A survey of 1,000 healthcare workers finds mental health concerns as well as significant levels of alcohol and substance abuse.
About half of healthcare workers are either at their breaking point or seeking new jobs because of the stress and trauma they are experiencing at work, according to new survey data.
The coronavirus pandemic has severely strained healthcare workers. A healthcare worker well-being expert has told HealthLeaders that burnout rates ranged from 30% to 50% before the pandemic and now range from 40% to 70%.
The new survey, which was conducted by All Points North (APN), features data collected from 1,000 healthcare workers between July 19 and July 25. Based in Edwards, Colorado, APN is a whole person health company that specializes in the care of healthcare workers, veterans, and athletes. Services provided by APN include group and individual therapy, medical detox, hyperbaric oxygen therapy, trauma-based therapy, medication management, and small-group fitness.
The survey generated several key data points:
49% of survey respondents said they are either at their breaking point or seeking new jobs because of the stress and trauma they are experiencing at work
40% of survey respondents said they feel anxiety or dread about going to work
64% of survey respondents said that the scrapping of Roe v. Wade either boosted their stress or made them feel betrayed
14% of physicians said they were using alcohol or controlled substances at work
21% of physicians said they were using alcohol or controlled substances multiple times per day
About 20% of healthcare workers said they had checked into rehab or a detox facility in the previous three months, but 14% said they did not want to admit they have a problem
Survey respondents cited several reasons for not seeking help: 32% said they were overworked and did not have time to seek help, 23% said they were concerned that colleagues or family would judge them, 23% said they feared license revocation, and 20% said they did not know where to begin and that the system was broken or too hard to navigate
Male healthcare workers were more likely to struggle with alcohol or substance abuse compared to their female counterparts: 21% of men versus 4% of women were more likely to use their work position to acquire controlled substances, 18% of men compared to 4% of women were likely to use alcohol or controlled substances while at work, 44% of men versus 17% of women were likely to use alcohol or controlled substances up to 12 hours before their shift
The survey report says the findings are troubling. "Our 2022 State of Mental Health: American Healthcare Workers Report indicates high levels of substance abuse, an acute mental health crisis, and stigma within the healthcare industry. This report also highlights the brokenness of the healthcare system, proving it is difficult to navigate, even for people who work within the system."
Interpreting the data
The founder and CEO of APN, Noah Nordheimer, told HealthLeaders that there are several ways to encourage healthcare workers to get help for mental health issues. "We have to keep chipping away at the stigma of mental health in healthcare from all angles—raising awareness around burnout, normalizing mental health days, encouraging organizational initiatives for work-life balance, and providing clear pathways for non-judgmental help. While we advocate for systemic progress, friends and family of healthcare workers can care for their loved ones by creating a safe space for honest conversations. Heroes are humans, too."
The challenges are similar in encouraging healthcare workers to seek help for alcohol and substance abuse, he said. "There is still so much progress we want to see in the stigma around substance use disorders in healthcare fields, much of which echoes our sentiments about mental health stigma. Still, it's important to remember that there are loads of healthcare leaders who want to help their employees to reach providers like APN to get them back to well-being and back to work. Healthcare workers and their families can also look into trusted, confidential resources like physician health programs through the Federation of State Physician Health Programs to help them navigate issues and options."
There are several reasons why male healthcare workers are struggling more than their female counterparts with stress, burnout, trauma, and alcohol and substance abuse, Nordheimer said. "As the data in APN's 2022 State of Mental Health: American Healthcare Workers Report shows, male healthcare workers struggle more because of the stigma attached with seeking help. They are often afraid their colleagues and family will judge them, afraid their license will get revoked, and some even think the system is broken and too hard to navigate, even though they work within the healthcare system."
Actions must be taken to reduce the stigma of behavioral health issues among healthcare workers, he said. "Every person in healthcare, especially those in policy, licensing, and management, needs to begin looking at healthcare as inclusive of mental health. Then operate from there. We need a fundamental shift in our philosophy of what health is. A person who is physically healthy but mentally struggling is not 'well' in the way that they can be. Healthcare providers, companies, and organizations can set the tone for a shift by educating and equipping the systems and people who may be affected."
Medical and pharmacy students learn about body language and visual cues that musicians use to communicate during performances.
Medical and pharmacy students at Wayne State University have learned about nonverbal communication from a string quartet.
Communication is a critical skill in medicine. Communication is crucial in interprofessional interactions as well as in encounters between healthcare providers and patients.
Recently, The Viano Quartet came to Wayne State University School of Medicine's Margherio Family Conference Center to hold a rehearsal and provide an educational session for 65 third-year medical students and 50 pharmacy students. This is the third year in a row that musicians have schooled Wayne State healthcare students about nonverbal communication.
