Community consulting pharmacists work with patients' prescribers and pharmacies for as long as a year after hospital discharge.
A medication management intervention to avoid patient harm that has been proven effective in the hospital setting also appears effective in the community setting.
Adverse drug events occurring outside the hospital setting have been increasing, according to the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance Project. From 2013 to 2014, the rate of emergency department visits for adverse drug events was estimated at 4 per 1,000 people. From 2004 to 2005, the rate was estimated at 2.4 per 1,000 people.
The Pharm2Pharm medication management intervention, which has demonstrated effectiveness in the hospital setting, can reduce adverse drug events in the community setting, recent research shows.
"The Pharm2Pharm model is an effective way to address the growing problem of community-acquired medication harm among high-risk, chronically ill patients. This model demonstrates the importance of deploying specially trained pharmacists in the hospital and in the community to systematically identify and resolve drug therapy problems," the researchers wrote.
The model features a hospital consulting pharmacist role and a community consulting pharmacist role. There are three facets to the community consulting pharmacist role.
Working with patients' prescribers and pharmacies for as long as a year after hospital discharge to enhance drug therapy regimens
Focusing on medication issues to reduce hospital utilization, especially in the time period soon after hospital discharge
Prioritizing medication management according to the patient's health goals and concerns
The recent research examined 189,000 hospital admissions from 2010 to 2014. The researchers found 70% of medication harm codes were community-acquired. On a quarterly basis, the Pharm2Pharm intervention reduced the rate of admissions with community-acquired medication harm by 4.28 admissions per 1,000 admissions.
"We found that the majority (70%) of medication-related harm seen among older inpatients during a 5-year period was community-acquired, suggesting the importance of targeting ambulatory and other community settings for improvement," the researchers wrote.
Boosting health and lowering costs
The Pharm2Pharm model generates population health benefits and lowers costs, the lead author of the research told HealthLeaders.
"It's all about better care and outcomes for patients and lower costs for payers," said Karen Pellegrin, PhD, MBA, director of continuing education and strategic planning at the University of Hawaii at Hilo's Daniel K. Inouye College of Pharmacy.
Reducing hospitalizations is a crucial element of decreasing healthcare spending, she said.
"Pharmacists are the medication experts who can work with patients across their prescribers in community settings to prevent medication-related hospitalizations. Hospital care is the biggest cost in our healthcare system, accounting for one-third of all healthcare spending in the U.S. at $1.1 trillion in 2017, according to the Centers for Medicare & Medicaid Services."
The Pharm2Pharm model has been shown to slash hospitalizations for adverse medication events, she said. "Pharm2Pharm strategically deploys pharmacists to fill a major gap in care—who's minding the medications? We achieved a 264% return on investment in our pharmacists because they reduced hospitalizations by optimizing the medication regimens for high-risk patients."
Training pharmacists
The Daniel K. Inouye College of Pharmacy provides training that prepares pharmacists to implement the Pharm2Pharm model.
"Best practice medication management and communicating effectively with patients and physicians are essential components of our training program, which is now available in an online, interactive, self-guided, six-hour continuing education program," Pellegrin said.
Medication management is a key element of the training, she said.
"Best practice medication management is not medication reconciliation or patient education—though these are important, and pharmacists do these well. Best practice medication management means systematically identifying and resolving drug therapy problems—first indication, effectiveness, and safety problems, and only then patient adherence problems."
Two forms of psychological therapy have been found effective in reducing perinatal depression.
The U.S. Preventive Services Task Force has issued new recommendations to treat perinatal depression.
One of the most common complications of pregnancy and the postpartum period, perinatal depression affects as many as 1 in 7 pregnant women, with both short-term and long-term impacts on the woman and the child.
Task Force member Karina Davidson, PhD, MSc, says adequate data has been gathered to indicate best practices for perinatal depression care.
"The Task Force was interested in whether sufficient evidence had become available to demonstrate that we can effectively address this serious public health issue, and we are glad that we can now make a recommendation about how clinicians can help women who are at risk of perinatal depression," says Davidson, senior vice president of research and dean of academic affairs at Northwell Health's Feinstein Institute for Medical Research.
The Task Force is recommending that women who are at risk of perinatal depression should receive counseling interventions from their clinicians or get referrals for counseling.
Risk factors for perinatal depression include individual or family history of depression, physical or sexual abuse, unplanned or unwanted pregnancy, stressful life events, and pregestational or gestational diabetes
The Task Force found counseling interventions reduced the likelihood of perinatal depression 39%
The optimal timing to offer counseling or a referral is unclear, Task Force members wrote in the Journal of the American Medical Association.
