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PSQH: Patient Safety & Quality Healthcare, June 16, 2021
The goal, according to CMS, is to improve care coordination by ensuring that important medical information is shared with primary care providers (PCP) when a patient shows up at the emergency department or is admitted into the hospital, as well as sharing information with providers after a patient is discharged.
This article was originally published June 15, 2021 on PSQH by A.J. Plunkett.
Review any policies you updated to meet the requirements under the new Information Management standard to reflect that The Joint Commission (TJC) has already updated the language in its new elements of performance (EP).
Also note that CMS has finally updated its interpretive guidelines for its own surveyors, with four new tags for Appendix A for hospitals and two new tags for Appendix W for critical access hospitals (CAH) under the State Operations Manual.
The updates are all related to the final rules last year designed to improve interoperability of electronic medical records (EMR) and communication between healthcare providers for patients as they are admitted or discharged from hospital care.
The goal, according to CMS, is to improve care coordination by ensuring that important medical information is shared with primary care providers (PCP) when a patient shows up at the emergency department or is admitted into the hospital, as well as sharing information with providers after a patient is discharged.
TJC revises newest IM standard
The revision by TJC is likely based on CMS feedback, according to Kurt Patton, MS, RPh, founder of Patton Healthcare Consulting and former director of accreditation services with TJC, as outlined in the consultant’s May newsletter to clients.
“The TJC change is noted in IM.02.02.07, EP 5, which discusses notifications the hospital must send to aftercare providers. The content changes are minimal but perhaps the breadth and scope of what surveyors will be examining may be more detailed,” advised Patton. “In last month’s wording, your EMR system needed to send notifications to post-acute service providers ‘as applicable’ and now the requirement says to ‘all applicable.’ ”
“There is a second change to send notifications to other medical providers and the wording change is the addition of the phrase ‘as well as any of the following” and then it includes the same list of primary care practitioners, primary care group or practice, and other practitioners or practice groups the patient identifies as primarily responsible for their care,” said Patton.
“So, if your patient has a PCP and a cardiologist or other specialist the patient identifies as primarily responsible for their care, you would want to ensure that both providers receive the aftercare notice,” Patton advised clients.
CMS issues interpretive guidelines
The CMS Quality, Safety and Oversight group memo, QSO-21-18-Hospitals/CAHs, was published on May 7, and state survey agency surveyors were supposed to have been educated on the new guidelines within 30 days of the memo’s release.
“The QSO memo makes it clear that hospitals and critical access hospitals have to send notice to other providers for emergency room visits and admissions, external transfers, and discharges,” Patton told clients.
All the new guidance for hospital surveys is under the Conditions of Participation (CoP) for medical records; for CAHs, the guidance is under the CoPs for clinical records.
“The first CMS tag touched is A-0470 and it requires notice be sent for registration as an inpatient or emergency room patient to external providers. CMS points out that this may require two notices, one stating that the patient has registered for treatment in the ED, and a second notice stating the patient has been admitted to the hospital. CMS also makes it clear in their guidance that emergency room notice must be sent regardless of the decision to admit or not,” he said.
The second tag is A-0471 and “requires notice be sent to post-acute providers when a patient is discharged from the hospital. The third tag addressed is A-1673 which contains the same registration in the ED or as an inpatient notice be sent but the guidance specifically refers to psychiatric hospitals. In this case, a specific consent must be obtained from the patient to send the notice to other providers. This contrasts with the general hospital guidance which included obtuse language stating the notice sent should ‘not be inconsistent with the patients expressed privacy preferences,’ ” noted Patton.
A fourth tag, A-1674, discusses how hospitals are expected to make a reasonable effort to ensure their systems are sending the required notices, noting that a patient may opt to send the information to a specialist other than their PCP. In addition, “This requirement does not limit the psychiatric hospital’s ability to notify additional entities based on hospital policy, such as ACO attribution lists,” according to the interpretive guidance.
Tags A-0470 and A-0471 correspond to the only two new CAH tags, C-1127 and C-1129.
Patton is advising clients to share the QSO memo with both their information technology department and hospital attorneys “to verify that you are ready to send these notices if using an EMR.”
PSQH: Patient Safety & Quality Healthcare, June 11, 2021
Long-haul COVID-19 symptoms may be caused by the immune system responding to the virus, not the virus itself, chronic illness expert says.
This article was originally published June 10, 2021 on PSQH by Matt Phillion.
We’ve all heard the stories: A patient comes down with COVID-19 and recovers, but not completely. Lingering symptoms plague them long after the virus itself is gone. It’s believed that this condition, known as long-haul COVID-19, is becoming a serious problem affecting millions of Americans, and the medical community is still trying to gain insight into the how and why. The CDC recently announced that it is working on guidelines for treating COVID-19 long-haulers who develop chronic illness.
Ashok Gupta, an expert on treating chronic illness through neuroplasticity principles, has been researching long-haul COVID-19 and how it can be treated through brain retraining. “There’s a number of different hypotheses on long-haul COVID,” he says.
Some theories believe that it’s excess mass cell activation, or an allergy causing cells to react. Others posit the virus is hiding out in the brain or body, waiting for an opportunity to create further issues. Still others believe the condition reflects long-term damage to the lungs. Gupta hypothesizes that it is due to a conditioned response.
“We are here because our nervous system and immune system has evolved to survive,” says Gupta. “We are survival machines.”
When we encounter an illness that is life threatening as far as the brain is concerned—and, in the case of COVID-19, also introduces significant stress, anxiety, and social isolation on top of physical illness—it takes longer for the immune system to recover, and Gupta says this plays into the long-term effects demonstrated by long-haulers.
“If the brain makes the decisions that this is potentially life threatening and we get to the stage where we’re overcoming it, a legacy is left in the brain that keeps over-responding to anything that reminds us of the virus,” says Gupta.
Even if we’ve fought off the virus, Gupta explains, the brain will react in a precautionary way to stimuli that resemble it. “The brain gets stuck in that overprotective response,” he says. “It keeps stimulating our nervous system and our immune system just in case the virus may still be present.”
This isn’t a concept unique to long-haul COVID-19, Gupta notes. He points out that the majority of flu symptoms, for example, are caused by the immune system responding to the virus, not the virus itself. Many patients develop chronic fatigue syndrome, sometimes known as “ME” (myalgic encephalomyelitis), after experiencing the flu, a stomach bug, or respiratory illness, he says.
“It’s a trigger of a form of chronic fatigue status—that’s a hypothesis,” says Gupta. He describes the phenomenon of long-haul COVID-19 as “a hypersensitive brain which thinks we’re still in danger.”
What is neuroplasticity and how can it help?
Gupta has been working with patients for two decades with a brain retraining program using neuroplasticity, or “limbic retraining.”
“Essentially, we believe that through neural rewiring, we can persuade the brain to get over the response—to be very clear, we’re not saying it is psychological in any way,” he says. “It’s accessing the unconscious brain.”
His team worked successfully with a 56-year-old male with long-haul COVID-19 recently, who prior to contracting COVID-19 in March 2020 was running half-marathons and cycling, but post-COVID-19 struggled to get off the sofa for months.
“We train the patient to be able to recognize those subtle unconscious danger signals on the periphery of consciousness,” says Gupta. “They recognize those signals and have a specialized, seven-step process to send safety signals to the prefrontal cortex down to the limbic system and insula.”
This, coupled with supportive techniques and the natural hallmarks of good health such as sleep and diet, help prepare the patient to respond to perceived threats that might trigger the response anew.
“The natural state of our brain is to default to protection,” Gupta says. “The brain prioritizes survival and passing on our genes to the next generation over any other impulse. It cares more about that than you feeling healthy and well! Protective responses are evolutionary and are the right thing for the brain to do—it’s survival.”
Gupta talks about the difference between pressure and stress, and the impact that stress has on our overall health, not just in terms of long-haul COVID-19 but general wellness. “With pressure, I can have a deadline and I respond to that pressure without the negative aspects of stress,” he says. “But then that pushes into stress and fear, and compromises our health.”
The mystery of survival instincts
Who will experience long-haul COVID-19 remains an unpredictable mystery, Gupta says. Most of the patients he has treated with neuroplasticity techniques came down with COVID-19 but did not require hospitalization.
“They aren’t the severest cases. Is there a correlation? We haven’t seen a correlation yet,” he says.
