The future of care hinges on a healthy nursing team that's in it for the long haul.
Editor’s Note: This is part 1 of a two-part story. Read Part 2 here.
2024 will be restorative, if CNOs have their say.
Amid geopolitical conflict, financial headwinds, and ramped nursing shortages and unrest, there's a lot of healing that needs to happen. Starting with the healers.
“The current times have required a new level of operational rigor [and] a keen focus on the people providing the care and service,” says Kate FitzPatrick, DNP, RN, NEA-BC, FAAN, executive vice president and Connelly Foundation chief nurse executive officer at Jefferson Health, which has 17 hospitals throughout New Jersey and Pennsylvania.
To set the stage for success in 2024 and beyond, CNOs must build up their teams, both in number and resilience, nurse execs and experts tell HealthLeaders. That means making compensation compelling, fostering shared purpose, redesigning care models, and playing a very long game when it comes to recruiting.
And while buoying wellbeing for beleaguered teams may sometimes seem at odds with imperatives like driving quality care and efficiency, it's the right strategy, says Jeff Doucette, DNP, RN, NEA-BC, FACHE, FAAN, chief nursing officer at Press Ganey, which provides experience survey solutions and consulting services to healthcare organizations, including nursing leaders and teams.
“What our data clearly shows is that if you are not taking an employee-first approach right now, you will never be able to meet the … patient promises that organizations are making to their communities,” he says.
That’s especially true as trends like aging baby boomers, escalating mental and behavioral health conditions, and worsening physician shortages ratchet up the demand for—and pressure on—nurses.
But that doesn’t mean CNOs can’t start turning the tide.
Foxx attributes a lot of Cleveland Clinic’s turnover turnaround to its robust total rewards.
“We have a professional ladder,” she says. “We have tuition assistance. We have loan repayment. We have a tremendous amount of resources in our wellbeing space.”
Her team has also enhanced communication around these benefits, many of which are longstanding, so nurses know the possibilities from the beginning.
“When I get to say a few opening comments [at orientation] to all the nurses starting, I tell them every time, ‘You can spend your entire career here and work in different locations, different specialties, have different opportunities.’ ”
Radiate shared purpose
When it comes to building a strong, committed team, compensation must be competitive, Doucette says. But that's not enough.
In Press Ganey's latest research on workforce loyalty, one’s relationship to work—liking it, finding it meaningful, feeling it makes a difference—was the top reason healthcare employees said they would stay with an organization for three years, even if offered a job elsewhere.
Other drivers include strong managerial and team relationships, as well as the organization's care quality; ethics; and follow-through on diversity, equity, and inclusion commitments for patients and employees.
It's “interesting given the national political climate around these types of conversations,” Doucette says. “But it is definitely at the top of mind for healthcare employees, and especially clinicians across all job categories.”
Resilience is a key to satisfaction across domains, he says.
“People talk about resilience all the time, but many leaders don't fully understand what it is,” he says.
To build it, CNOs should focus on the two major aspects that are measurable:
Activation: “How connected to the work we are, how we feel about the work, as well as our connection to the organization's mission, vision, and values,” Doucette explains.
Decompression: “How we get away from the work and recharge our batteries,” he adds. It's a big issue right now at all levels of the organization and especially for clinicians.
“How do we take what was already a fragile professional practice environment prior to the pandemic—and of course, these cracks turned into canyons during the pandemic—and how do we repair and rebuild an engaged and highly resilient workforce?” Doucette asks.
Listening can help.
“We've got to stay connected, especially to folks on the sharp edge of care,” he says.
Healthcare organizations that boast the highest employee engagement scores in Press Ganey's database have robust continuous listening strategies, meaning they check in with their teams in a variety of ways throughout the year (e.g., through surveys, stay interviews, and coffee chats with CNOs and other executives), he explains.
And all that listening should lead to talking.
FitzPatrick and Sievert find the people in their purview—from nursing teams and leaders to the C-suite—expect more transparency and communication on the macro conditions affecting healthcare.
“We have seen these national trends really take on a life of their own through social media and other media outlets,” Sievert says. “Part of my role as a CNO is to keep our team aware of the changes, the implications, and the risks [and] benefits.”