"There are no data on the ideal timing for offering or referral to counseling interventions; however, most were initiated during the second trimester of pregnancy. Ongoing assessment of risks that develop in pregnancy and the immediate postpartum period would be reasonable, and referral could occur at any time," they wrote.
Detection challenge
Screening for perinatal depression is a significant challenge for clinicians, Davidson says.
"Unfortunately, there is no accurate, formal screening tool available to identify individuals at risk for perinatal depression. This can make it tricky for clinicians and other healthcare professionals to decide who will benefit most from these preventive interventions," she says.
Assessing risk factors is crucial in deciding whether to provide perinatal depression counseling services to pregnant or postpartum women, Davidson says.
"Since there is limited data on the best way to identify who is at risk, the Task Force suggests that clinicians provide or refer counseling interventions to those with risk factors including a history of depression, current depressive symptoms, socioeconomic risk factors, recent intimate partner violence, and other mental health-related factors."
Providing leadership
Leaders at health systems, hospitals, and physician practices should embrace counseling interventions for women who are at increased risk for perinatal depression, Davidson says.
"Healthcare professionals working at the organizational level should ensure their staff is aware of the research backing these interventions, and they should make sure that clinicians are committed to identifying people who are at increased risk for perinatal depression and thus might benefit from these interventions."
Texas Children's Hospital is implementing the latest technology to dispense, store, and administer medications.
With an automation initiative in full swing, Texas Children's Hospital is expecting to reduce medication inventory costs by 16% annually.
"Right now, we are purchasing more than $100 million per year, so 16% will be a big cost savings. It should almost pay for the cost of the automation immediately," says Gee Mathen, assistant director of pharmacy applications and technical services at the Houston-based hospital.
With the potential to improve the consistency and accuracy of dosing processes, pharmacy automation can improve patient safety—particularly in the pediatric care setting. Children's hospitals care for a wide range of patients from neonates to young adults, which creates a need for precisely calibrated medication dosing and flexibility to produce a range of doses tailored to individual patients.
For example, Texas Children's is about to start using IV robot technology in the hospital's pharmacy that will draw up doses for administration to patients. The automated technology will replace some of the effort of human technicians.
"An IV robot can draw a dose with up to 99.9% accuracy. A human gets only 97% to 98% accuracy in best runs. That 3% variation in a pediatric institution is huge. Sometimes, it could mean the difference between life and death," Mathen says.
Adopting new technology
In addition to the IV robot technology, Texas Children's has installed or is adopting several other forms of pharmacy automation.
Next generation smart pumps: At the bedside, the hospital is installing the newest available smart pumps for administration of drugs to patients. With the new smart pumps, doses labeled with bar codes can be scanned into the pump, and the pump is automatically programmed with orders from physicians verified by the pharmacy.
Omnicell XT automated cabinets provide more usable space inside medication storage cabinets. In combination with the IV robot, the hospital will be able to fill the cabinets with doses that are pre-made and have longer beyond-use dating.
Omnicell XR2 Automated Central Pharmacy System: XR2 is expected to allow the hospital to improve management of inventory, procurement, and storage. The hospital's goal is to examine total inventory and have complete visual control over it. The system is also expected to minimize the difficulties with back orders such as maintaining multiple formulations.
Omnicell Performance Center: This automated system will show exactly what pharmacological stock the hospital has available.
Achieving cost savings
With the new technology, waste avoidance is expected to generate significant cost savings at Texas Children's.
The hospital's pharmacy dispenses about 5,000 doses of medication daily for patients in three buildings and lost or missing doses are a major source of wasteful spending, Mathen says.
"Every time a lost or missing dose happens, we get a phone call from someone who has not gotten their dose. To be responsible to the patient, we dispense another dose. Ten minutes later, we get another call and have to dispense another dose. So, for one dose that we can charge for we have dispensed three doses. At least two of those doses will end up being wasted."
Inventory control challenges also drive wasteful spending.
"We have medications on the shelf that six vials cost a million dollars," Mathen says. "Can you imagine if those six vials just sat on a shelf and expired? That has happened before. We want to get away from that. We want visibility of our inventory."
Creating staff flexibility
Texas Children's automation initiative allows the hospital to redeploy human resources in the pharmacy, Mathen says. "We are not focusing on reduction—we are focusing on reassignment."