The treated patients range in severity, from housebound to still working, as well as in age, including patients in their 20s. “I would say the majority had to come off work and had to pace themselves,” says Gupta.
Major symptoms his patients have experienced are extreme exhaustion, post-exertional malaise, headaches, breathlessness, and sometimes stomach or gastrointestinal challenges. “It’s unique to each patient,” says Gupta.
The brain reaction is almost like muscle memory, in a way. Gupta identifies this as immune memory, or a stress signature.
“We see this demonstrated in hospitals every day,” he says. “Our immune systems are overreacting to COVID, causing a cytokine storm—an extreme immune reaction. That’s why a lot of drug therapies are trying to modulate the cytokine storm. In the same way, even after the original virus may have been removed from the body, the immune system continues to over-respond.“
The long-term prognosis of long-haul COVID-19
As with many ailments, it’s better if you identify long-haul COVID-19 early, says Gupta.
“If you leave it for too long, it can become more deeply entrenched in the brain,” he says. “The brain has a memory of health and a memory of defensiveness. The longer you have a condition, the memory of health becomes erased or difficult to experience, so the brain gets into a new state and forgets its original homeostasis.”
Will new strains or variants of COVID-19 also involve a long-haul illness? “It’s far too early to tell,” says Gupta. “It’s always possible a new variant could come along that would not cause long-haul COVID, or it could be more likely to do so. We believe these things could be triggered by a whole host of conditions.”
If patients seek out neuroplasticity treatment, Gupta makes sure that they are not feeling isolated and that they work together with a like-minded community on regaining health.
“Many people will say it’s in their head,” says Gupta. “But it’s in the unconscious brain.”
He compares it to phantom limb syndrome, often seen in amputees and war veterans. “You wouldn’t say that [condition is] psychological. It’s an illness. You train the brain to know that the limb no longer exists,” he says.
This training is a new way of treating chronic illnesses via the brain, Gupta says. “We are reprogramming the software, not the hardware,” he says. “Mainstream medicine focuses on when our hardware goes wrong, but many illnesses are software based. We need to be reprogrammed so we can bring the body back to homeostasis.”
The challenge is that medicine often focuses on measurements, and although we can measure hormones, enzymes, and physical changes, the brain is still a “black box,” Gupta says.
“I believe in 20 or 30 years we’ll have a full map of the brain,” he says. “Until that happens, we have to use these brain training techniques, creating neural pathways that allow the brain to reboot and reset.”
PSQH: Patient Safety & Quality Healthcare, June 11, 2021
Consider lessons learned from COVID-19 to drive adoption forward.
This article was originally published June 10, 2021 on PSQH by Megan Headley.
Telehealth may be here to stay, but it’s not being consistently adopted by all people in all places.
According to the Telehealth Adoption Tracker from The Chartis Group, a healthcare management consulting firm, there have been significant variations in telehealth adoption based on geography, demographic data, and service line, among other factors. The index was designed to measure how rapidly COVID-19 has accelerated the trend of telehealth adoption across the country, and measures data from several million claim records from January 1, 2020, through January 25, 2021. However, it’s also now providing insight into how health systems and physician groups might create a more cohesive telehealth offering going forward.
“We adopted telehealth during the COVID-19 pandemic out of necessity. Now we’re at the point where health systems and physician groups are asking themselves how we can optimize the role that telehealth plays in our care models,” says Chartis Group principal Ryan Bertram.
In flipping the “digital switch” to widespread telehealth during the early days of the pandemic, many organizations were forced to scramble to leverage a variety of solution platforms to meet all patient needs. Now, as vaccinations take hold and infection rates have lessened, many of these same organizations are exploring ways to use lessons learned from COVID-19 in building an enterprisewide telehealth solution. “I think we’ll see an evolution over the next few months and years to really build that enterprise capability out,” Bertram predicts.
The variability in telehealth adoption across the country and across clinical specialties presents some key strategic questions for providers as they evaluate their telehealth portfolios to figure out how they can incorporate telehealth into their broader care models.
Understand the gaps
Chartis’ data indicates that telehealth adoption has been driven more by lack of availability of in-person clinical services than of local COVID-19 outbreaks. However, the most densely populated states are now showing the highest sustained telehealth adoption. Regions such as New England, for example, are demonstrating a greater adoption of telehealth solutions across neighboring state lines. Pockets of sustained adoption are appearing on both coasts and some parts of the Midwest, but telehealth adoption has been lower in most of the Gulf Coast and up through the Great Plains, according to Chartis’ analysis of its findings.
Chartis concludes that health systems in more urban areas may be pushed to transform care models rapidly to compete. However, the firm also notes that the widening gap in sustained telehealth adoption rates between states with the highest adoption (33%) and the lowest adoption (7%) will make it more difficult for low-adopting states to catch up to the digital-forward care models being adopted elsewhere.
“That’s going to be one of the challenges that providers face in more rural communities, where access to broadband may be heterogenous or digital literacy might be lagging,” Bertram says. “It’s not to say that telehealth can’t provide a role in providing care for those patients, but organizations need to design what the telehealth experience is to meet the needs of those patients differently.”
Consider the experience
Crafting an enticing experience across the enterprise will be key in developing a consistent telehealth approach going forward. By Chartis’ analysis, a poor experience may have driven some of the earliest telehealth-adopting consumers back to in-person visits.
At the onset of the pandemic, individuals ages 65 and up were the largest group of telehealth adopters. Today, however, that population accounts for the lowest utilizers of telehealth as tracked by Chartis (14%). Adults ages 18–44 are the highest sustained adopters of telehealth. The trend, Bertram notes, indicates a stronger preference for in-person care, and perhaps an underwhelming telehealth experience, among older patients.
A wide range of factors can contribute to a poor telehealth experience, but providers will need to identify exactly what those factors are to secure customer buy-in where appropriate. “Examples of those barriers might be if I have an experience where I have to download multiple apps in order to get into my visit. Do I have to answer the same questions multiple times? What is the virtual waiting room experience like?” Bertram says.
He suggests that an “outside-in approach to designing the patient experience,” diving deep into the experience of telehealth across the enterprise, will prove critical in long-term adoption.
“A lot of health systems across the country and vendors that are creating these solutions and bringing them to market are now at the point where they need to elevate the experience and recognize those shortcomings,” Bertram adds.
Maintain human-centered design
Although the overall telehealth platform should be consistently integrated across the organization, Bertram emphasizes that there will likely be different ways to approach telehealth in specific service lines. The right approach will be determined by the need for in-person diagnostics and the ability to connect patients with the appropriate members of their care team. In fact, Bertram notes that people, not technology, will play the most critical role in how service lines’ telehealth offerings are developed.
“I would reiterate the importance of human-centered design in all of this,” he says. “Take an outside-in approach to make sure that you understand what patients are experiencing, what the providers and nursing staff are experiencing. That will allow organizations to tweak and improve their models over time for success.”
This may be particularly true in determining which service lines can adequately shift some healthcare experiences to telehealth. Despite relatively similar telehealth adoption levels prior to the pandemic, primary care and medical specialties spiked quickly and maintained their higher adoption compared to surgical specialties. Within specialty areas, sustained adoption was seen in neurology (36%), gastroenterology (29%), and cardiology (23%). These trends indicate which service lines may require more diagnostic insight or where patients especially prize convenience, compared to areas where all parties prefer in-person discussions.
“The last thing we want is a patient to have a telehealth visit where issues can’t be resolved,” Bertram cautions. “You can get ahead of that if you’re more discerning and thoughtful about how you design that care model so that you’re using telehealth for appropriate patient conditions—not thinking that telehealth can replace all in-person care, because it certainly can’t.”
Gather input from all parties
It’s become clear that telehealth solutions will play a key role in patient care going forward, but organizations now must define how their telehealth experience will serve as a differentiator. Health systems and physician groups may want to track their own trends in telehealth usage against national trends to identify opportunities for potential improvement, as well as strengths upon which to capitalize. Now is also the time to secure input on your telehealth experience from everyone involved.
“In the same way we see consumers with variability in their experiences and how that informs their willingness to adopt telehealth, we’re also seeing that on the consumer and care team side,” Bertram notes. “It’s important for healthcare organizations to make sure they take a multidisciplinary approach to planning, building out, and maturing platforms.”