The string quartet modeled valuable communication skills, says Aline Saad, PharmD, director of interprofessional education at Wayne State's Applebaum College of Pharmacy and Health Sciences. "We want to show our students how musicians communicate with each other—they give cues to each other to decide who is going to lead utilizing intonations and body movements to send messages to their colleagues. As healthcare providers, we can communicate amongst each other similarly and emphasize the importance of working as a team."
The musicians show that communication takes practice, she says. "When a quartet goes on stage, they have practiced many times before. We want to give our students the message that communication is a skill that does not always come intuitively and that we must practice it. With the string quartet, we can learn from a group that is cohesive, coherent, and capable of producing a piece of music that an audience can enjoy. They prepare themselves to communicate. We want our students to prepare to communicate effectively and cohesively with patients."
Members of the string quartet engage in several forms of nonverbal communication, says Georgina Marusca, MD, a resident in internal medicine at Detroit Medical Center and a graduate of Wayne State University School of Medicine who has attended all three of the musician sessions. "From an audience standpoint, you can see mostly nonverbal communication such as body language. Sometimes, there are subtle cues with head motions. There are also breathing cues—if they have a rest in the music, they take a breath."
The exercise helps prepare healthcare providers to work with patients, she says. "When it comes to communication between clinicians and patients, from a quartet we can learn facial expressions and visual cues that can help guide us in our treatments and how we make diagnoses. You also learn that it is helpful to practice communication beforehand. For example, if you are going to give a patient a diagnosis that is unfavorable, then you can practice what and how you are going to say with another medical professional before you talk with the patient."
Learning about nonverbal communication generates several benefits for healthcare providers, Marusca says.
"It is tied into the sensitivity that you need in this profession. It also helps strengthen the patient-physician relationship because if you are attuned to nonverbal communication, it is less likely that you will dismiss the patient or not pick up on things that the patient is reluctant to talk about. Mastering nonverbal communication can also reduce medical mistakes in terms of what is prescribed and what can work with a patient because nonverbal communication can be applied not only with the patient but also family members who come to a visit. Among medical professionals, nonverbal communication can help with verbal communication by giving you cues on what to say or giving you feedback from a colleague," she says.
More than two dozen CMOs from across the country gathered in Coeur d'Alene, Idaho, to discuss the top issues facing their health systems, hospitals, and physician practices.
Executives at the HealthLeaders Chief Medical Officer Exchange this week discussed a range of high-priority topics impacting their health systems, hospitals, and physician practices.
The HealthLeaders Exchange program features peer-to-peer interactions to address industry challenges. The intimate conference format of small-group breakout sessions encourages open conversation and deep networking.
This year's CMO Exchange included vibrant discussions on four topics.
1. Post-COVID environment
Tracy Breen, MD, chief medical officer of Mount Sinai West in New York, New York, said health systems and hospitals are emerging from the emergency phase of the coronavirus pandemic.
"Our challenge is moving past just surviving and into thriving. The first year and a half of the pandemic, it was about survival. Now, we have to find ways to thrive even with The Great Resignation. We need to bring joy back to work. We need to bring purpose back to work. Our staff and our teams really need to understand why they are there and to get joy from their work in the setting of massive disruption," she said.
The healthcare sector is experiencing the "post pandemic hangover," said Anil Keswani, MD, corporate senior vice president and CMO for ambulatory and accountable care at San Diego-based Scripps Health.
"Over the last few years, our minds were focused on the waves of COVID-19. We focused on new treatments, changing guidance, and the repeated surges that we faced. COVID still exists but we are in a new phase of this health crisis that we think of as the post pandemic hangover. Many of us are experiencing the after effects of what happened over the last few years—financial challenges, deferred care that is driving additional demand, patients with long COVID, workplace fatigue, labor shortages, and clinician burnout. This is all built upon increasing costs. The unanswered question is how long this hangover will last and if there is a cure for this hangover," he said.
2. Medical errors and transparency
Breen said the recent criminally negligent homicide and gross neglect of an impaired adult conviction of RaDonda Vaught, a former nurse who made a fatal medication error at Vanderbilt University Medical Center in Nashville, has impacted how healthcare providers address medical errors.
"After the nurse in Tennessee was convicted criminally of a medical error, it is chilling for all of us. In New York, which can be a litigious environment—we have always talked about protecting the record and protecting our staff. Now, it takes on a whole other view. We not only have to educate our staff but also build quality and peer review systems that are better protected. We need to go into our departments and talk about quality assurance. Then, you have to get the staff to disclose errors—they happen every day. Staff may be worried that anything they say could affect their job, their license, and even bring criminal charges," she said.
3. Workforce vitality
Efforts to promote workforce well-being and engagement generated vigorous discussions at the CMO Exchange.