Doucette agrees. To keep everyone focused on the big picture, even amid the “everyday fires” that are bound to flare, he says, CNOs need a “well thought-through strategy that is well-communicated to all levels of that organization and creating that alignment and accountability.”
Design the future of care
Creating a professional practice environment that reinforces purpose and loyalty—what Doucette calls “the new PPE”—is a must to fortify nursing ranks.
Projected shortages in key clinical roles over the next decade are “forcing needed innovation in the care delivery models,” FitzPatrick says. “We will have to move fast and agile and the new models will have to demonstrate a more financially sustainable model with the same or better quality outcomes.”
It's quite an undertaking, especially in acute care.
“The biggest challenges that I believe we are facing are around making this 24/7/365 environment appealing to the younger generations,” Sievert says.
In the past, new graduates coveted bedside positions. Today, they're calling for balance and more predictability.
“That simply isn't the hospital setting where holidays and weekends are required, night shifts are necessary, and often many positions require on call beyond the normal work week,” Sievert explains. The challenge is to “create flexibility for the staff but ensure adequate, safe staffing for the patients,” all while keeping costs low.
One solution that all the nurse executives highlighted to HealthLeaders: Virtual experiences on the floor and behind the scenes. FitzPatrick now uses virtual nursing to offload administrative tasks so bedside nurses can focus on top-of-license practice, while Sievert says that ambient listening can cut down on clinical documentation.
Another common refrain: Be brave, bold, and agile.
“Get comfortable with taking some risk,” Sievert says. “In this market and time we are in, the first one out of the gate will be ahead.”
That means ditching perfectionism.
“Don't be afraid … if it doesn't work out exactly as you planned it the first time,” Foxx says. “We spend a lot of time discussing the what-ifs.” As long as patients aren’t put in harm’s way, “just go for it and fix things along the way.”
Foxx adopted this mindset when launching a virtual patient companion program earlier this year. The initiative allows unlicensed nursing assistants to monitor patients from afar—specifically, from existing onsite bunkers to preempt additional real estate costs—so bedside caregivers can focus on providing hands-on service.
“I'm giving you permission to be agile,” she says of her teams’ approach to implementation. And they’re being just that, with work underway to roll the program out to all system hospitals to reduce overall sitter hours and expenses. “We've had a lot of success with that this year. And so we definitely want to scale and push it out further.”
Delaney Rebernik is a contributing writer for HealthLeaders.
The health system is seeking new ideas and technologies that can help improve cancer diagnosis and treatment in rural areas.
Tampa General Hospital is looking for innovative ideas to help improve cancer care in rural communities.
The hospital, through its TGH Innoventures venture capital and innovation arm, and its Cancer Institute are partnering with the non-profit Synapse Florida on the Innovation Challenge, which “encourages individuals and organizations to propose innovative solutions that address the significant need for cancer care where it otherwise may not exist.” Submissions are due by January 20, 2024.
Health systems and hospitals across the country have been turning to crowdsourcing in recent years to tackle vexing healthcare issues, with the idea that innovation doesn’t have to come from within the healthcare space. Some of the industry’s biggest disruptors, like Amazon, Apple, and Microsoft, are approaching healthcare with ideas and lessons learned from retail, hospitality, banking, and other industries.
Several health systems have launched their own innovation centers, often fueled by venture capital, to promote new ideas and technologies from within and in collaboration with the surrounding community. The health system can then test and fine-tune those products within the enterprise before marketing them through a new business line.
“Hosting an innovation challenge is a strategic move for any business seeking fresh, creative solutions,” Lauren Prager, CEO of Synapse Florida, said in a press release issued by TGH. “Through these challenges, organizations like Tampa General are establishing a direct channel for new ideas by engaging with innovators beyond their immediate sphere. This approach is particularly effective as it draws from a diverse pool of contributors, including those from outside the healthcare industry, such as patients, caregivers and businesses from varied sectors. Large organizations can significantly benefit from this open exchange, as it not only drives innovation but also strengthens community ties, fostering a culture of collaboration and inspiration.”