PSQH: Patient Safety & Quality Healthcare, May 27, 2021
Dr. Sanjay Gupta, chief medical correspondent with CNN and a practicing neurosurgeon, shares his takeaways from the COVID-19 pandemic, and his views on where we go from here.
This article was originally published May 24, 2021 on PSQH by Matt Phillion.
The last 15 months have been a transformative time in healthcare, and as the world faced down a culture-changing health crisis, how we take care of ourselves and how healthcare organizations take care of patients have been front and center.
Dr. Sanjay Gupta, chief medical correspondent with CNN and a practicing neurosurgeon, spoke with attendees at the recent Health Experience Design Conference 2021 to talk about his observations as a correspondent, his takeaways from the COVID-19 pandemic, and his views on where we go from here.
“It’s been quite a year. That goes without saying,” Gupta said. “Anyone watching this knows this has been a year that’s been transformative in many ways. I’m optimistic about where we’re going over the next several weeks and months. The fact that we have three authorized vaccines—that’s an incredible thing. It can take years, if not decades, to create a vaccine.”
He expressed hope that the U.S. is in a better position heading into the warmer months, despite seeing virus numbers rise in different parts of the country.
“We’re not done yet,” said Gupta. “It’s one of those things where science is amazing and can help rescue us, but our own personal behavior and how much we lean into those behaviors are ultimately what wins the day. … I think we’ll have cause for some sense of relief and normalcy, but it still requires some work.”
News of the vaccine expanding to individuals 16 and older had just broken at the time of the event, and Gupta chatted briefly about the impact of ramping up vaccination efforts and the risks of vaccine hesitancy.
“Now there’s a concern about vaccine fade,” said Gupta. “ ‘Do I still need it? If I’m not at risk, if I’m relatively healthy?’ Part of the reason they’re advancing overall eligibility is to say, ‘Hey, look, get vaccinated. Do it in the spring.’ ” Not only does this lean into the potential for herd immunity, but as we head into the fall, a vaccinated population will be less likely to have a resurgence, which will help keep infections manageable and contained.
Speaker Amy Heymans, founder and CXO for Mad*Pow, asked Gupta what he believed the reasons for the U.S. being so adversely affected by the virus were. “It’s an important question,” said Gupta in response. “It has to do with overall health.”
A nation’s health
Before this pandemic, the U.S. had the highest pandemic response scoring based on resources, overall wealth, and more. Yet the reality was harsher than those scores might have predicted. There are a lot of reasons the U.S. was hit so hard by COVID-19, Gupta noted, and exercises have looked at the country’s response when it came to the pandemic to shed light on why we didn’t do better.
“We should have been a leader of the response, but we were tremendously adversely affected,” said Gupta. “We’re not even 5% of the world’s population, but at times we had 20% to 25% of new coronavirus cases.”
This is due to a couple of factors, Gupta said. “One, philosophically speaking, we’ve become a society in the U.S. and other wealthy countries where we wait for the science to rescue us,” he said. “We focus more on a pill, an operation, some sort of therapeutic instead of good, healthy behaviors because we’ve had the convenience option. It’s hardly any work: Just pop a pill. We want the home run, the knockout, the touchdown—we don’t want the single base hits.”
That hubris can get in the way of success, he noted, pointing to the dire effects of the 1918/1919 pandemic in the U.S. based on attitudes similar to those espoused during COVID-19. “We believed, we’re the U.S., we can weather this, and that adversely affected us,” said Gupta.
The other factor: The U.S. is, on the whole, an unhealthy country to begin with.
“The overall substrate of the U.S. is not a very healthy country compared to the rest of the world,” he said. For example, 30% of Americans are considered severely overweight or obese, which was considered a known risk factor.
“When you start looking at the overall health of the country, and [the fact that] we didn’t lean into basic public health practices, it was a prescription for being truly adversely affected,” said Gupta. “The lessons are clear, but I don’t know how well we’ve learned from them and if we will be able to lean into the basics next time.”
Gupta said he is optimistic, though, because of what we’ve witnessed with other countries where previous pandemics hit hard. Places like Hong Kong, which grappled with SARS not long ago, immediately went into aggressive containment mode in response to COVID-19, Gupta said.
“Hopefully, we will learn these lessons. Epidemiologists say there will be another pandemic in our lifetimes. It doesn’t have to be a black swan event as this pandemic was,” he said. “We can make it more of a blip on the radar instead of a changing event.”
Heymans circled back to the overall health of the U.S. and its impact on the pandemic—and what we can do to improve those stats.
“You’re trying to provide people with good health knowledge, accessible knowledge that makes a difference in their lives,” answered Gupta. “As a position reporter, you’re spending at least half of your time clearing out bad information first. It’s important to do because 90% of the journey toward good health is getting rid of bad info at the start.”
Gupta said getting rid of those bad assumptions, removing the things incorrect information is predicated on, is a matter of explaining things well.
“I’ll say something generally which has really informed me in terms of how I look at this: There’s all sorts of [specifics] about how you tell people to nourish their body, move their body, rest their body,” he said. “There’s a reason I say nourish versus eat, move versus exercise.”
It’s about how the person or patient lives, Gupta said—finding the right nourishment for the individual.
“One of the great fallacies, and it took me a long time to arrive at this and how I educate my own patients or talk to people on TV, is the belief that we have to engage in these healthy behaviors and I’m not going to enjoy it,” said Gupta. “First of all, it’s not hard. It’s probably easier than what you’re currently doing in the pursuit of good health. The human body is remarkably good at staying healthy if we get out of the way.”
We often think of adopting healthy practices for the long term, for the future, Gupta said—to live longer, to be more functional at the end of our life. But we can focus instead on how to feel better right now.
“Abiding by healthy practices isn’t about the future. Those things feel good now. It’s closing the loop,” he said. “Don’t just tell patients what to do. ‘So, Doc, you’re asking me to eat right and exercise, and nothing happens to me?’ So I’ll tell them, ‘If you do these things, you’ll feel better.’ ”
This includes rest, Gupta noted. “Remind people that that’s a time when your brain can be metabolically active,” he said. “It clears out the waste from your brain. Waste is always being cleared out, but during rest is when it’s most efficient. I’m not just spouting anecdotes—there’s real research behind what I’m saying.”
The impact of stress on healthcare
Heymans brings up Gupta’s recent documentary, One Nation Under Stress, and the concept of deaths of despair. “Right now we’re dealing with a lot of stress, and stress is a big deal during a pandemic,” she said.
Gupta said the documentary was a labor of love, because of all developed nations, only the U.S. is seeing a decrease in the life expectancy of its citizens. The top three causes the documentary focuses on are suicide, accidental drug overdoses, and cirrhosis of the liver due to alcoholism, which Gupta identifies as the deaths of despair.
“There’s a very long discussion to try to figure out why the U.S. in particular is affected by this,” Gupta said. “And when it all came down to stress, I talked to researchers, isolation researchers, loneliness researchers, and all of these things emerged. We always say stress is bad, we want to obviate stress from our lives, but we now know that’s not the answer. We need stress. Stress gets us out of bed.”
Stress in animals, for example, can save lives, Gupta said, such as by helping them outrun predators. Humans also need stress as a survival mechanism, but the difference is “when [the danger is] over for the animal, the stress is gone. For humans, we have a hard time turning it off. We’re constantly bombarded,” said Gupta.
Rather than remove all stress, Gupta pointed to a reasonable goal of letting the stress come down so we’re not constantly hit with stress hormones. “I will say this: Don’t stress about stress,” he said. “It just compounds the problem.”
Reciprocal altruism
“You have this quote: ‘In order to best care for ourselves, we have to also care for each other,’ ” Heymans said. “In the past year—where stress has been an issue, there’s more isolation than usual—that quote reminds me of the things you say about joy and gratitude and relationships and social connections, and how all these things connect to our health.”
Gupta said that when he wrote the quote, he knew it might be interpreted as a euphemistic thing to say. But it has to do with something researchers term reciprocal altruism.
“It means exactly what it sounds like—reciprocating altruistic behaviors,” Gupta said. “Why would we give away some of our resources to someone else? How did that get encoded in our DNA? I think the reason it happened is it’s how we survive as a species. It’s helped us as a species. And it feels good: how can you ask for more than that? It’s a guiding light for me. You want twofers in life? Where it feels good to do good? You’ve got it right there.”