"We are facing multiple challenges in the hospital setting presently. For example, we have many patients coming to the emergency department requiring hospitalization but are challenged by staffing shortages. On top of that, we have seen a sharp increase in workplace violence. The staff need support and do not like it when they are on an island dealing with these challenges on their own. They want to see leadership—they want to see you on the floor commiserating, collaborating, and listening. You need to be visible to the staff and to offer solutions. Staff have options today. If they don't feel supported, they will leave, be it locum tenens or otherwise. We have worked to have leadership on the frontlines, and it has made a difference," said Erik Summers, MD, CMO and vice chair of internal medicine at Wake Forest Baptist Medical Center in Winston-Salem, North Carolina.
Mount Sinai is encouraging leaders to return to face-to-face interactions with staff rather than virtual engagement, Breen said.
"We have been intentional in re-wiring the human component whether it's on formal leadership rounds or what I call my walkabouts—I walk the units and whenever I do that I run into people and talk with them about what is going on. The leadership team has made a commitment to go around to every unit to thank them for their work. It has become a structured, weekly effort, where we go in and visit one or two units. They know we are coming—it is not a surprise. We take note of what the staff's issues are and have a structured way of going back to the unit within a few weeks to tell them what we have done and what we cannot do. This process has been helpful, and the follow-up is important," she said.
Rounding is important, but it is just a modest piece of employee engagement, said Richard Morel, MD, CMO of Optum Tri-State, which employs healthcare providers in Connecticut, New Jersey, and New York.
"I heard a term recently, it is not The Great Resignation—it is The Great Upgrade. Staff is feeling more mobile, and they are looking to improve their situation. We hear it all the time—a competitor group has offered $10,000 signing bonuses for ultrasound techs. There are three things you need to compete on because you want to be The Great Upgrade. First is what staff get for doing their work—their income, their benefits, and their work-life balance. Second is the staff's purpose at work. In healthcare, this is a relatively easy factor because there is a high purpose in work, but you have to continually promote that in the organization. Third is who is the boss. People will quit over bosses. You have to look at your management team and leadership structure," he said.
4. Workplace violence
Health systems and hospitals have to work closely with law enforcement to address workplace violence, said Peter Arnold, MD, PhD, associate CMO of hospital operations at University of Mississippi Medical Center in Jackson, Mississippi.
"I have always been an advocate that if someone hits one of my nurses, I would seek to have charges brough against the perpetrator. If somebody says, 'I am going to come back and shoot the place up,' and they come back and shoot the place up, I would argue that in addition to the front line providers, the administration is at high risk. I advocate to have law enforcement involved under those circumstances to attempt to de-escalate the situation," he said.
Reducing workplace violence requires a multipronged approach, Breen said. "There are multiple layers to addressing workplace violence. There is no single solution. You have to layer your response. For example, you have to have de-escalation techniques, good administrative policies, and a low threshold for taking a threat seriously."
Health systems and hospitals need to be willing and ready to confront patients about workplace violence, Summers said.
"In the inpatient setting, we have developed a process. If a patient can make their medical decisions and engages in verbal or physical abuse with staff, we will go to the floor and talk with the staff to make sure they are OK. Then we talk to the patient to let them know that behavior was not acceptable. We let them know that a behavior contract may be required if their behavior does not change. And, if necessary, we discuss removing the patient from the hospital. While a patient would need to be medically stable to remove, it is imperative to support our staff and keep them safe just as we keep our patients safe. Any patient who engages in workplace violence gets a behavior alert in the electronic medical record, so when they come in again, our staff is aware and prepared for any concerning behavior," he said.
Recent research found that home caregiver engagement during care transitions reduced hospital readmissions by 17%.
For adult patients living with chronic illness, home caregiver engagement plays a significant role in patient outcomes during the transition of care from hospital to home, a recent research article found.
The recent research article, which was published by Medical Care, examines the findings of more than 50 studies of transitional care interventions. The study includes two key data points:
In studies that involved home caregiver engagement in transitional care interventions, the overall likelihood of hospital readmissions was reduced by 17%
Transitional care interventions that did not have caregiver engagement in the components of the interventions did not have significant impacts on hospital readmissions
"Whether in research or clinical practice, transitional care should not be conducted without careful consideration of where and how caregivers will be incorporated and supported as active partners in optimizing patient care across healthcare transitions," the study's co-authors wrote.
Forms of home caregiver engagement
Healthcare providers can engage home caregivers, who include family members and friends, in several ways, the lead author of the recent research article says.
"When we think about engaging home caregivers, we need to adequately support them beyond just information provision. Caregiver engagement truly involves not just giving them information but also understanding what their preferences and needs are. We also need to collaborate with them to develop the plan of care. That is the way that care gets personalized. Engagement can take the form of understanding what caregivers' needs are in terms of anticipatory guidance for symptoms that might be experienced at home and how to navigate those symptoms at home with medication management. You can discuss red flags and signals that may indicate a need for calling a physician," says Kristin Levoy, PhD, MSN, RN, a Regenstrief Institute research scientist and an assistant professor at Indiana University School of Nursing.