In this case, TGH officials say they want to target not only lack of access to cancer care services in Florida, but care for the estimated 46 million Americans living in rural areas, where lack of resources and higher risk factors are contributing to higher cancer and mortality rates.
“While we are working to increase access to world-class care across Florida, we recognize there are some challenges we face that require system disruption,” John Couris, president and CEO of Tampa General, said in the press release. “Through TGH Innoventures and in partnership with Synapse, we’re working to incentivize innovation so that we can transform care delivery. With this challenge, we invite experts, entrepreneurs and critical thinkers to offer up solutions that have the potential to have a real, meaningful impact.”
“The Innovation Challenge is illustrative of the work we do at TGH Innoventures, assisting Tampa General’s stakeholders in solving big problems in healthcare by looking outside the four walls of the organization,” added Rachel Feinman, the health system’s vice president of Innovation and managing director of TGH Innoventures. “By fostering partnerships and supporting projects, we can advance cancer care across Florida.”
Aurora Health Care has integrated the technology into new clinics, giving providers and patients a pathway to better care coordination
Real-time location system (RTLS) technology has long been used to keep track of objects, supplies, medicines, and even staff and patients within the healthcare space. Now some organizations are using the platform to map out provider workflows and patient journeys.
At Aurora Health Care, a Milwaukee-based health system encompassing 26 hospitals and more than 600 other care sites, leadership decided to incorporate an RTLS platform into new clinic construction. With that technology in place, the health system has been able to boost patient visits and streamline provider and staff workflows so that patients spend as little time as possible waiting around.
“We really appreciate it because it expedites the visit process,” says Elise Dieringer, BSN, RN, Aurora’s manager of clinic operations. “It really comes down to enhancing workflows. And we’re still learning every day how we can use it more, how we can use it better.”
With many health systems looking to maximize patient time and reduce workflow inefficiencies, RTLS technology offers an innovative platform for understanding the care pathway. Upon checking in to a clinic for an appointment, patients are given a badge and assigned an exam room, similar to a self check-in. The badge links to the clinic’s EHR and the patient’s record and alerts the patient’s care team, with the appropriate care team member sent to that room. If the patient is seeing multiple providers, the badge issues alerts when one provider is finished, when diagnostic tests are needed, or when it’s time to finish the visit. The patient can then be discharged from the room instead of the front desk.
Health system officials say the platform increased capacity at one clinic by about 15%, or an additional 86 visits per month, without reducing face-to-face time.
What it does reduce, Dieringer says, is time spent waiting to see a physician or nurse, or time spent by care team members waiting for a patient to be ready. Care team members know immediately when a patient is ready, and staff can use the data accumulated over time to better schedule patient visits and map out room utilization and care team workflows.
Dieringer says new clinics are designed so that the care team is based in a central area, rather than individual offices (one of the sticking points to provider buy-in, she adds, was getting physicians to see that they didn’t need to have their own offices). The floor plan is then mapped out to facilitate quick and efficient patient flow, with the idea that the entire care team, from nurses to doctors to specialists, goes to the patient rather than having the patient move around to meet each care team member.
“It really is a team-based approach” to healthcare delivery, she says.
Dieringer says the next step will be integrating the RTLS platform into an existing clinic, a bit of a challenge considering the technology will need to be designed around an existing floor plan. Beyond that, the health system will be looking at how it can use the data collected for other purposes, such as tracking the spread of viruses and infections within the clinic, monitoring supply chain efficiency and device use, even improving staff and patient safety.
To beat payers at their own game, one CFO is looking to his revenue cycle to even the playing field.
The payer/provider relationship has been strained in 2023, to say the least. Between ever-changing payer requirements and frequent denials, providers often feel like they are in a no-win situation.
As more hospitals and health systems look to fight back, many are bringing in more AI and technology to streamline revenue cycle process and reduce burdens across the board.
Most hospitals and health systems have a workforce that was heavily strained and became burnt out during the pandemic, and Mazurkiewicz says they are still dealing with the aftereffects.
“One of the effects of that burnout has been in documentation,” he says. “Insurers have raised the bar on expectations of documentation and prior authorization and will not pay if those expectations are not met.”