With the IV robot set to focus on commonly dispensed medications, pharmacy technicians will have more time to produce specialty formulations, he says. "This allows us to free up technician time to focus on more specialized doses such as chemotherapy and medications that take a long time to dilute."
The XR2 Automated Central Pharmacy System is going to reduce the amount of time that technicians spend pulling medications from storage carousels for dispensing to patients, Mathen says.
"Without XR2, our technicians have to come in every morning, get orders from more than 200 Omnicell cabinets, and see how many products are running out and require refills," he says. "Then technicians take an order, go to the carousel, and pull each item from the carousel and put it in a bag."
The automated system will be more efficient and enable the pharmacy to assign technicians to other tasks such as quality control functions.
"With XR2, it can receive a feed in the middle of the night from an Omnicell cabinet saying it needs some products, and XR2 can fill what is needed, bag it, label it, and put it in a bin for a tech to pick up the next morning," he says.
Keys to automation success
Mathen is convinced that the Texas Children's pharmacy automation initiative is destined for success. "I have great confidence that we will exceed many of the benchmarks that we have set," he says.
The anticipated improvement of inventory capabilities should result in a giant leap forward for the hospital's pharmacy operations.
"We are going to be able to keep better track of inventory. Until now, our inventory processes have been set to carousels and Omnicell machines," he says. "We have not had a good way to look at our inventory as well as our lot numbers and expiration dates. A lot of that has been done manually."
The automation initiative has been launched with a solid foundation.
"You need buy in from the institution because technology has a cost and it's a capital cost," Mathen says. "You need buy in from your department, and you need to be able to support the functionality when it comes into play. You need to minimize human touch—consistency is what we need in pharmacy."
Texas Children's expects to lead other children's hospitals in pharmacy automation, he says. "The autonomous pharmacy is the pharmacy of the future. We can reduce repetitive tasks, we can achieve consistency from automated functionalities, and we can put robotics into play to provide accuracy."
Research demonstrates a method to prevent MRSA and vancomycin-resistant Enterococci infections in patients with medical devices.
A new study based on a recently developed form of clinical trial has advanced efforts to prevent hospital-acquired infections.
Unlike traditional explanatory clinical trials, which focus on specific interventions in controlled settings, pragmatic clinic trials are done in real-world clinical practice settings and produce more generalizable results.
"What constitutes a pragmatic trial is that it is conducted in a typical care environment—oftentimes with unselected patients—by usual caregivers in the course of routine operations. In contrast, more traditional trials are limited to small numbers of patients with high exclusion criteria conducted in dedicated research units with dedicated research personnel," says Jonathan Perlin, MD, PhD, president of clinical services and CMO at HCA Healthcare in Nashville, Tennessee.
The pragmatic clinical trial research published today in The Lancet sought to determine whether interventions to prevent multidrug-resistant organisms and bloodstream infections that had been found effective in the ICU setting could be effective for all inpatients. Methicillin-resistant Staphylococcus aureus (MRSA) was one of the primary targeted organisms.
The study featured 53 hospitals in HCA Healthcare's health system. Patients in some non-critical care units received routine care, while other patients in non-critical care units received daily chlorhexidine bathing for all patients plus nasal mupirocin for known MRSA carriers.
There were 156,889 patients in the routine care group and 183,013 patients in the intervention group.
The study has three key findings.
When compared to a control group, intervention patients with medical devices such as central lines experienced a 32% greater reduction in all-cause bacteremia and a 37% greater reduction in MRSA or vancomycin-resistant Enterococci (VRE) clinical cultures
Patients with medical devices accounted for 10% of the routine care population, but they accounted for 37% of MRSA or VRE cultures and 56% of bloodstream infections
Universal chlorhexidine bathing and the antiseptic bathing plus nasal mupirocin for MRSA carriers did not reduce multidrug-resistant organisms or bloodstream infections for all non-critical care patients
"There was a specific group of patients in the general medical and surgical units who received the biggest benefit," Perlin says.
Adopting pragmatic clinical trials
The Lancet research, which was completed in 21 months, demonstrates the speed potential of pragmatic clinical trials, he says.
"We discovered a new best practice that can help reduce life-threatening infections for a set of patients who are at high risk. For this study, it would otherwise take a single hospital 93 years to aggregate the data to answer the question solved by our 53 hospitals in 21 months."
HCA Healthcare plans to adopt the new best practice to prevent infections in non-critical care patients with medical devices immediately. "We will eat our own cooking. The first thing we will do is put this new best practice into place across all of HCA," Perlin says.