Health systems and hospitals also need to have an infrastructure in place to support care transitions and home caregivers, she says. "Having a common healthcare provider or spokesperson who can advocate for communicating the plan of care to the scope of practitioners who are involved with the patient's care should incorporate the family caregiver in that process. You also need to coordinate services—make sure that home health shows up, make sure any change in medication is adequately communicated to the primary care provider, and make sure that routine follow-up phone calls are happening in the home to maintain health and prevent hospitalizations."
Preventing hospitalizations
Home caregivers can help avoid hospitalizations and hospital readmissions, Levoy says. "To the extent that home caregivers are equipped and engaged in things like anticipatory guidance for symptoms, caregivers can contribute to reducing hospitalizations."
Active engagement of home caregivers is critical, she says. "What we found was that when home caregivers were actively engaged in the transitional care process—actively receiving education, actively being asked about the needs in the home, and receiving help in care coordination—caregiver engagement with the various components of interventions influenced overall reduction in the probability of hospital readmissions. Those interventions that had caregiver engagement in their intervention design yielded better outcomes. We all anecdotally recognize the contribution that home caregivers are making to patient outcomes, and we have provided some empirical evidence to support that perception."
Impacts beyond hospitalizations
Home caregiver engagement has positive effects beyond limiting hospitalizations, Levoy says. "Home caregiver engagement broadly helps to ensure a common understanding between the patient, provider, and caregiver about the patient's condition and their treatment plan. That common understanding helps inform healthcare decision-making. That can be in decisions about selecting treatment options, decisions about self-care in the home, and managing disease with medications. It can also impact decisions about whether to seek emergency care, to go back to the hospital, or to call a provider. All of these things impact patient outcomes."
Home caregiver engagement also has a positive impact on the caregivers, she says. "Home caregiver engagement not only helps patients—it also helps to improve caregiver outcomes. Other studies have looked at home caregiver engagement and noted improvements in caregiver depression, reduced caregiver burden and distress, and improved quality of life. When we are actively engaging home caregivers as partners in care delivery, we are not only influencing the patient's outcomes and helping them make better-informed decisions on their own behalf, but also helping caregivers achieve better outcomes for themselves."
Part of the care team
Home caregivers can play an active role in a patient's care team, Levoy says. "The home caregiver can serve in a variety of functions. They might be the information broker, where they are soliciting information on the patient's behalf from the healthcare provider on how to navigate symptoms or deal with issues that come up with the condition between visits. They can advocate for the patient's preferences when they feel their preferences are not being honored or incorporated into the plan of care."
Home caregivers can be involved in a patient's care decision-making, she says. "Oftentimes, patients defer decisions to their caregivers, and they function as the primary healthcare decision-makers for patients. To the extent that they are not tangentially involved in clinical interactions, caregivers are active partners. They can make informed decisions on the patient's behalf or provide guidance to patients. Home caregivers and patients often move forward together."
Genetic testing identifies coronary artery disease patients who are at highest risk for sudden cardiac death.
A new research article shows a precision medicine technique is promising for identifying patients at highest risk for developing sudden cardiac death—an electrical malfunction of the heart that causes the organ to stop beating.
Sudden and/or arrhythmic death (SAD) is a leading cause of death in the United States, causing about 300,000 deaths annually. Internationally, SAD is responsible for 15% to 20% of all deaths. SAD is often associated with coronary artery disease.
The new research article, which was published this week by the Journal of the American College of Cardiology, is based on data collected in the PRE-DETERMINE study of more than 5,500 patients with coronary artery disease. The researchers used a polygenic risk score to identify patients at highest risk for SAD. A precision medicine technique, polygenic risk scores combine the different versions of many genes that an individual has that are related to a specific disease.
The researchers used a polygenic risk score that has been successful in predicting coronary artery disease. They found that coronary artery disease patients who did not have severely impaired heart function had the highest polygenic risk score. These patients had a 77% increased risk for SAD.
The first author of the study says the research is a significant step forward in SAD research. "In order to better predict and prevent sudden cardiac death, we must first understand the genetic connection between it and coronary artery disease. We found incorporating information from this genetic risk score improved our ability to predict sudden death beyond the contributions of other known risk markers. Most exciting, the genetics were able to identify patients where sudden death was more likely to limit their life expectancy," Roopinder Sandhu, MD, MPH, an interventional cardiology and cardiac electrophysiology specialist at Cedars-Sinai, said in a prepared statement.
SAD is different than myocardial infarctions—commonly called heart attacks. In most heart attacks, clogged coronary arteries reduce blood flow to the heart. Typically in SAD, there is the sudden onset of erratic electrical activity in the heart that decreases the pumping function of the organ. There usually is little or no warning of SAD, and death occurs within minutes unless resuscitation is performed.