Mazurkiewicz says payers have been ramping up initiatives to ensure what they’re paying for has all the clinical documentation they require and more, so payers are now auditing more claims, delaying more claims, and that’s delaying cash flow.
“In the past year we’ve seen a substantial increase in initial denials, primarily coming from Medicaid and Medicare Advantage managed care plans. That means our revenue cycle initiatives need to be more focused on denials management,” he says.
So how will McLaren be achieving this? By continuing to prioritize revenue cycle AI and technology.
“We’re using AI to help with claims processing and documentation of our care. These tools help ensure physicians are fully and accurately documenting why they recommend a certain course of treatment, and then assess whether a claim is likely to be denied based on each insurer’s rules,” Mazurkiewicz says.
He says that these revenue cycle tools even provide insights into the reasons why a claim may be denied, so they can make those corrections before a claim is even submitted.
“It’s making sure our documentation is as right as our diagnoses.”
On a more basic operational level, Mazurkiewicz says for 2024 he will also increase McLaren’s focus on collecting cash at the point of service, when appropriate, which will in turn reduce its billing costs.
Leonard Mazur looks back on a 50-year career in pharma and forward to the anticipated launch of new treatments for three health concerns.
Leonard Mazur is a 50-year veteran in the pharmaceutical field with a myriad of product launches, patents, and titles under his belt. But it wasn't until he turned 50 that he decided to become an entrepreneur and started establishing his own companies.
Today, in his late 70s, he is steering Citius Pharmaceuticals toward anticipated launches of potential first-and-only prescription treatments for three health concerns and a next-generation, scalable stem cell therapy program.
"I didn't really go entrepreneurial till I was 50 years old, which is the worst possible age that you can try something like this," the co-founder, CEO, and chairman of Citius Pharmaceuticals says. "I remember I used to bring documents home for my wife to sign, signing over our house, to keep everything going."
When Mazur commits to something, he says, he's all in.
"I put money directly into the company, as does my business partner and co-founder, Myron Holubiak," he says. "We both have millions of dollars invested in the company. That's something you normally don't see."
This strategy sets up Citius Pharmaceutical in the enviable position of having little to no debt burden.
A long career path
Mazur spent the first 10 years of his pharma career at Cooper Laboratory, where he got his taste for working in smaller, faster moving environments.
"It was a dynamic company led by a dynamo CEO and I loved the environment," he says. "Smaller companies are much more driven towards getting results quickly."
Leonard Mazur, CEO of Citius Pharma. Photo courtesy Citius Pharmaceuticals.
He also worked in various roles at the Medicis Pharmaceutical Corporation, ICN Pharmaceuticals, Knoll Pharma, and Cooper Laboratories. He then founded Akrimax Pharmaceuticals, Triax Pharmaceuticals, and Genesis Pharmaceuticals.
Prior to its merger with Citius in March 2016, he was the co-founder and chairman of Leonard-Meron Biosciences.
Years later, Mazur refers to his time at Cooper Labs as setting the foundation for his success and setting him on the path to entrepreneurship.
"There was no formal training program, but you did have a chance to witness decision-making firsthand," he says. "Being a part of a company like that, I found that you learned very quickly a lot about the business in general. So that all played an important part for me as far as my own development and my own way of looking at things and also, in all likelihood, my own desires as far as pursuing an entrepreneurial career."
The future at Citius
Citius has three potential first-and-only prescription treatments in their indications and a next-generation, scalable stem cell therapy program in the works.
Lymphir, a purified reformulation of denileukin diftitox, is waiting for FDA approval as a cancer immunotherapy treatment for a rare form of non-Hodgkin lymphoma. Citius filed a BLA in 2022 for the treatment, and earlier this summer the FDA asked the company to incorporate enhanced product testing and additional controls during the market application review. There were no concerns relating to the safety and efficacy clinical data package submitted with the BLA, or the proposed prescribing information. Citius plans to complete the CRL remediation activities by the end of the year and file the resubmission in early 2024.
Two other products are Halo-Lido, which could become the first FDA-approved prescription product to treat hemorrhoids in the United States, and Mino-Lok, an antibiotic lock solution to treat patients with catheter-related blood stream infections that Citius has licensed from The University of Texas MD Anderson Cancer Center.