PSQH: Patient Safety & Quality Healthcare, May 27, 2021
The trauma that medical professionals witness isn't "normal" for an average person's experience—let alone the trauma associated with COVID-19, unprecedented in our lifetimes.
This article was originally published May 26, 2021 on PSQH by Matt Phillion.
In the worst stretches of the COVID-19 pandemic, healthcare professionals were profoundly impacted by the rigors and trauma of their work. Experiencing daily challenges associated with the harsh realities of COVID-19 brought the topic of grief and burnout to top of mind for many practitioners.
Yet clinician burnout as a whole did not originate during the pandemic. Stephanie Queen, senior vice president of clinical services and chief nursing officer of Air Methods, an air medical transport organization, began researching clinician grief and burnout as far back as 2004 to better help her colleagues—and herself—with the experience.
“My entire career I’ve been surrounded by death and dying,” says Queen. “I started out my nursing career in adult oncology and transitioned into pediatric oncology, and since the early 2000s I’ve really focused on pediatric ICU and critical care. In school, they do a great job of preparing you for how to physically care for the patients, but a gap still exists in preparing nurses for how you’re going to be changed by the things you see.”
The trauma that medical professionals witness isn’t “normal” for an average person’s experience—let alone the trauma associated with COVID-19, unprecedented in our lifetimes.
“At the beginning as we were preparing—and I remember first hearing about it in January of 2020—it was reminiscent of swine flu or Ebola,” Queen says. “But burnout and compassion fatigue were compounded by the pandemic. While others were isolated, we were still going to work—others had the ability to work from home, which was a beautiful thing, but for those of us who were still out there providing care, we faced concerns about our own mortality, and particularly from the Air Methods standpoint, we were seeing the worst of the worst, transporting potentially positive patients.”
For herself and others in leadership roles, concern for the staff keeps them up at night, Queen says. Keeping up with best practices and adapting to the latest recommendations is one thing, but the simple act of encountering seriously sick patients remains a shock to frontline staff. The weight of it has taken a toll on healthcare, Queen says.
“It was hard even before the pandemic,” Queen notes. She recalls that during her research, she came across literature stating that 55% of nursing staff said they would not enter the profession if they had a chance to do things over.
During COVID-19, many clinicians found themselves pushed to their limits—working in organizations that were over capacity, or transporting very sick patients. Adding to clinician stress was a change in care-seeking behavior. Queen notes that more patients avoided care until the last minute because of fear of COVID-19, which meant that systems were seeing even sicker patients.
“We’ve tried to relay the message: Don’t wait, seek care,” she says. “But the volumes were so low, even in pediatric care.”
Caring for the carers
Air Methods actively decided to continue providing services during the pandemic. “We chose to transport COVID patients, and felt very strongly that we had to do it,” says Queen. “It was important for us that these patients were able to be cared for, no matter how unknown the situation.”
The organization adapted quickly, sending resources to hot spots where ventilators and other equipment were in short supply. But Air Methods also had to keep its staff’s well-being in mind. “Our biggest concern was that we wanted to provide care in the community, but how do we keep our employees safe?” says Queen.
This started with communication. Queen describes talking with staff in New York early on, and how they agreed with and were up to the task of providing pandemic care—but leadership had to remain available to any questions or concerns.
“We were making sure we were talking to them, ensuring they had the support, having a lot of open platforms to answer questions,” says Queen. “And we specifically talked to them about grief. You want to first help them to recognize the symptoms of burnout, and make sure they’re well rested and able to recognize the burden placed in their hands.”
This open communication helped enable peer support between clinicians and other support staff. “We wanted them to know that what you see is not normal, and it’s OK to not be OK, to say, ‘I’m having a rough day,’ ” says Queen. “It’s about supporting them transparently.”
And this meant sharing those concerns from the top down. Queen says that if leaders are willing to demonstrate such openness and admit when they are struggling, staff will feel empowered to express those struggles as well.
“I had one mentor specifically who said, ‘I’ve done this for so long that I give all I have when I’m at work, and when I get home I have nothing to offer,’ ” she says. “We pride ourselves in caring for others, but often don’t take care of ourselves.”
Sympathy versus empathy
In her research, Queen came across documentation on the difference between sympathy and empathy, and says that empathy is a place where healthcare has room to improve.
“In healthcare, often we want to just fix it—that’s what we do; we fix our patients,” says Queen. “But often what you need to do is sit alongside someone. You look down that well and the person might be there struggling, and empathy is sitting down with them and saying, ‘It’s OK. I can’t fix it, but we’re going to talk about it together.’ Empathy is just looking down the well and saying, ‘Yup, looks pretty dark.’ ”
As with admitting to personal struggles, leadership must set the tone by demonstrating and normalizing the practice of empathy for frontline staff. Healthcare is good at debriefing on the facts, but not necessarily at squaring off with emotional challenges. “I’m looking at ways to debrief emotionally,” says Queen. “We’re good at debriefing medically.”
Peer support programs can be a huge step forward. Weeklong courses, for example, help staff become trained as trauma counselors, supplying methods for peer support, stress management, survivorship, and dealing with traumatic incidents before and after.
They also look at the topic of suicide, which for many years has been an oft-unspoken challenge for healthcare workers. “Despite our best efforts, we can’t save them all, and there’s guilt that surrounds that,” says Queen. “Sentinel events have two victims, and the second victims are the healthcare workers who live with the event.”
Grief is personal
There is no one right way to help clinicians with grief and burnout, which means helping an individual clinician can be challenging.
“The way you manage and deal with grief is personal,” says Queen. “You can’t force it on anyone. It’s about consistent caring, something I call 40 seconds of embarrassing bravery. Asking, ‘Are you OK?’ Just asking a simple question, allowing them to meet you, listening, and being brave enough to say it. Sometimes it’s the toughest personalities who need to talk the most. You can’t pressure them, and they have to do it in their own time.”
In the past few years, Queen says she has seen some of her colleagues walk away from medicine completely due to burnout, and she wonders if she could have reached them. And this impact extends well beyond clinicians, she notes—it also includes first responders, communications staff, pilots, and maintenance workers.
“Early on in my career, I was struggling and didn’t realize that I was,” she says. “And often for those who can recognize it, there’s no formalized program to reach out.”
Even today, with an increased awareness of mental health, organizations and leadership need to be very aware of grief and burnout. “You hear about compassion fatigue, but what’s buried in there is grief,” she says. “There’s no formalized pattern. You push it down because you have to be ready to care for the next patient, and it’s damaging to do this.”
With the right open dialogue and the right resources, colleagues and leadership can learn to help both others and themselves.
“Over time, you really can say, ‘This was my experience, and everyone has personal experiences. I really do need to take care of myself,’ ” Queen says. “We talk about work-life balance, but if you’re not taking care of yourself and if we’re not taking care of them, we can’t expect great outcomes. Making sure we are taking care of our staff is what keeps me up at night.”
The industry is ready for this kind of improvement, she says. “The colleagues I’ve collaborated with all share the same sentiment. We need to talk about this. We need to talk about what support looks like,” says Queen.
Spreading the message that it’s OK to not be OK, and to talk about that fact, is the change the industry needs, she says. In healthcare, clinicians will likely witness life-changing events that are impossible to fully prepare for, but they still need to be in the room and professional.
“Talking is the best medicine,” Queen says. “And you can’t make them talk, but you can make sure they have resources and [let them know] that it’s OK to not be OK. Making sure they know it’s nothing that needs to be stuffed in a corner. It takes a special person to do this job.”
PSQH: Patient Safety & Quality Healthcare, May 25, 2021
Shannon Ford, senior manager of human-centered design with Alluma, spoke at Health Experience Design 2021 recently to discuss how her team used technology and adaptability to conduct field visits when in-person observation became untenable.
This article was originally published May 24, 2021 on PSQH by Matt Phillion.
A global pandemic can derail even the best of plans, but when those plans include face-to-face, in-person field visits, a sudden worldwide shift to remote work can make things all but impossible.
Shannon Ford, senior manager of human-centered design with Alluma, spoke at Health Experience Design 2021 recently to discuss how her team used technology and adaptability to conduct field visits when in-person observation became untenable.
The field visits were part of in-context observation, shadowing, and interviews, all meant to help put together an application and implementation enrollment process for a healthcare coverage system.