The senior author of the study says the polygenic risk score could be used in the future to identify patients who could benefit most from lifesaving therapies such as an implantable cardioverter-defibrillator.
"This study indicates there is opportunity to identify patients at highest risk for sudden cardiac death, and then offering meaningful, preventative treatment solutions like a defibrillator. Based on our pivotal research, we now have the foundation to achieve this," Christine Albert, MD, MPH, chair of the Department of Cardiology in the Smidt Heart Institute at Cedars-Sinai, said in a prepared statement.
The assumed annual clinician attrition rate in the prediction of an emergency physician surplus appears to be too low.
A predicted emergency medicine physician surplus by 2030 may not be as large as anticipated, according to a recent research article.
A study published in December 2021 that analyzed Medicare claims data and the American Medical Association Masterfile forecast there would be a surplus of 7,845 emergency physicians by 2030. The study assumed a 3% annual clinician attrition rate.
The recent research article, which was published by Annals of Emergency Medicine, features data collected about more than 82,000 clinicians from 2013 to 2019. In that timeframe, emergency physicians experience a collective annual attrition rate of 5.3% to 5.7%, including 3.8% to 4.9% permanent attrition.
The co-authors of the recent research article say that if the attrition rate for emergency physicians was 1% higher than the assumed 3% rate, the forecast surplus would be only 2,486 clinicians. "The annual rate of emergency physician attrition was collectively more than 5%, well above the 3% assumed in a recently publicized projection, suggesting a potential overestimation of the anticipated future clinician surplus," the co-authors wrote.
The recent research article has four other key findings about the emergency medicine workforce, which consists of emergency physicians, non-emergency medicine physicians, and advanced practice providers.
The proportion of advanced practice providers in the emergency medicine workforce increased from 20.9% in 2013 to 26.1% in 2019, while the proportion of emergency physicians decreased from 68.1% in 2013 to 65.5% in 2019.
Emergency clinician entry to the workforce peaked in 2016 and clinician exit from the workforce was still rising in 2018.
Emergency physicians account for less than half of the rural emergency medicine workforce, with a 51.3% proportion of all clinicians in 2013 and 46.4% proportion in 2019. The proportion of advanced practice providers working in rural areas increased significantly during the study period, rising from 23.0% of rural clinicians in 2013 to 32.7% in 2019.
There was significant state-level variation in emergency clinician densities per 100,000 population. In 2013, the three states with the highest emergency physician densities were Washington, DC (23.0), Michigan (16.5) and Rhode Island (16.4), and the three state with the lowest densities were South Dakota (6.0), Nebraska (6.9), and Montana (7.0). In 2019, the three states with the highest densities were Washington, DC (24.2), Rhode Island (20.6), and Michigan (19.6), and the three states with the lowest densities were Alabama (7.0), Idaho (7.4), and South Dakota (8.3).
The study has troubling findings for the practice of emergency medicine in rural areas, the co-authors wrote. "Rural clinicians providing emergency care in 2019 are now more likely to be nonemergency physicians or advanced practice providers rather than emergency physicians. Our work uniquely identifies a concerning trend regarding the recruitment of rural emergency physicians. From 2013 to 2019, the number of emergency physicians entering the rural workforce never offset the number leaving from the prior year, suggesting that shortages and inequities in access will persist unless substantial efforts are made to address emergency physician recruitment and retention issues."
Integrative care includes interprofessional collaboration and interdependent considerations such as genetics, social determinants of health, and community support and resources.
In a recently published report, Northwestern Health Sciences University (NWHSU) has identified seven domains of knowledge, skills, and behaviors that clinicians need to provide the best integrative care.
Integrative care has many elements. At NWHSU, the concept of integrative care extends beyond multi-disciplinary care, including team-based and holistic care, interprofessional collaboration, and partnerships between patients and communities. Integrative care also includes interdependent considerations such as genetics, social determinants of health, community support and resources, and beliefs and habits that influence health.
Domain 1, values, ethics, culture, and diversity: In integrative care, clinicians work with colleagues in other professions in a climate of mutual respect and shared values, with the recognition that there is diversity in and between disciplines as well as diversity in patient populations.
Values, ethics, culture, and diversity are the connective tissue of integrative care and a transdisciplinary approach to healthcare, says Michele Renee, DC, director of integrative care at NWHSU. "It is the shared mindset that unifies diverse paradigms of healing, creating a dynamic approach in which each point of view is honored and yet not sufficient in and of itself. We are also acknowledging the importance of social factors, from socio-economic status to religion to cultural norms, and professional diversity, from indigenous healing to mainstream medicine to complementary and integrative healthcare approaches. All these differences are important considerations in providing robust, multifaceted, and individualized approaches to care."