Speed is not the only advantage of pragmatic clinical trials, he says.
"You also have the advantage of generalizability. These studies are incredibly powerful because they have a breadth of patients, so the signal is very strong in terms of applicability. They are conducted in routine care settings, so it's a real-world environment with real-world hospitals, and the findings are generalizable to the real-world."
HCA Healthcare is well-suited to conduct pragmatic clinical trials for four reasons, Perlin says.
An organizational mission committed to the care and improvement of human life
A learning-health-system culture
Scale that allows for the aggregation of voluminous data
A clinical data warehouse and information systems that create a platform for learning and improving care
The new initiative includes clarifying local housing priorities and creating pipelines of affordable housing opportunities.
A half-dozen health systems and hospitals have joined an initiative to work with community partners to increase affordable housing in their markets.
There is significant evidence showing that affordable housing makes a difference for people's physical and mental health as well as their feeling of connection and social cohesion. For example, if people are forced to make a choice between paying for rent and paying for medicine their health can deteriorate.
Last month, the Center for Community Investment (CCI) at the Lincoln Institute of Land Policy in Cambridge, Massachusetts, launched Accelerating Investments for Healthy Communities. The initiative is designed to help health systems and hospitals marshal resources to increase affordable housing in the communities they serve, CCI Executive Director Robin Hacke says.
"They are able to help each other, and they are able to share their experiences. We are also putting together a pool of pre-development resources at their disposal, so it's a combination of technical support, an enabling environment in which they can do their work, and some specific assistance," she says.
The participating health systems and hospitals stretch across the country.
Cincinnati, Ohio-based Bon Secours Mercy Health
Boston Medical Center in Boston, Massachusetts
San Francisco-based Dignity Health
Oakland, California-based Kaiser Permanente
Nationwide Children’s Hospital in Columbus, Ohio
UPMC in Pittsburgh
'Taking real responsibility'
The CCI initiative will help the health systems and hospitals to increase affordable housing in three ways.
CCI will work with the healthcare organizations to clarify local housing priorities and to understand market forces and community desires.
CCI will help the health systems and hospitals to create a pipeline of affordable housing opportunities then set criteria for prioritizing those projects. "We want them to get beyond the details and intricacies of a particular transaction to think about what it takes to move affordable housing in proportion to the size of the need," Hacke says.
CCI will encourage the healthcare providers to foster an enabling environment to support affordable housing expansion. This effort includes influencing policy, intervening in affordable housing trust funds, and using tax credits.
"What we are seeing is behavior that is going to become more common over time. We often say the future is now, it's just not evenly distributed. The health systems that are participating in this initiative are the ones that are seeing the move from volume to value and taking real responsibility for the health of their communities," Hacke says.
Finding community partners
Each health system and hospital has put together a team of partner organizations that reflects their local situation, she says.
"Sometimes, the partners are local governments like an urban redevelopment authority or a mayor's office. There are resident organizations like community development corporations or other neighborhood groups. Community foundations and local United Ways are part of the teams."
Other partners include banks, universities, and specialized development intermediaries called community development financial institutions that lend funds in areas that have low incomes.
CCI will help the health systems and hospitals identify community partners such as neighborhood groups, churches, civic associations, and philanthropic organizations, Hacke says. "We encourage the hospitals to have community benefit managers and others with this kind of knowledge."
Stakes are high when recruiting new clinical staff, including costs associated with making new hires.
Health systems, hospitals, and physician practices face several daunting challenges in hiring candidates for clinical roles.
All organizations face "staggering" costs in the recruitment and selection of new employees, according to the Society for Human Resource Management. When replacing supervisory, technical, or management staff, costs are estimated at 50% to several hundred percent of employee salaries.
The lead author of a recent article in Journal of Hospital Medicine told HealthLeaders that there are unique aspects of hiring clinical staff.
"When we hire for clinical faculty, we try to make sure that a clinical recruit will be able to care for patients in our setting—a quaternary care medical and referral center. We look to see where someone trained or where they have practiced in the past to make sure that they will succeed in our institution," said Vineet Chopra, MD, MSc, associate professor of medicine and chief of the Division of Hospital Medicine at Michigan Medicine and VA Ann Arbor Health System.
They make three recommendations to achieve good hiring decisions.
1. Expansive vetting process
Have candidates meet with multiple existing members of the clinical and non-clinical staff. This kind of depth in the hiring process increases the odds of catching potentially problematic characteristics of candidates and helps get the team committed to new hires.