“The program is designed to provide primary coverage to adults living in 35 California counties,” said Ford. It addresses a patient population of adults who earn too much to qualify for Medicaid, but don’t make enough to afford healthcare coverage through the ACA marketplace—in essence, providing a stopgap between Medicaid and other coverage opportunities.
The program uses assisters working in clinics and other settings to help with applications and renewals, working with patients to find the best program for their needs. The goal is to help patients get their care in the clinic covered financially, whether through Medicaid, SNAP, or even the clinic’s own programs.
“These assisters are incredibly dedicated and bend over backward … to make sure these people get the care they need,” said Ford.
The original plan was to conduct field visits—shadowing assisters and then conducting semi-structured interviews with assisters, supervisors, the program managers who make the decisions for which coverage to support, and even the front desk staff—to get a feel for everyone who works with these patients along the way.
“We wanted a full picture of anyone touching that patient, helping them connect to these programs,” said Ford.
The shadowing was mostly observational, such as observing the assister helping with shopping for an apartment, or following a family through a morning or evening routine. The observer might interrupt with a clarifying question, but otherwise would hang back. The goal was to paint a picture of how the assisters interact with spaces, what other people they may collaborate with, and what tools they need to do their job, while also questioning what they’ve seen, which can’t be done in a purely observational setting. The semi-structured interview would have some predefined topics but remain open ended, allowing the participants to bring up topics the researchers might not otherwise know to raise.
“The interviews are inductive in nature, a bottom-up reasoning process. We don’t have a hypothesis we’re trying to prove but rather trying to find a hypothesis based on the interview,” said Ford.
Vitally, the interviews needed to take place in context, such as in a home or workplace. “[In-context interviews are] important because if you’re talking to someone, there’s so much you do and use that have become habit that you don’t even think about them anymore. As a researcher, I see things in the environment you might not think to tell me about out of context,” said Ford.
The plan was in place and ready to go, but “by the time the ink was dry and everyone got board approval, we ended up in COVID,” said Ford. “We wanted to go into the field last summer, toward the end of July, and this took in-person clinic visits out of the picture. The assisters were working from home as well.”
The situation could have presented an impossibility. “There really was no opportunity to go into the clinics, and not much happening there anyway. But we started thinking: What if we did it virtually?”
Changing to virtual
Remote research was not new, Ford noted: It had been used for usability testing, small-group work, and more. But for field testing, the whole point was to be there in the room, to watch the assisters and clinics interacting, see the movement of people and paperwork through the office, observe processes, and more. “We were a little uneasy with the idea and how we could accomplish that remotely,” said Ford.
They began with video conferences and screen sharing, or working with assisters and putting the clients on speakerphone. The clients were told ahead of time that there would be researchers shadowing the appointment, and they were reassured that it was up to them to grant permission for the researchers to be there.
“We went through the typical prep, sending a three-page document to our clinics explaining who we wanted to talk to and what they could expect,” said Ford. “We’d then get on a conference call with the coordinator, talk about the technology that would be involved, which staff we should talk to. We’d then set up sessions and create meetings, and the invites would include instructions on how to use the application we were using.”
The process, which evolved over time, had both challenges and successes. Ford started her conference presentation with a look at the former. “There were two kinds of challenges: one around tech … and one around context,” she said. Neither came as a surprise.
The first technology challenge involved the chosen research platform. They asked clinics for permission to record the shadowing session, but were not able to obtain that permission. Then, when conducting their validation dry run, they found that they could not share their screen without recording, so they were forced to use a different technology.
“We’d also been planning on using [the platform] for the interviews,” said Ford. “But despite talking about tech during our initial site meetings, we ran into in-the-moment issues where we couldn’t connect through computer audio, and the assisters and clients had to call in on a phone line.”
The app had no way of doing this easily, and so they did a “quick punt” to Webex®, which let them set up audio and video—but when a participant didn’t have video enabled, the screen display wasn’t optimal. Still, “we rolled with it as best we could with the tools we had,” said Ford.
In terms of context challenges, in most cases observers could use the webcam to see the room for context or ask the participants to hold up items on camera. “We could actually see those things pretty well in those cases, and even for those who were using the phone, though the image was very small, we could still see the context,” said Ford. While not ideal, it was workable, and they were able to obtain important data for the research with various on-the-fly improvisations.
The successes
The successes, like the challenges, were twofold.
First, “we had an interesting view of clinic operations during COVID-19 we wouldn’t have gotten if we didn’t decide to do our research this way,” said Ford. They were able to observe the clinic assisters sitting with patients, finishing applications, putting data in, collecting validation documents, and sending that bundle of documents into the client system.
Second, this observation yielded key insights that drove functionality in their system.
“On the client side, we have an eligibility worker who looks over the documentation to make sure it’s in order, then approve or deny,” said Ford. “The eligibility worker has about 30 days to make that turnaround. Waiting for those results was more of a source of frustration for the assisters. We came back with a clear imperative to make that determination process transparent, so they could see what applications were being worked on, how long they had before the time was up—basically, when they should start calling the eligibility worker to ask what’s happening.”
The speed to decision was more important than the speed to application, Ford explained.
“My organization was focused on how to make the application process go as quickly as possible: asking for the least amount of information, making it easy to attach documents,” she added. “We were paying less attention to making the turnaround time go faster.”
Meanwhile, COVID-19 was making collecting the verification documents even more painful than normal, and “normally it’s very painful to document,” she said. One assister explained that clients were sending her texts with their documents, but she had a flip phone for work—so she’d then have to forward the message to her private phone, and then forward it again to email. COVID-19 was forcing assisters to cobble together a system to get things done.
Takeaways from moving to virtual
Any move to a remote solution requires a look at the technology involved. “We usually give time and attention to tech, but in these times, [it’s important to] give even more time and attention to tech,” said Ford.
Planning and dry runs go a long way, she said. Allow more time before every session for tech wrangling, pre-check meetings, and testing the setup to make sure your sound and video are ready to go. “And have backup plans if your technology doesn’t work in the moment,” said Ford.
Additionally, find other ways to observe contextual data. “During our planning, we thought about asking assisters to give photo tours of their workspaces,” said Ford. “We held off, but it would have been a fruitful way to get more data about the environment they are working in.”
This could be done through more pointed questions, as well. “Ask: ‘Tell me about your setup.’ ‘What is on your desk you use constantly?’ ” said Ford.
She also recommended using a more purpose-built tool to document tool usage over the course of a workweek. “This makes it easier to push those tasks out and [can] help to organize visual data you get back,” said Ford.
Overall, the move to remote field visits has paid off.
“You can get value out of doing this work virtually,” said Ford. “I would still rather be in person, but I’m glad we did this. We have to be flexible and OK with less-than-perfect data.”
PSQH: Patient Safety & Quality Healthcare, May 24, 2021
BD recently published two papers on specific data discoveries during COVID-19, and Kalvin Yu, MD, FIDSA, senior medical director with BD, discusses some of the key takeaways from that research.
This article was originally published May 21, 2021 on PSQH by Matt Phillion.
If a year of COVID-19 could be said to have any positives, one is the immense amount of data the pandemic has generated for the healthcare industry. That data has been both vast and valuable, and resulted from a wide array of resources, including medication management solutions.
Researchers have begun to dig into the results of this data collection and identified trends that have helped them understand mortality rates during the pandemic and beyond. BD recently published two papers on specific data discoveries during COVID-19, and Kalvin Yu, MD, FIDSA, senior medical director with BD, discusses some of the key takeaways from that research.
“We try to pick topics that are germane to our end users—clinicians—but also tie it to public health,” says Yu.
Antimicrobial use during COVID-19: How much is too much?
The first of the two papers appeared in BMC Infectious Diseases, an open-access, peer-reviewed journal about all aspects of infection prevention and control. The paper dug into antimicrobial use during the pandemic, analyzing pathogens, antimicrobial use, and healthcare utilization in hospitalized U.S. patients both with and without COVID-19.
“We found that [antibiotics were] being disproportionally used for COVID patients,” says Yu.
The paper was not a new rallying cry on that topic, Yu notes; antimicrobial overuse has been a challenge in the healthcare industry for the last 20 years. “Clinicians were sounding the alarm worldwide,” he says. “Antibiotics don’t treat viruses. On the one hand, you could understand why frontline physicians were throwing antibiotics at a new virus, but what we know about the virus is that bacterial co-infection is quite low.”