Domain 2, patient-centered care: Clinicians should seek out, integrate, and value contributions and engagement of the patient, family, and community in designing and providing care.
Patient-centered care acknowledges the pivotal role of patients in their care, Renee says. "Patient-centered care calls out the importance of acknowledging the bio-psycho-social-spiritual nature of whole person care. It is vital that healthcare providers are not doing to the patient, but rather with the patient. Our patients are active participants in care and the most important person in a healthcare team."
Domain 3, roles and responsibilities: Clinicians should use knowledge of their role and the role of other professions to identify and address the healthcare needs of patients, families, and communities.
"For team-based care to work, we must each understand the part we play, the unique skills others bring, and how we all fit into the larger picture. This is a dynamic process, created uniquely for each person we serve. These skills are essential to ensure care is complete and wraps around our patients and communities," Renee says.
Domain 4, interprofessional communication: Clinicians should be responsive and responsible in their communication with patients, families, communities, and other healthcare professionals, which helps establishing a team approach to health and the treatment of disease.
Communication is often where healthcare fails, so shared communication competencies are essential, Renee says. "This includes understanding ourselves, acknowledging biases, identifying and resolving conflict when it arises, and documenting care in a way that is universally understood. Multilayered communication is key to building trusting relationships."
Domain 5, team and teamwork: Clinicians should practice relationship-building values and embrace team dynamics to perform effectively in different team roles to plan, deliver, and evaluate patient-centered care that is safe, timely, efficient, effective, and equitable.
Patients and communities rely upon their healthcare teams knowing how to evaluate, plan, and deliver care, Renee says. "This involves designing and implementing evidence-informed systems that support effective teamwork, and creating accountability for each care team member to focus on all aspects of patient and population focused problem solving. Team-based care goes beyond what happens in the treatment room or hospital to include social determinants of health and health equity."
Domain 6, collaborative leadership: Clinicians should foster shared leadership and collaborative practice of care.
Healthcare professionals need to cultivate the skill of passing the baton as needed, Renee says. "One provider may be providing the primary intervention at one moment in time and complementary care at another. The needs of the patient change over time and the care team needs to be prepared to collaborate and share leadership accordingly, leaning on one another's unique insights and expertise as needed."
Domain 7, well-being and resilience: Clinicians need to recognize that the health of an individual has positive and negative effects on their ability to make change around them and adopt sustainable strategies to address challenges, while remaining committed to their sense of purpose.
Building a resilient healthcare system starts with the well-being of healthcare professionals, Renee says. "Health creation begins with prioritizing self-care, which in turn reduces burnout and improves job performance and satisfaction. Learning the skills to identify one's circle of influence, develop a growth mindset, and cultivate grit prepare providers to better support patients in their own health creation by putting the focus on well-being and resilience instead of disease management."
The cancer center has patient navigators who specialize in particular cancers, and they are permanently assigned to specific patients.
Specialized patient navigators are making a difference for patients and care teams at Detroit-based Karmanos Cancer Institute.
At health systems and hospitals, patient navigators are deployed to play a key patient engagement role in the organization. Patient navigators can be involved in the patient journey in several ways, including helping patients communicate with care teams, setting appointments for doctor visits, and securing financial, legal, and social support.
At Karmanos, specialized patient navigators are trained to work with patients who have specific kinds of cancer. "Patient navigators are better equipped to assist their patients when they understand the way the cancer affects the patient. At Karmanos, our physicians are specialists, and our patient navigators are specialists. What we decided to do was embed our navigators into a multidisciplinary team, where they specialize in a particular kind of cancer such as breast cancer or head and neck cancer," says April Brown, director of concierge services at Karmanos.
Having specialized patient navigators drives several benefits for patients and the cancer institute, she says.
"The benefit of having specialized patient navigators is understanding a particular kind of cancer and the needs that those patients have. For example, for a breast cancer patient versus a head and neck cancer patient, they are going to have different needs in areas such as medical records, treatments, and psychosocial issues. Our patient navigators also address financial toxicity. We do a lot of research on cancer-specific endowments and patient assistance programs. There can be a set of money available for lung cancer patients or a set of money for lymphoma patients. With patient navigators focused on specific cancers, they know what financial assistance is available for specific patient populations."
The specialized patient navigators received extensive training, Brown says. "Our patient navigators undergo online training with George Washington University and online training with the American Cancer Society. Our clinical staff also mentors the patient navigators. They work with our physicians to understand a particular type of cancer. We also utilize our pharmaceutical companies—they come in as new drugs are developed for various types of cancer. They educate us about these new drugs. We also have an education office that works with our patient navigators."
Best practices
There are several best practices for running a specialized patient navigator program, Brown says.
At Karmanos, a patient is assigned to a particular specialized patient navigator. "When a patient navigator starts working with a patient, they are often the first point of contact. The patient navigator begins to build a relationship with the patient. Then, that patient knows that when they run up against an issue or a concern, they can feel comfortable seeking out their particular patient navigator. The patient knows the patient navigator is always there for them," she says.
