Patient Outreach: Lost to Follow-up Doesn't Have to Mean Lost

Take a moment to go over to your chart wall or look in the patient registry of your EMR. How many patients with a history of abnormal skin lesions have you seen in the past three years? How many of those patients have not been seen for the past six months and have no appointment scheduled? How many patients are sitting at home right now with precancers, abnormal moles, skin cancers, or a melanoma? An effective patient outreach campaign can get 20-30 percent of those patients to return to your office for a body exam, improve outcomes by finding skin cancers earlier, and save lives. Patients appreciate that you are watching out for their health, and the return on investment is substantial. It is both good medicine and good business.

I discovered patient outreach the day I stumbled onto the patient registry of my EMR. Patient outreach can be done with either paper charts or EMR. However, the fact that we had EMR enabled me to do something I was never able to do before: search our entire database of patients. I asked myself some of the questions posed above, namely how many of our patients with a history of skin cancer were lost to follow-up. Taking a quick sample, I discovered something that alarmed me. About 30 percent of patients with a history of BCC/SCC had not been seen in six months and were “lost to follow-up.” These people needed to be contacted. I discussed these findings with my supervising physician and we decided to take immediate action. And so I discovered the power of patient outreach.

My Experience

A review of current studies reveals numerous peer-reviewed controlled studies on patient outreach for various conditions (none in dermatology). Response rates are as high as 43 percent. Outreach groups present for treatment at rates two to four times higher than groups where no outreach was performed (control group). I decided to adopt the most thoroughly researched method of patient outreach with the highest documented rate of return: a letter followed two weeks later by a phone call if the patient had not already scheduled. The research was promising, and I felt reassured that I would have a good response.

Since this was our first experience with a patient outreach campaign, we decided to keep our initial group small. We achieving a 25 percent success rate, found numerous skin cancers, precancers, and abnormal moles, and patients were pleased that we contacted them. With these results in hand, we expanded the scope and speed of the outreach program. The only downside was that we struggled under the increased surgical loads for a few months. This is preventive medicine at its best! Patients were very grateful for the reminder and wanted a thorough skin exam. Outcomes were improved, revenue was increased, and patients were satisfied with the program. In this article, I will describe the basics of how to design and execute a successful patient outreach campaign aimed at patients with a history of abnormal lesions who have been lost to follow-up.

Building an Outreach Plan

Step One: Patient selection and data collection. Whether you have EMR or paper charts, you have all the information you need. As in clinical research, you have to define your patient population and set up an inclusion/exclusion criteria. For this campaign, I would recommend going back three years and including all patients with a history of BCC/SCC, AKs, dysplastic nevi, and melanoma who have not been seen for six months and have no future appointments scheduled. Whether you have EMR or paper charts, your biopsy book is often your best place to start. Simply cross-reference your biopsy book with your scheduling software to see when the patient’s last visit was. You can also ask the billing department to assist you with a list of patients by diagnosis or procedure. Once you have the names, addresses, and telephone numbers of the patients who meet your criteria, proceed to the next step.

Step Two: Choose an outreach method(s). Your choices are mail, live calls, automated calls, email, or a combination. By far, the most effective, professional method is mail followed by a live call two weeks later, if the patient has not scheduled. This is the method I use. It also is the most well-researched method. Sending the letter first educates the patient about why they need to restart their care. Many will call to schedule an appointment. Mail also has the advantage that a caretaker or spouse will open the letter and “assist” the patient in making their appointment.

The follow-up call restates the information from the letter, gives the patient an opportunity to ask questions, and provides the convenience of scheduling immediately over the phone. Many patients may be unclear on their diagnosis and why there is need for a follow-up. Some elderly patients have so many medical problems they may forget that they did have a skin cancer and where that skin cancer was. Often times after receiving a clear explanation, the patient will gladly schedule. The employee calling should have access to the medical records, be properly trained, helpful, polite, and never pushy. A follow-up call increases response rates significantly. Keep in mind these are patients who are lost to follow-up. Even after getting the letter, many will continue to procrastinate. In my experience, when the follow-up call is made, if staff are able to talk to the patient, the patient usually schedules an appointment and expresses gratitude for the call.

