patients need it. So, let’s say a single nurse can do 10 patient interactions—one interaction per patient, 10 interactions for 10 patients. Well, with automated care, now a nurse can do one interaction for all 10 patients, and then that one patient that might have an issue, they might need 10 interactions themselves. And then there’s everything in between. 

Q. What is one piece of advice in terms of identifying opportunities for automated care programs that you might give to another health system considering this strategy?

Brown: This can help with every aspect of patient care, from something very simple to something very complicated. There are many use cases and because you are trying to do something for so many people, this can surface a lot of very helpful information to make people well. Basically, you’re talking about a new way of delivering care and communicating with patients.