After a clinic visit, the patient navigators have a follow-up phone call with their patients and have a conversation, Brown says. "We have found that those calls are like peeling back an onion because there are multiple layers to our patients. Listening to our patients is another best practice. Sometimes, our patients just want the patient navigators to listen to them."
Specialized patient navigators have multiple points of contact with patients throughout the patient journey, she says. "It makes the patients feel comfortable reaching out to our navigators. If a patient misses an appointment, the patient navigator will call and ask, 'What is going on?' It does not have to be a long conversation—just the fact that you called and checked on the patient makes them feel more comfortable."
Generating positive results
Having specialized patient navigators has resulted in positive results for patients and the cancer institute, Brown says. "Our no-show rates decreased because patient navigators were following up with patients. We have improved dealing with financial toxicity, and we have improved our bottom line. Patients are adhering better to their chemotherapy appointments because patient navigators address barriers such as transportation difficulties. Patient satisfaction has also improved. It helps to have one person the patient speaks to when they have a problem."
The work specialized patient navigators conduct to connect patients with financial resources is a financial benefit for patients and Karmanos, she says. "We found that we were writing off bills because patients were not able to pay for deductibles and co-pays. By getting our patient navigators to find financial assistance such as payments from the pharmaceutical companies, that affected our bottom line."
Part of the care team
Specialized patient navigators are a vital part of the Karmanos care teams, Brown says. "Patient navigators are in constant contact with our physicians, sometimes three times a day depending on the situation. The patient could have a new issue that is going on. Patient navigators are also in constant contact with our nursing staff and social workers. Patient navigators are a central point of contact for everyone. They go between the patient and all of the resources that we have at Karmanos."
Although specialized patient navigators are not clinical specialists, they often facilitate clinical care, she says. "After a clinical visit, patients may have questions about their treatment and contact their patient navigator. That will prompt a call to a physician or a nurse, who will be asked to call the patient. Sometimes, the patient is not feeling well, and they reach out to their patient navigator. They know that we will take the call and connect them with a clinical team member who can assist them quickly."
The specialized patient navigators also get involved in care coordination, Brown says.
Students in the community medicine medical degree track will learn at one of the top community medical centers in Ohio during their third and fourth years of medical school.
Physicians tend to practice in urban and suburban areas of the country. About 20% of Americans live in rural areas but only about 11% of physicians practice in rural communities, according to Kristina Johnson, PhD, president of The Ohio State University.
The community medicine medical degree track is set to begin enrolling medical students in 2024. The program was spawned by the Healthy State Alliance, an initiative between The Ohio State University Wexner Medical Center and Bon Secours Mercy Health to address thorny healthcare issues in Ohio.
An important facet of the new medical degree track will be to encourage students to be leaders in their communities, says Carol Bradford, MD, MS, dean of The Ohio State University College of Medicine.
"Working as engaged leaders in the community will enable our students to become more empathetic and compassionate caregivers and help them to quickly build relationships within the community where they serve. As leaders within these communities, they will be uniquely positioned to bring teams together who can effectively address the challenges their patients face and to work collaboratively to eliminate local inequities in care. In addition, our students will become the physician leaders of the future who will transform care and impact the health of the communities. They will help innovate solutions to solve our most pressing healthcare needs," she says.
The curriculum will be geared toward practicing medicine in less densely populated areas, Bradford says. "During the first and second years of medical school, students will begin their clinical experiences in a longitudinal preceptorship with a practicing physician in a community setting. During their third and fourth years of medical school, students will learn at Mercy Health—St. Rita's Medical Center in Lima, Ohio, one of the top community medical centers in Ohio. Students will get hands-on experience with patients from less densely populated areas with a multitude of health issues that affect these populations. Faculty who practice at St. Rita's will provide them with the education they need to learn how to better serve these populations."
Interprofessional education
Medical students will be taught about team-based collaborative care with pharmacy, nursing, social work, and behavioral health professionals help prepare them to practice medicine in less densely populated areas, she says.
"Interprofessional education brings students from two or more professions together during their training to learn about, from, and with one another to improve health outcomes, cultivate collaboration, and provide patient-centered care. It connects students and caregivers with people where they spend most of their time—in the community—and helps them to develop skills to effectively lead and be part of teams solving pressing healthcare challenges, such as those imposed by social and other determinants of health and advancing the social and humanistic missions shared across the health professions. This is particularly important for physicians who will be working in less densely populated areas, where resources are often scarce and reaching across sectors and professions is essential to serve patients."
Interprofessional education will equip medical students with the ability to provide comprehensive care to their patients, Bradford says. "Using this educational approach will prepare our students to enter the workforce ready to provide the best care for their patients in the future. Establishing a framework for team-based care will ensure that those patients who do not always have easy access to all members of their healthcare team will still receive comprehensive care."