2. Standardized interviews
Direct managers to create a standardized template of questions for candidates, so other members of the team follow a consistent approach while interviewing recruits and generate uniform feedback.
The standardized template should have both structured and unstructured questions, Chopra told HealthLeaders. "Domains within the template should include interpersonal characteristics, background and training, their stated interest in the position including whether or not they asked insightful questions, and positive and concerning aspects."
3. Match skills to role
Make sure a candidate's skills are well-suited for their new role. One of the first steps in the hiring process should be an assessment of the skills necessary to succeed in the open position.
The selection process should be geared toward ensuring a candidate's skills are matched with the open position, he said. "We use the CV as the first step—training and background is key to ensuring fit. We then use the interview as the next filtering process."
Importance of good hires
Chopra and his co-author wrote that there are three primary imperatives of making good hires.
Making the right hiring decision is crucial to the success of initiatives and reflects directly on hiring managers
Managers and other co-workers often feel compelled to compensate for the shortcomings of new hires, which can be costly in terms of efficiency and work hours
It can be challenging to terminate or transfer an underperforming staff member
"When hiring, you have to think hard about the role and an individual's skill set that makes them well-suited for it. Based on experience, we can tell you that once you go 'soft' by selecting a suboptimal candidate, you are in trouble," Chopra and his co-author wrote.
After spiking from 2012 to 2015, the increase in hospital-employed physicians and hospital-owned physician practices eased from 2016 to early 2018.
Rapid growth in hospital-employed physicians and hospital-owned physician practices has leveled off, but an organization that has followed the trend since 2012 says the consolidation activity is still momentous.
"The trend from July 2016 to January 2018 remains significant. Even though the trend is starting to taper, it's amazing that we had an additional 14,000 physicians who shifted into employed situations and an additional 8,000 physician practices that were acquired," says Kelly Kenney, JD, CEO of Austin, Texas-based Physicians Advocacy Institute.
In 2016, PAI published a report that showed meteoric growth in hospital-employed physicians and hospital-owned physician practices. From July 2012 to July 2015, the number of hospital-employed physicians increased 49%. The number of hospital-owned physician practices increased by 31,000, which amounted to an 86% hike.
A new PAI report published this month features several key data points.
From July 2016 to January 2018, the number of hospital-employed physicians increased 6%
From July 2016 to January 2018, the number of hospital-owned physician practices increased 5%
In January 2018, hospitals employed more than 168,000 physicians
In January 2018, hospitals owned about 80,000 physician practices
From July 2016 to January 2018, the western portion of the country had the hottest consolidation markets, with the number of hospital-employed physicians increasing 6.6% and the number of hospital-owned physician practices increasing 8.1%
Whether this consolidation activity is approaching its ceiling depends on the financial strength of hospitals, Kenney says. "A lot of this is driven by incentives for hospitals because they are in the driver's seat."
Commercial payers could determine whether hospitals continue their physician acquisition spree, she says.
"Hospitals lose money on Medicare, but they have remained profitable overall. They lose money on Medicare, but they make up for that with a payer mix that is heavily commercial, so we need to watch the commercial side and see whether they screw down on hospitals."
Consequences for physicians
The ongoing consolidation has important implications for both hospital-employed physicians and physicians who remain in private practice, Kenney says.
"Physicians who are working in employed settings have shed themselves of administrative and regulatory burdens. They don't have to worry about a lot of the things they had to worry about in private practice. However, some of the concerns they are having relate to having clinical autonomy and feeling like they can practice medicine based on their best medical judgment."
PAI is advocating for hospitals to have empowered medical staffs, she says.
"Physicians should be leading healthcare innovation from a clinical perspective in employed settings. Some employed physicians have reported feeling pressured to meet patient quotas and maximize the revenues they can generate for hospitals. That is a reality, but we want to make sure we don't damage the patient-physician relationship."
Physicians who remain in private practice face a different set of challenges, Kenney says.
"In smaller settings, physicians have trouble keeping abreast of the new evolving rules. There are a whole plethora of Medicare-related rules and reporting requirements. They also have commercial contracts, and they have to navigate the rules for each of those payers, including prior authorization rules that can be difficult and expensive for private practices to manage."
The ongoing expansion of responsibilities for physician assistants and nurse practitioners is renewing opposition from physician groups.
Efforts to expand the roles of physician assistants and nurse practitioners are expected to accelerate this year over the objection of physician groups.