Considering the rate of COVID-19 patients versus patients who were believed to have the virus but tested negative, the overuse of antimicrobials was quite high. “We were able to help educate clinicians on the fact that yes, antimicrobial overuse is occurring, and as we moved further into the pandemic, while there can be co-infections, they tend to happen later in the hospital stay,” says Yu.
The paper advocated for more targeted antimicrobial use, limiting it to patients who are not doing well or who have need of a longer hospital stay.
“The stewardship movement over the last 10 years has been [aimed at encouraging the] judicious and targeted appropriate use of antimicrobials rather than [acting as] a police force,” says Yu. “We showed in that particular paper that those who had a secondary infection had an increased risk for marked increase in hospital stays and ICU usage.”
The paper also identified that approximately 80% of COVID-19 patients did not have a detectable co-pathogen, so antimicrobial treatments should be evaluated daily and de-escalated when possible. “At the time, it was new evidence that these patients [with co-pathogens] were actually doing worse,” says Yu.
The presented data also highlighted the need for smart resource allocation and usage on a more general level. “As a former hospital administrator, I’d look at these signals to strategically budget for ICU nurses, ventilators, or certain key medications, for example. We now know this type of COVID patient stays longer, which can help with shoring up resource planning.”
With COVID-19 settling in for the long haul even with vaccines more and more available, the ability to better plan for and budget for these most resource-intensive patients will be valuable for hospital leaders now and in the future.
“Responding to a crisis like this is difficult,” says Yu. “We want to influence changes through these publications—clinicians universally understand the process of peer-reviewed journals as quality evidence generation, that they’ve gone through a process they can trust.”
A look at mortality rates during COVID-19
While the first published paper is the “downer paper,” Yu says, identifying antimicrobial overuse and the evidence that COVID-19 patients had both higher ICU use and higher risk of in-hospital death, BD was simultaneously also able to offer some positive news via its second recently published paper. Published in JAMA Network Open, this paper looked at mortality rates during the pandemic from March to November 2020.
“It showed that mortality rates across the board were decreasing,” Yu says. “Even adjusting for the fact that younger people were being admitted with the start of schools—at the time, the media was reporting a lot of schools were suspending students because of parties and gatherings—but even adjusting for younger people being hospitalized, who have a lower risk for mortality, the mortality rates were decreasing, particularly among older age groups.”
What this seemed to imply, Yu says, is that compared to the beginning of the pandemic, healthcare providers were learning how to treat COVID-19.
“There was never a golden-bullet treatment breakthrough, no big aha moment” in treating COVID-19 on the front lines, Yu says. Nevertheless, the paper showed that mortality rates were beginning to decrease—particularly in the oldest age brackets, who were expected to have higher death rates. The data demonstrated that, in general, frontline clinicians had adopted workarounds and provided better supportive care for these patients.
But what specifically was causing the numbers to go down? Much of it was a combination of lessons learned on the fly and best practices from other breathing or respiratory treatments. The media, Yu notes, picked up on the use of proning, for example—a method of turning the patient onto their stomach so they can aerate, as the position allows the patient to oxygenate more lung tissue. The technique wasn’t new, but its application was.
“I was trained on this in the 1990s for severe pneumonia, but it creates challenges when dealing with central lines or urine catheter care at the front of the body and other invasive device infection prevention considerations,” says Yu. “But in treating COVID, it appeared to have helped.”
Much of the learning was organic, Yu notes. Reports circulated that putting a patient on a ventilator too soon made it harder to wean them off, for example, something frontline clinicians became cognizant of and altered their treatment processes to accommodate. “Clinicians learned different ways of treating COVID that went against conventional wisdom for an average person with pneumonia,” he says.
Other areas of improvement included diagnosing. “There were case studies reported of people talking normally, and then upon doing an arterial blood gas test, the clinicians could see their arterial oxygenation was very low,” says Yu. “The x-ray is completely white, but the person is able to talk to the clinicians in full sentences, which belied the x-ray findings. Those learnings, and faster diagnostics, over time” made a difference.
“If they’re having changes in imaging scans and particularly if they have trouble breathing or their oxygen saturation is low, put them in a monitored bed,” says Yu.
Lessons about surge capacity
Many people don’t realize that healthcare organizations experience surge capacity issues every cold and flu season. Those in the industry, though, are well aware of that reality.
“There are times of high influx, lack of beds. Organizations live with that yearly,” says Yu. “When I was a clinician and administrator in a large integrated healthcare system, we would plan the next flu season the day after the last one ended.”
COVID-19 has helped highlight this challenge in previously unseen ways.
“One thing COVID has done is shone a spotlight on how hospitals have a problem with [cold and flu season surges],” says Yu. “We found a way to highlight the problem. The way hospitals prepare for surge capacity is going to need to be revamped.”
Most hospitals, Yu says, will look at the prior year’s census and budget for that number of patients. Sometimes, he says, nature doesn’t agree, and more ICU nurses and ventilators are needed. “COVID has changed the paradigm. Our eyes have been opened to this.”
Additionally, the triage process will need to be improved upon. “How you triage and who gets priority can be a moving target, and therefore can always be improved,” says Yu. “For sure, that is going to be a goal for hospital administrators.”
Emergency department (ED) processes will likely also be looked at based on pandemic data, Yu says. “We had a lot of people waiting for beds, and that’s not a good thing,” he says. “This really opened our eyes to what you can do in the ED.”
The data coming out of a year-plus of COVID-19 research will lead to further, more specific research in future endeavors.
“We’re seeing interesting signals we’re going to explore that involve empiric antimicrobial therapy,” says Yu. “We do think COVID will be a seasonal thing, and we’ve called that out as a future focus.”
BD has released regular newsletters with highlights on COVID-19 research throughout the brunt of the pandemic. The newsletters can be accessed on the BD website.
PSQH: Patient Safety & Quality Healthcare, May 22, 2021
How telehealth coaching can improve patients’ health outlook and outcomes, while saving on care-delivery costs.
This article was originally published May 20, 2021 on PSQH.
By Peter Rasmussen, MD
The days of “one-off” telehealth consultations are rapidly morphing into an era that will be characterized by mainstream integration of remote care as an optimal option for many use cases. As telehealth makes this shift, virtual condition-specific health coaching is poised to become telehealth’s next big value proposition, in a market potentially worth $7 billion.
This is unsurprising as the benefits of virtual coaching—where patients connect with condition-specific experts from around the world to inform chronic disease management—are seemingly endless. Employers are slowly catching on, and as one 2020 survey noted, they are turning to third-party virtual coaching solutions for mental and behavioral health (51%), metabolic syndrome and diabetes (37%), maternity care (29%), and other conditions.
However, while 60% of health plan members want condition coaching, eight in 10 have never had it offered to them, according to another study.
With chronic conditions accounting for seven of the top 10 causes of death worldwide and 90% of $3.8 trillion in U.S. annual healthcare costs, employers are wise to pay attention to this opportunity and look for ways to incorporate coaching into benefits packages.
Virtual health coaching 101
Today, an estimated 128,000 health coaches and educators work with clients to manage chronic conditions, modify lifestyle choices, and achieve challenging health goals. And while virtual coaching can take many forms, from bimonthly telephone calls to weekly video-based consultations, even the most basic telehealth coaching program can make a big impact.
In 2017, a 12-week digital health program for patients with rheumatoid arthritis (RA)—which paired patients with virtual coaches for weekly telephone calls focused on lifestyle changes—led to measurable improvements in medication adherence, sleep, and activity levels. A similar 2016 study of telephone-based health coaching that incorporated motivational interviewing, shared decision-making, and collaborative goal setting led to reduced hospital admissions for heart failure patients.
Given that these coaching interventions were relatively low tech, the results and return on investment speak for themselves. Consequently, it is safe to reason that coaching strategies could be significantly leveled up through use of state-of-the-art virtual care platforms, remote monitoring tools, and other resources.
Think of it this way: If a team is aiming to win the World Cup, would it rely on just any decent coach? Or would it work with an elite coach who utilizes best-in-class techniques, technology, and experience to achieve that goal?
In the long game of healthcare, patients who have access to top coaches to engage and collaborate with them, as part of a comprehensive virtual care program, have the best shot at improving outcomes and avoiding adverse events linked with chronic diseases.