The company is also working on a stem cell platform for the treatment of respiratory conditions associated with acute inflammation, with an initial indication in the treatment of acute respiratory distress syndrome (ARDS).
Citius' most recent news is its merger with TenX Keane Acquisition, creating a separate oncology company, Citius Oncology. Citius Pharma will continue to focus on completing the Mino-Lok trial and evaluating next steps with the Halo-Lido program. The acquisition is expected to be finalized in early 2024.
"Our objective there is the NASDAQ listing that would come with this backing," Mazur says. "That's the primary reason we're doing it that way. Once it starts trading, we don't have to go through a whole separate process to get NASDAQ-qualified, which will enable us to raise the funds a lot quicker. The objective is to raise the funding to launch, without diluting the Citius shareholders any further. Down the road we would start distributing the shares in a subsidiary to the Citius shareholders."
Growing as a leader
Mazur says he has honed his leadership skills over the years to focus on motivating every person in the company and creating a work environment that values everyone's input. To do that, he believes in "giving everyone all the space that they need" to take responsibility for their work.
"I think if you've got professional people employed, they are the ones that have to make the decisions,” he says. “You are relying upon them to make the right calls to make things happen."
It’s also important, he says, for employees to feel they are a part of the company's success and have the opportunity to participate in that success.
Mazur says he learned from a former boss that stock options are a great way to create that atmosphere.
"Every single person from the lowest to the highest position has stock options in our company," he says. "In reality, I think stock options are an important motivational tool for everybody. And over the years I've had people that received stock options from years ago, come up to me and thank me for it because they were able to pay for their children's college tuition and other things of that nature. So, you know, it usually works out very, very well."
To lead successfully, Mazur says, one has to first believe in oneself, as well as one’s ideas.
"You have to have confidence, you have to believe in what you're working towards, and what you have in your portfolio," he says. "When all those things come together, it gives you a strong feeling that you will succeed. From the beginning, one of my favorite sayings has always been 'Failure is not an option.'"
One of Mazur's many career highlights occurred at ICN Pharmaceuticals. He had been brought in as vice president of sales and marketing to launch Virazole, the brand name for ribavirin, to treat RSV in infants.
"I love our industry," he says. "I think it's a great industry to be part of because you get involved in something and you never know how it's going to work out. For example, ribavirin was the very first drug approved for infants to treat a rare respiratory virus, called RSV. Most of the RSV episodes would occur in a neonatal intensive care unit. And if the infants were immune compromised, they could die.”
“The great thing that happened was [that] once the drug first launched, I can't tell you the number of times we received phone calls at the office from parents, nurses, and doctors thanking us for the availability of that drug because it had saved an infant's life,” he says. “I remember telling everybody in our small marketing group at the time: 'Pay attention to this moment. It's never going to get any better than this. This is what we're here for. What better thing can you experience than being a part of saving infants' lives?'"
Born in Germany, Mazur emigrated to the U.S. when he was young, and later in life became a recipient of the Ellis Island Medal of Honor. The medal is presented to those who immigrated to the United States during the Ellis Island era and have shown an outstanding commitment to serving the United States either professionally, culturally, or civically.
Mazur believes strongly in giving back, and his charitable contributions have been many.
“I was deeply moved to receive the Ellis Island Medal of Honor," he says. "The United States is the only place in the world where immigrants have access to opportunities that far exceed those from where they came. I am very grateful to have been able to tap into those opportunities while celebrating my Ukrainian heritage, which has always been central to my personal growth and professional success. I am living the American Dream and feel honored to work in the healthcare sector where my team and I continue to strive to improve the everyday lives of those in need.”
Mazur has made two significant contributions to his Pennsylvania alma maters: West Catholic Prep High School and Temple University. He says he believes in the value of a liberal arts education and credits his undergraduate degree in psychology from Temple with his entrepreneurial success.
A few years ago, he and his wife donated $5 million to support scholarships and professional development opportunities to students in the College of Liberal Arts. in recognition, Temple is renaming its liberal arts building from Anderson Hall to the Leonard and Helena Mazur Hall.