Community focus
The new program is designed to attract students who want to make an impact in less densely populated areas, she says. "These students are looking for the innovative, top-tier education from The Ohio State University College of Medicine combined with the community care expertise of Bon Secours Mercy Health. This program will produce some of the most sought-after physicians in community medicine but more importantly produce physicians with the knowledge and heart to serve such an important population of patients."
Training medical students at Mercy Health—St. Rita's Medical Center will hopefully encourage them to work in mid-sized and rural areas, Bradford says. "It is our hope that physicians trained in less densely populated areas will be drawn to stay in those communities, to work as residents, and ultimately as physicians who are passionate and uniquely prepared to improve health and health outcomes."
In 2015, homebound seniors accounted for about 11% of total Medicare fee-for-service spending but they were only 5.7% of the Medicare fee-for-service patient population.
Homebound seniors are more frequent users of hospital-based care and have higher Medicare spending than non-homebound seniors, a new research article says.
In the study, homebound was defined as leaving home once per week or less. There are an estimated two million homebound seniors in the country. Homebound adultsare often medically complex, with high levels of dementia and chronic disease.
The new research article, which was published by the Journal of General Internal Medicine, features data collected from nearly 6,500 adults aged 70 years and older with Medicare fee-for-service coverage. A primary source of data for the study was the National Health and Aging Trends Study (NHATS), which conducts annual in-person interviews of Medicare beneficiaries or proxy respondents for information such as living arrangements, health conditions, and functional status.
The research article, which examined data from 2011 to 2017, has several key data points.
About 40% of homebound seniors had a hospitalization annually compared to about 20% of non-homebound seniors
Total annual Medicare spending is more than $11,000 higher for homebound seniors compared to non-homebound seniors
In 2015, homebound seniors accounted for about 11% of total Medicare fee-for-service spending but were only 5.7% of the Medicare fee-for-service patient population
Homebound seniors account for nearly 14% of Medicare beneficiaries in the 95% percentile of Medicare fee-for-service spending
In the year following the NHATS interview, homebound seniors compared to non-homebound seniors were more likely to have a potentially preventable hospitalization (14.8% versus 4.5%) and more likely to have an emergency room visit (54.0% versus 32.6%)
After adjusting the data for demographic, clinical and geographic characteristics, homebound seniors were less likely to have an annual primary care visit or specialist visit compared to non-homebound seniors
"Homebound older adults use more hospital-based care and less outpatient care than the non-homebound, contributing to higher levels of overall Medicare spending," the study's co-authors wrote.
Interpreting the data
Homebound seniors are not receiving home health services that could offset the lack of outpatient services, the lead author of the study said in a prepared statement. "When we adjusted for demographic, clinical, and geographic differences, we found the homebound have a negligible increase in the probability of having a home health visit compared to the non-homebound, suggesting that the gap in outpatient care is not being addressed by a home-based care model within Medicare. It's concerning but not surprising; the finding is consistent with well-known barriers in Medicare to accessing home health services," said Benjamin Oseroff, a third-year medical student at Icahn School of Medicine at Mount Sinai.
Home-based primary care would likely benefit homebound seniors, the study's co-authors wrote. "The lower rate of primary care utilization we observe may partially explain our finding that the homebound experience more potentially preventable hospitalizations than the non-homebound and higher spending. Previous research suggests increasing access to home-based primary care may lower hospitalizations and overall spending for the homebound, depending on the intervention type."
Targeting homebound seniors for enhanced care would decrease Medicare spending, the study's co-authors wrote. "We find that homebound older adults in 2015 accounted for 11.0% of Medicare spending among those over 70 despite making up only 5.7% of this population. The homebound are even more concentrated among the top spenders, making up 13.6% of those in the 95th percentile or above of Medicare spending. Our findings suggest that the homebound, a group often invisible to the healthcare system, may be an important population to target for quality improvement and to reduce Medicare spending."
Telehealth could improve care for homebound seniors, but it has limitations for this population of patients, the study's co-authors wrote. "Telemedicine provides another alternative to in-person visits, though recent experiences during the COVID-19 pandemic highlight the challenges of virtually reaching homebound older adults."
One of the study's co-authors who helped write a journal article on telehealth barriers for homebound seniors said in a prepared statement that there are several telehealth difficulties to overcome. "The types of barriers we uncovered ran the gamut from lack of broadband access to lack of support help to use the technology, and cognitive and sensory impairments. In this population, older age may compound some of the inequalities that this population is already facing. A high-tech solution will not always work for this high-need, medically and socially complex population," said Katherine Ornstein, PhD, MPH, an adjunct associate professor of geriatrics and palliative medicine at Icahn School of Medicine at Mount Sinai.