Incorporating coaching into your virtual health program
While numerous case studies highlight the value of condition-specific virtual health coaching, they also raise several questions for employers, benefits managers, and even health plans. For example: What coaching programs should take priority, given limited resources? And which patients stand to benefit the most?
Consider the following three best practices when rolling out a successful condition-specific virtual coaching program:
Align patients with the right coaching experience. Virtual condition-specific coaching is an ongoing commitment, and a client’s first few sessions with a clinical coach are critical in establishing the cadence of a relationship that supports the client’s progress and goals. Individuals who participate in a coaching program should have access to experienced professionals who not only can relate to their struggles and needs, but also are digitally savvy and experienced in communicating over web-based video interfaces.
Incorporate tools and apps into the coaching program. Building the right remote monitoring apps or digital tools into the coaching experience can improve compliance and help an individual’s care team track progress and spot negative trends (e.g., weight gain of five pounds within 48 hours) before they escalate and lead to high-cost emergency care. For example: a lifestyle coaching program for individuals with diabetes would benefit from the use of digital apps or connected remote monitoring devices to track blood sugar levels, log meals, and issue alerts if something requires clinical intervention.
Offer unlimited access to medical expertise. While a health coach can address ongoing lifestyle maintenance needs, patients at risk for disease who have one or more chronic conditions, such as diabetes or hypertension, are at higher risk for more complex, problematic diagnoses (e.g., heart disease, cancer). An employer’s virtual care program should be comprehensive and include access to virtual second opinion programs (which facilitate access to leading medical experts), so that patients can receive the best and most accurate diagnosis and care when they need it.
Going forward, employers and health plans have an enormous opportunity to serve individual beneficiaries through virtual, condition-specific health coaching. Organizations that take into account the real-life needs of their particular workforce (e.g., healthcare professionals, train operators) in developing their programs will be well positioned for 2021 and beyond to make a significant impact in the lives of individuals with chronic care management needs.
Peter Rasmussen, MD, is chief clinical officer at The Clinic by Cleveland Clinic, and professor of neurosurgery in the Department of Neurosurgery, Cleveland Clinic and Cleveland Clinic Lerner College of Medicine, Case Western Reserve University. Dr. Rasmussen is a past-president of the Society of Neurointerventional Surgery, where he played a leading role on the national stage in continuing societal initiatives to train and support veteran and new practitioners in an area of medicine that is transforming treatment approaches to neurovascular conditions.
PSQH: Patient Safety & Quality Healthcare, May 21, 2021
Impact4Health has developed a set of best practices to help health systems create an inclusive culture for patients, staff, and visitors.
This article was originally published May 20, 2021 on PSQH by Megan Headley
Data from the COVID-19 pandemic has overwhelmingly highlighted the longstanding inequity in healthcare.
A May 2020 study from Sutter Health researchers that analyzed 1,052 confirmed cases of COVID-19 from January 1 through April 8, 2020, determined that African American patients had 2.7 times the odds of hospitalization, after adjustment for age, sex, comorbidities, and income, than non-Hispanic white patients.
The APM Research Lab reported in March that Pacific Islander, Latino, Indigenous, and African Americans have died from COVID-19 at least twice as often as white and Asian Americans. And this is just the tip of the research mounting on this disparity.
The question now is what health systems are going to do about it.
For Maria Hernandez, president and CEO of Impact4Health, an organization that provides training and support for health systems around health equity, physicians may face a unique challenge in addressing the biases that can lead to this uneven treatment.
“In healthcare, the assumption is always that ‘we’re providing the best care possible,’ and that means treating everybody the same,” Hernandez says. That might just be the problem. Treating everyone the same too often ignores the fact that many communities are struggling with vast differences regarding treatment and preventive care accessibility, among other factors.
“If you’re poor, if you live in a food desert, etc., all of those factors make a difference in what you as a patient may need,” Hernandez says. “I think we are becoming more sensitive to that, but it’s a lot of work.”
Examine the data
Data will be a key part of the solution to this challenge. A January executive order on addressing the inequity in the healthcare response to the COVID-19 pandemic stated, “The lack of complete data, disaggregated by race and ethnicity, on COVID-19 infection, hospitalization, and mortality rates, as well as underlying health and social vulnerabilities, has … hampered efforts to ensure an equitable pandemic response. Other communities, often obscured in the data, are also disproportionately affected by COVID-19, including sexual and gender minority groups, those living with disabilities, and those living at the margins of our economy.”
“It really does start with data,” Hernandez adds. More specifically, it starts with a willingness to examine the data in search of problems. “You need to be willing to look at your health outcomes by demographic groups,” Hernandez says. That could include rehospitalization rates and HCAHPS patient satisfaction scores, she suggests.
As another example, Hernandez points to research from Sutter Health on racial and ethnic disparities in pain medication prescriptions.
The researchers examined electronic health records for adults with bone fractures across more than 20 emergency departments. The study concluded that patients were prescribed opioids at similar rates, but Hispanic, Black, and Asian Americans received fewer milligrams of morphine than non-Hispanic whites.
Identifying this trend became the first step to having a conversation about the unconscious bias, and the assumptions based on dialogues about patient pain, that might be driving these decisions.
“Once these findings were elevated to the organization, there’s been real effort to take responsibility and try to educate people how to avoid that,” Hernandez says. Impact4Health has supported health systems with unconscious bias training to raise awareness of this finding and help organizations understand how to respond to it.
Adopt a new mindset
No matter how critical it is to make a change, physicians may be reluctant to address their unconscious bias by adding one more thing to their already-overloaded plates. “Most physicians on the front line are seeing patients in 15-minute increments. When you add this additional level of detail that needs to be thought of, it really creates some enormous stress and strain on physicians who are trying to do the right thing,” Hernandez says.
Doing the right thing and opening the door to better care, however, can take only a few additional steps. The first, Hernandez suggests, is simply accepting that some form of bias is at play in every patient interaction. “Every single person on the planet has unconscious bias. It’s the way your brain works. We all take these mental shortcuts,” she says. Accepting this, rather than arguing against it, paves the way for solutions.
Next, Hernandez advises slowing down interactions to consider the big picture. Impact4Health frames this as the “ACE” mindset; ACE stands for Attention, Connection, and Empathy. In action, ACE looks like this:
Pay attention to the individual and the context of what’s going on. Hernandez encourages physicians to slow down and think about their own bias as part of this context. Research indicates that people make roughly 11 decisions about the people they’re interacting with within the first seven seconds of that interaction. This includes rapid assumptions about likability, trustworthiness, competence, and aggressiveness. Paying attention to the judgments being made is a critical first step in moving past them.
Make an authentic connection with the patient by leaning in and listening into what they’re saying. Listening may seem obvious—but the data indicates otherwise. A 2018 study in the Journal of General Internal Medicine revealed that patients get about 11 seconds to talk before they’re interrupted by their physician. Slowing down, listening for context, and digging deeper with questions about what spurred the patient’s visit can help physicians get a more complete picture of the problem without letting their bias drive decision-making.
Demonstrate Hernandez encourages physicians to make their assessments “knowing that there’s so much happening in Black and Brown lives today, and really trying to have empathy for that population in a way that is more attentive to the fear, the anxiety, and the trepidation that some people feel just even going into the doctor’s office.” She calls empathy “the superpower of this era” because it can help people move past their differences.
On an organizational level, Impact4Health has developed a set of best practices to help health systems create an inclusive culture for patients, staff, and visitors.
Its Inclusion Scorecard for Population Health is an online dashboard that identifies more than 70 best practices organized around the kinds of metrics hospitals need to collect to be more inclusive.
However, setting out policies is just the first step. Organizations must also hold themselves accountable to link quality of care with health equity and make this care available to their communities through inclusive outreach and programming.
Connect with patients
Prioritizing health equity is a key strategy for providing better-quality care. It opens the door to stronger connections with patients: connections that can provide insight into the person’s condition, environments, and other factors.
Hernandez has experienced such insights firsthand. “When my dad had his first battle with cancer, and was being wheeled into the surgery room to have part of his lung removed, he was talking to me and my mom and my brothers in Spanish,” she shares. “And he says, ‘Stop speaking Spanish. They’re going to think I’m stupid and they’re not going to help me.’ ” For Hernandez, that became a moment of clarity in recognizing not just the presence of bias, but also the fear it could create among patients.