The Mazurs also donated $5 million to his high school, West Catholic Preparatory, of which he is a member of its Hall of Fame. It’s the largest single donation in the school’s nearly 100-year history.
"I totally believe you have to give back," Mazur says.
HealthLeaders Senior Editor Eric Wicklund talks with Amy Lerman, a member of the law firm Epstein Becker Green, about how health system executives should plan their telehealth strategies for the coming year based on what we're seeing coming out of the nation's capital.
A study led by Brigham and Women's Hospital found that a sensor-embedded pill can accurately track vital signs in patients being treated for sleep apnea and can be used to monitor fentanyl overdoses.
Researchers at Brigham and Women’s Hospital are reporting good results from a study that used a sensor-embedded ‘pill’ to monitor a patient’s vital signs.
The study, published in Device, gives new value to a digital health form factor that has seen its share of ups and downs, but could prove valuable in remote patient monitoring programs for a wide variety of health conditions.
“We have developed an ingestible electronic capsule that detects different movements associated with specific vital signs,” Giovanni Traverso, MB, BChir, PhD, a gastroenterologist in the hospital’s Division of Gastroenterology, Hepatology, and Endoscopy and co-corresponding author of the study, said in a press release. “We anticipate that there will be broad applications for this device, with the potential to improve monitoring for sleep apnea and other breathing conditions.”
In their research, Traverso and his colleagues tested the Vitals Monitoring Pill (VM Pill) on 10 patients living with sleep apnea. They found that the device, developed by Massachusetts-based Celero Systems, which was launched through the Mass General Brigham innovation network, captured respiratory and heart rate data that was comparable to other monitoring devices. It also captured moments when the patient stopped breathing, either intentionally (when a patient holds his or her breath) or during a sleep apnea event.
The device was also tested in a preclinical model for fentanyl overdose, and was able to detect respiratory depression caused within a minute of overdose in real-time. That capability is timely, given the nation’s opioid abuse epidemic and efforts to find new ways to monitor patients and reduce deadly overdoses.
The study was done by researchers at Brigham and Women’s, a member of the Mass General Brigham health system, the Massachusetts Institute of Technology, and West Virginia University, as well as members of Celero’s team. Some 57 hours of data was gathered from the patients at WVU Medicine’s Sleep Evaluation Center.
Healthcare organizations and pharmaceutical companies have been experimenting with ingestibles for years, but have struggled to find the right technology and use case. One of the first companies to develop “smart pills’ was Proteus Digital Health, which at one point was valued at $1.5 billion and had a partnership with Otsuka under its belt before filing for bankruptcy in 2020. Smaller, more recent studies have centered on monitoring GI issues and delivering and tracking the effectiveness of timed doses of medications.
Traverso, who launched Celero in 2017 and sits on its board of directors, says sensor-enhanced pills have great potential in RPM programs where providers need accurate data without worrying that the patient will affect the data-gathering. Data is transmitted from the pill to a receiver attached via USB interface to a laptop until the pill is discharged.
“Our study provides a tangible product with real commercial value,” he said. “Ingestible vital monitors can really transform our capacity to rapidly respond to life-threatening events.”
A new program at Bassett Healthcare monitors email inboxes and helps the health system react quickly to important patient emails.
With more and more healthcare being conducted online these days, health systems are struggling to get a handle on messaging between care teams and their patients.
Enter the Inbox Ninjas.
Launched in late 2022 by the Bassett Healthcare Network, the Ninjas are full-time advanced practice clinicians (APCs)–or staff with similar qualifications–hired by the health system to review email messages sent by patients to their care providers. The Ninjas separate the messages into different categories, giving high priority to messages that require action, such as answering an urgent medical question, scheduling an appointment, or filling a prescription.
The program addresses a vexing pain point for healthcare organizations, putting pressure on already stressed doctors to keep their inboxes up to date, even when they’re away. Missing those messages often leads to interrupted or delayed care, which affects care plans and clinical outcomes and boosts expenses.
Some health systems, including the Mayo Clinic, Cleveland Clinic, Vanderbilt Health, UCSF Health, Northwestern Medicine, BJC Healthcare, and even the Department of Veterans Affairs, are charging fees to answer emails, under the idea that a fee will cull out unnecessary messages and compensate care teams for their time.