Step Three: Craft the message. We all know what a delicate matter it is to discuss skin cancer with patients in our treatment rooms. We take great care with everything we say. The same level of thought needs to be applied to communication with patients about skin cancer outside the office. The communication must be professional, informative, clear, and concise, without causing undue alarm or underemphasizing the preventive health message. You need to get it just right.

Keep in mind that these patients are “lost to follow-up”— that is assuming that they did not slip through the cracks and a follow-up was never recommended. You must assume that their level of concern about their history is too low and they need to be re-educated and re-motivated to return. Just letting them know that it’s time for their skin exam is not enough. You need to include the date of their last visit, their diagnosis, what their diagnosis means (briefly) and that they are overdue for their recommended exam. A preventive message should be included letting them know that skin cancer is preventable if caught early. Patient surveys reveal that most patients would like even more information than this. In addition, I recommend providing a brochure or color pictures describing their skin condition. It costs a little more but will increase the rate of response. A picture is worth a thousand words when it comes to skin cancer.

Step Four: Prepare for the patient’s arrival. Before the first letter goes out, the staff needs to be prepared. They need to understand the details of the outreach program and be familiar with the outreach letter. For every patient outreach letter or call completed, there should be documentation in the patient’s record, and front desk should have access to a list of outreach patients. Be sure that before an outreach call is made, you check to make sure the patient does not already have an appointment. So there is no confusion, the staff should be able to differentiate a call from a patient who received an outreach letter from a patient who received a pathology letter. The front and back office should document if the patient visit is in response to patient outreach so the provider is aware before she/he enters the room. I would strongly recommend that these patients be scheduled for an appointment as soon as possible, as a significant number of them will have skin cancer and are already overdue for an appointment. If your office does online scheduling, appointment requests through your website, or email, include this information in the outreach letter. Chances are this patient will receive the letter or phone message after hours, and the ability to just sit down and schedule an appointment increases the chances that they will schedule immediately.

Step Five: The office visit. It pays to craft a special message for your outreach patients. You have proven that you are a diligent and caring provider by reaching out to your “lost to follow-up” patients. In general, outreach patients will be grateful they were contacted. Start the visit by explaining what their previous diagnosis was and that skin cancer is preventable, which is why you sent them the letter. Preventive medicine has a tremendous positive buzz. Patients like to see their dermatologist taking actions to prevent skin cancer. Make sure you do a thorough exam and explain everything. This is a valuable second chance to reeducate patients. This is a high-risk group, and you will find many abnormal lesions. When abnormal lesions are found, be sure to emphasize the advantage of catching them early. For patients with a long history of AK, SCC, or BCC now is a great time to introduce topical medicines for actinic keratosis, physical sunscreens, and/or photodynamic therapy, as appropriate.

Conducting a patient outreach campaign is not very expensive and the return on investment is excellent. This is because these patients need multiple procedures like cryodestructions, biopsies, excisions, and Mohs, as well as followups. If you have a pathology lab, read your own slides, have a surgery center, or practice in a high-risk area, ROI is even higher. In addition to generating income, patient outreach generates something perhaps more important: satisfied patients. Medical practices depend on satisfied patients to drive referrals. Surveys reveal patients have a positive experience with patient outreach and see it as proof that their physicians care about them and are keeping track of their health. If you have HMO patients, they will frequently present your outreach letter to their PCPs who will then have all the information they need to generate a dermatology referral. Patient outreach is indeed where good medicine meets good business.

The Real Payoff

As dermatology professionals, our highest duty is to find melanoma and find it as early as possible. No matter how good our clinical skills, we can’t find melanomas if the patient doesn’t present for a skin exam. Was there a melanoma in my “lost to follow-up” population? Would I find it in time? These were key questions when I started my first patient outreach campaign. Three months after my first patient outreach campaign started, I found what I was looking for. A 39-year-old Caucasian male with a history of dysplastic nevi who was “lost to follow-up” for one year returned in response to a follow-up call after not responding to an outreach letter. He had a melanoma in-situ on his back. When I called him, I wanted to explain all of the details of the patient outreach campaign and how we suspected someone like him was out there. Instead I told him, “I’m just happy we found it in time.” With a good patient outreach program in place, we are just one letter or one phone call away from saving lives.

Steven Leon MS, PA-C is a Dermatology Physician Assistant. He lives in Los Angeles. He can be reached for any questions about starting a patient outreach campaign at sleon@westernu.edu

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