“Imagine that kind of fear among your patients, and imagine what that means in your engagement with that patient,” Hernandez advises physicians.
Clinicians who demonstrate a willingness to address their unconscious biases can garner patient trust. “You’re going to make them feel more assured that you’re there for them and that you’re going to do everything possible to have the best outcome. That’s culturally competent or culturally effective care,” Hernandez says.
PSQH: Patient Safety & Quality Healthcare, May 12, 2021
Facilitated virtual care is a method for overcoming one of the biggest barriers to telehealth: technology.
This article was originally published May 12, 2021 on PSQH by Matt Phillion
Telehealth is not a new concept—the industry has been considering it for many years. But a global pandemic has put telehealth at the forefront of patient care, and the industry is looking to the successes of early adopters for best practices, key takeaways, and lessons learned.
During the Health Experience Design 2021 conference, Dennis Mihale, MD, chief medical officer for Upward Health, discussed lessons learned not only as an early adopter of telehealth in general, but also by having that advance familiarity when COVID-19 forced healthcare organizations across the world to reconsider their approach to telehealth.
“To be truthful, we’ve been doing telehealth for nine years,” says Mihale. “For us, it was a little easier to switch over. One day we were doing telehealth, and the next day we were doing telehealth during COVID.”
That experience doesn’t mean his organization’s program is faster or better than anyone else’s; they simply had the benefit of being an early adopter. But the organization uses specific tactics for telehealth that do make a difference.
Facilitated virtual care is a method for overcoming one of the biggest barriers to telehealth: technology. “When you’re talking about seniors, 38% don’t have the technology or skill set for telehealth, no matter what anyone tells you,” Mihale says. “But with a facilitator, you can bring someone into the home, and bring with them the technology to facilitate the visit.”
A facilitator can perform any number of tasks core to tracking the patient’s health: taking vitals, checking medications, looking at the environment the patient is in, or reviewing social determinants of health.
“But most importantly, they bring the technology, so the only thing the patient has to worry about is being a patient,” says Mihale. “The patient satisfaction with the ability to bring a clinical person into the home is phenomenal. Our patients love it, and surprisingly our doctors love it—they were a little afraid of it at first, but then they took to it.”
Bringing care to the patient
What kind of technology the facilitator brings with them will vary based on the organization and the patient population. They may bring glucometers for checking on diabetes, digital stethoscopes, or whatever works best to tailor the facilitator’s capacity to the practice’s and the patient’s needs.
“The idea is that the doctor is, in real time, hearing, listening, seeing, and evaluating the patient in their home,” says Mihale.
What are the benefits to this approach, aside from patients preferring it? First, Mihale notes, an organization can deliver care through a multidisciplinary team. This begins with the facilitator themselves, who may be a licensed practical nurse (LPN), an RN, a specialized RN, a nurse practitioner, or any other skill set that meets the needs of the role.
“Every patient is partnered with a care specialist. This is important, because they develop a relationship of safety and trust with the patient,” says Mihale. It’s similar to what happens within a practice or doctor’s office. Having someone on staff the patient looks to and trusts allows an organization to carry out the treatment plan and better diagnose, prescribe, and assess the patient.
“It’s everything that is necessary for a complete and comprehensive visit, including social determinants of health, behavioral health, and so on,” Mihale adds.
Beyond that personal relationship, there are other, more tangible benefits. Mihale notes that, pandemic or not, avoiding unnecessary ED visits is incredibly beneficial. “If a patient needs to be in the [ED], I want them there now,” he says. “But if they don’t need to be there, I prefer they stay home and let us treat them in their home.”
And it works: Following implementation of their facilitated care program, the organization saw a 40% reduction in ED visits.
Facilitated care also makes regular or follow-up visits more reliable for patients who might otherwise fall through the cracks. “It’s phenomenal for transitions of care,” says Mihale. “You’re able to resolve issues over the phone, perform quarterly assessments, even do visits with new providers.”
In addition, specialists who are seldom able to get out of the hospital, such as neonatologists, hospitalists, orthopedic surgeons, or endocrinologists, have access to patients they otherwise would not. “You’re bringing the doctor to the patient,” says Mihale.
The services patients and providers want
Facilitated virtual care isn’t just conference calls or checking vitals, Mihale notes. “If you can do it in an office, you can do it remotely through facilitated care,” he says. “There are even portable, on-demand systems you can bring out.”
Facilitated care isn’t so different from traditional telehealth, he says, but the difference is that there is someone in the home. “They make the technology transparent,” says Mihale. “So the patient doesn’t have to worry. And they’re able to do a lot of other things in the home: looking at pills, checking on electric and water bills, checking out the refrigerator. They can check the entire situation, the whole person.”
And, of course, facilitated care and telehealth alleviate the other biggest barrier to in-person visits: transportation. “You solve social isolation,” says Mihale.
The openness creates and advocates for a relationship of safety and trust. Looking back on the benefits of this relationship, Mihale notes that with facilitated care, the organization saw a drop in ED visits, admissions, and readmissions.
“We find that when a patient leaves the hospital, two days later they often don’t remember everything they were told at discharge,” he says. “It’s very difficult sometimes to educate the family. But going to the home four or five days later, speaking with the patient, reminding them why they went to the hospital, making sure they understand their treatment plan… it all goes such a long way to helping patients feel comfortable and recover.”
Quality improvement
Mihale, who has worked in quality improvement for much of his career, says that facilitated care can markedly boost the success of quality improvement plans.
“When you can evaluate the patient’s environment, take vitals, make assessments, you can truly understand if a quality improvement program is delivering improvements,” says Mihale. “They can respond to deficiencies, take advantage of opportunities, work on self-care, improve engagement.”
And that face-to-face time can solve a problem patients may not even know they have: communication.
“Patients may not call you when they don’t understand something, but if they have a visit, they’ll open up,” he says. “And most importantly, you can respond to same-day or next-day needs of the patient. If you don’t have a policy of same-day or next-day visits in your office, you’re going to have more ED visits and more readmissions than you deserve.” Sometimes, Mihale says, the patient physically can’t get there the next day—so you have to go to them.
“You can deliver comprehensive care” through facilitated virtual care, he says. His organization leverages an interdisciplinary team to deliver that care: primary care physicians (PCP), behavioral health professionals, nurse practitioners, RNs, LPNs, nutritionists, social workers, and more. Telehealth simplifies communication between those team members.
“Try doing that in a conference room when those people don’t all work in the hospital,” he says. In contrast, with telehealth, “we can meet at one time. They’re in the meeting, notes are being taken, the follow-up is there.”
What the patients like about it
Patients enjoy improved access to care—and that access is responsive and timely. Rather than being told to come to the facility in two weeks for a problem they have now, they can receive more immediate care without the challenges of transportation and travel time. They also benefit from a lower cost of care without an on-site copay.
Facilitated care also helps patients in an unexpected way, Mihale says. “One thing I didn’t predict was it helping reduce health inequities,” he says. “We thought it would improve the health of the overall population, but not address health inequity.”
Many of these inequities are the result of social determinants of health. “If you have someone worried about food, legal problems, transportation—well, keeping an appointment at the clinic is difficult and may be number 10 on their list of concerns for the day,” says Mihale. “If you’re a single mom and your child is getting off the bus in a place you don’t want them to be alone, to heck with your appointment—you go to your child.”
The facilitators will help with problems that may not be immediately recognizable as health related: legal issues, housing, food security. But “until you solve those problems, they can’t think about self-care, and they’re not going to work toward bettering their health,” says Mihale.
In many ways, facilitated virtual care is a sort of surrogate PCP, he notes. “We’re bringing in observations and information to the PCP, who may not be one of us, and at the same time we know the treatment plan and are able to advocate for that PCP and their treatment plan,” says Mihale.
Upward’s patient population is in the highest 5% of risk and need utilization, and traditionally among the lowest in engagement. “We take on the toughest to manage and treat,” he says.
One lesson learned looking at the health of this population is that 5%–10% of patients with chronic disease may not have seen a doctor in 12–18 months. Lack of annual wellness visits and coordination of care make it very difficult to help these patients.
And with regard to chronic conditions, facilitated care helps enable remote patient monitoring for conditions such as heart disease, diabetes, asthma, or hypertension, which helps facilitators know when they “really have to get into the neighborhood and into the home,” Mihale says.