Paul Uhrig, chief legal and digital health officer at New York-based Bassett and executive director of the Bassett Innovation Center, says leadership didn’t want to add that burden to their patients, many of whom live in rural areas and are concerned about the cost of healthcare.
“There’s a lot of messages coming into our providers now through the portal that need to be answered, and [those providers] were answering them during their pajama time,” he says, referencing the time spent by providers at home. “We wanted [a program] that takes the burden off them while not shifting that to their patients. We’re very conscious about not shifting cost to patients.”
Meeting a distinct need
Bassett launched the program to meet a very distinct problem. According to Halley Chiodo, the health system’s telemedicine specialist, a large primary care provider in Cooperstown, New York, had closed down, leaving thousands of patients without a PCP. Bassett stepped into the void to help but needed a means of sifting through the inboxes of the departed PCPs, tagging urgent messages to prevent lapses in any care plans, and shifting those patients to new providers.
They had little to work with at first.
“We built this program from the ground up,” she said during a presentation at the Northeast Telehealth Resource Center’s (NETRC) annual meeting this fall in Nashua, New Hampshire. “We had no model to work with.”
Chiodo said management didn’t want to pull in current staff and add to their workflows, so they created a new position, one that is all-virtual and requires APC-level qualifications so that they can answer questions and fill prescriptions on their own (the health system currently requires a New York license and three years of clinical experience). The role seems especially suited to clinicians at the late stages of their career or in retirement, who might enjoy a job that they can do from home.
With approval from leadership to hire five FTEs, the program launched in late 2022. Uhrig said that while the initial intent was to focus on the inboxes of doctors who were no longer with the health system or those on vacation or out of office for a period of time, leadership realized the program could benefit any and all care providers.
It also became apparent very quickly that addressing every single email message would be too much, even for the Inbox Ninjas. Chiodo said the health system adjusted the protocols to enable the Ninjas to sort through all emails but answer only the priority messages.
“Nobody needs a clean inbox,” she said.
With that model, Chiodo said, the health system found that the Ninjas could also be put to use supporting Bassett’s telehealth programs, providing an extra layer of clinical backup.
Calculating the ROI
Both Chiodo and Uhrig say the Inbox Ninjas have been successful in cleaning up inboxes and addressing care gaps for patients, but whether that makes the program sustainable is uncertain. Chiodo—who noted Bassett is hiring more Ninjas soon—said the program is all-virtual, so the workforce is unique and requires a different management style. She also noted that other departments have asked about having their own Ninjas.
As for cost, the program can be adjusted to fit the needs of the health system. The higher level of clinical proficiency, the more that a Ninja can do with regard to fielding and addressing requests for medical services, which also means the money spent on staffing will increase.
Chiodo said the health system is working on a formula that would establish the number of billable clinical encounters needed to support one Ninja—while adding that ROI shouldn’t be linked solely to billable encounters. Uhrig, who noted the program did receive some outside funding to get off the ground, also noted the challenge of determining value.
“How do we turn some of these activities into billable activities?” he asked. At the same time, he added, there are benefits that aren’t billable, including improved patient satisfaction and engagement and a less-stressed corps of doctors who aren’t worrying about their inboxes so much. Eventually, he added, the health system might be able to link those timely responses to e-mails to specific improvements in clinical outcomes and reduced healthcare expenses, along with less staff stress, a better workplace, and improved staff retention.
Chiodo says there’s no shortage of qualified people who are interested in the job.
“After all,” she said. “Who wouldn’t want to be called a Ninja?”
Research finds that patients are less likely to get follow-up diagnostic tests after a telehealth appointment than after an in-person visit. To address this, health systems need to provide better follow-up services.
Telehealth programs may be great for connecting patients to their doctors, but new research suggests it isn’t closing the gap on diagnostic tests and referrals.
A new study posted in the Journal of the American Medical Association (JAMA) by researchers from several notable health systems finds that diagnostic loop closures for colonoscopies, cardiac stress tests, and dermatology referrals were worse for patients after virtual visits than for those patients seeing their doctor in-person.
The research, conducted by affiliates of Harvard Medical School, Beth Israel Deaconess Medical Center, Brigham and Women’s Hospital, Northeastern University, and Stanford, suggests that health systems aren’t providing the appropriate support after a telehealth visit to ensure follow-up tests are done. That would include sending messages to the patient after an initial visit to schedule and follow through on diagnostic tests.
Without that follow-up to close the loop, diagnostic tests aren’t taken and the care plan is interrupted. This could mean patients aren’t alerted to a serious health concern such as cancer or advanced cardiac disease and don’t take the necessary steps to seek treatment.
“When investigating notable differences in loop closure for orders placed during telehealth visits, our findings suggest that differences in loop closure may be inherent to telehealth as a modality,” the study team concluded. “One potential mechanism to explain this may be the lack of systems in place to help patients complete test and referral orders. During in-person visits, members of the support staff team sometimes help patients schedule their tests at checkout; however, this support is absent during telehealth visits. After the visit, patients do not receive any communication reminding them to schedule the test or referral, which may further limit loop closure.”
“Other potential explanations include the possibility that it may be more difficult to remember information provided during telehealth visits, that telehealth may present unique communication barriers, or that it may be more difficult to engage patients in shared decision-making during virtual visits, thus decreasing patient engagement with test and referral orders,” the team added.
In the study of more than 4,100 patient visits at a Boston-based primary care practice and affiliated health center between March of 2020 and January of 2021, researchers actually found low follow-up for each of the three tests, but lower after a telehealth visit. Overall, 58% of tests ordered during in-person visits were completed, while 43% of tests ordered after a virtual visit were completed.
Broken down further, colonoscopy referrals made up 78.7% of all orders. Of those, almost 57% were completed within a year by patients who’d seen a doctor in person, while about 39$ were completed by patients who’d used telehealth. For dermatology referrals, comprising 11% of all visits, 61.5% of those ordered after an in-person visit were completed within 90 days, and 63% were completed by those using virtual visits. For cardiac stress tests, comprising 10.3% of all orders, the numbers were 63% completed within 45 days of an in-person visit and 59% completed after a telehealth visit.
While identifying the challenges associated with virtual care, the researchers also emphasized that neither in-person nor virtual visits are performing well in closing the diagnostic testing loop.
“While the differences in loop closure between telehealth and in-person visits may be concerning, system-level changes are needed to improve test completion rates across all modalities,” they wrote. “These might include automated tracking for outstanding tests within electronic medical records and interventions such as telephone outreach to patients, automated text and email reminders, and the use of referral managers. These considerations may be particularly important for patients who rely heavily on telehealth, such as those in remote rural areas and disadvantaged patients with limited health access and literacy.”
The partnership with Talkspace addresses a surge in teenagers—both in the city and nationally--reporting severe behavioral health concerns and not receiving care.
New York City officials have launched a telehealth platform specifically designed to give teens access to behavioral health services.
The ‘TeenSpace’ platform, developed in a partnership with digital health company Talkspace, enables those between the ages of 13 and 17 to meet with a licensed therapist by phone, video, or text at no cost.
The program comes at a time when healthcare organizations across the country are struggling to find the resources to help a teenage population facing a surge of behavioral health issues. The National Institutes of Health (NIH) says depression in that age group has increased to the point that it’s a “major public health concern,” with some studies estimating one in every five is in need of care and more than half of those aren’t getting the care they need.
NYC officials say that percentage is even higher in the Big Apple. According to the city’s Department of Health and Mental Hygiene (DOHMH), some 38% of NYC high school students in 2021 reported feeling so sad or hopeless almost every day for at least two weeks during the past 12 months that they stopped doing their usual activities.
"Coming out of a once-in-a-century pandemic, we know that levels of anxiety and depression have increased particularly among our young people," Deputy Mayor for Health and Human Services Anne Williams-Isom said in a press release put out by the mayor’s office. The new telehealth portal "puts access to mental health support right in the hands of our young people. They can use their smart phone or other devices to connect with a practitioner in a time and space that works for them.”
Talkspace will manage the platform, which was designed by the company and city officials with input from teens. The service also enables a mental health professional treating a teen to refer that teen to additional resources, including in-person care.