The National Commission on Certification of Physician Assistants expects reform ofscope of practice, supervision, and delegation of authority legislation to be a top trend regarding physician assistants this year. Advocates of loosening restrictions on physician assistants and nurse practitioners claim the reforms can boost productivity, lower cost of care, and improve access to healthcare services.
For example, recent research found physician assistants and nurse practitioners provided equivalent care for diabetes patients, and the American Academy of Physician Assistants has reported that PAs increase access to care.
"PAs expand access to care in rural areas: 15% of Americans live in rural areas; AAPA data indicates that 12% to 15% of PAs overall—and 20% to 25% of PAs in primary care—practice in rural areas, compared with 10% of MDs," the AAPA reported.
The American Medical Association (AMA), which represents more than 200,000 member physicians, opposes relaxing rules that require physician assistants and nurse practitioners to practice under the supervision of a doctor.
"Independent practice and team-based care take healthcare delivery in two very different directions. One approach would further compartmentalize and fragment healthcare delivery, while team-based care fosters greater integration and coordination," an AMA spokeswoman told HealthLeaders.
Carmen Kavali, MD, of Kavali Plastic Surgery and Skin Renewal Center in Atlanta, and a board member of Physicians for Patient Protection in Massapequa Park, NY, says PPP has taken an even harder line on the relaxing of restrictions for PAs and NPs.
"There are absolutely patient safety concerns associated with NP and PA care. We don't diminish the fact that physicians make mistakes, of course, but the type of mistake is often very different from those of non-physician practitioners. We have had many physicians and patients share stories with us of missed diagnoses and misdiagnoses by NPs and PAs, as well as excessive and inappropriate testing, prescribing, and treatment," Kavali says.
PPP is a grassroots physician organization spawned on social media in 2016 and formed officially in August 2018. "Our mission is to ensure physician-led care for all patients and to promote truth and transparency in healthcare, particularly in healthcare credentialing," she says.
PPP reality check
Physicians are far more well-prepared to manage patient care than non-physician practitioners, Kavali says.
"The educational differences are vast between physicians and NPs and PAs. A primary care physician completes medical school and three years of residency with around 15,000 hours of patient evaluation and treatment, beyond the 'book learning' hours. Today, an NP can attend NP school with no prior nursing experience and complete online education with as few as 500 clinical shadowing hours. A PA finishes PA school with about 2,000 clinical hours."
The educational differential between physicians and non-physician practitioners has important implications for how care is delivered, she says.
"Because it is hard to know what you don't know, and because many patients present with potentially confusing and confounding symptoms, a physician should see all initial patient consults, develop the diagnoses, then formulate the treatment plan(s), which can then be carried out seamlessly by an NP or PA. Simply co-signing a chart without laying eyes on the patient is not adequate supervision."
PPP is particularly concerned over the relaxation of practice restrictions on NPs, and the organization rejects contentions that NPs can solve clinician shortages in rural areas, increase access to care, and lower cost of care, Kavali says.
"Here's the reality—in states where nurse practitioners have had independent practice, they are not going rural. For example, in Arizona the nurse practitioners have had independent practice unsupervised since 2001, and in 2017 there were fewer than 11% of nurse practitioners in rural areas of the state. They are not going rural more than anyone else is for the same reasons. As far as costing less, NPs order more tests, order more radiographs, and order more labs. For basic chronic disease care, they spend more annually than primary care physicians do."
PPP is trying to help the AMA to turn the regulatory tide regarding the supervision of NPs and PAs, she says.
"We are trying to educate legislators and members of the public. A nurse practitioner was never intended to replace a physician. This is not about turf. This is not about territory. This is about truth, transparency, and patient safety," Kavali says.
AMA guidance for physician assistants
The AMA has adopted several recommendations for the supervision of physician assistants by physicians.
Physicians should bear ultimate responsibility for coordinating and managing patient care, with appropriate input from physician assistants
Physicians should supervise physician assistants in all care settings
Physicians and physician assistants should set mutually agreed-upon guidelines for physician assistant participation in patient care
Physicians should be available to consult with physician assistants at all times, either in person or through remote communication
Physicians and physician assistants should regularly review all delegated patient services
Physicians should clarify and familiarize supervising methods with physician assistants
"The American Medical Association encourages physician-led healthcare teams that utilize the unique knowledge and valuable contributions of all clinicians to enhance patient outcomes. Physician assistants and nurse practitioners are valuable members of this team, and patients win when each member of their healthcare team plays the role they are educated and trained to play," the AMA spokeswoman said.
Predictors of frequent geriatric users of the emergency department indicate that a multidisciplinary approach to care is required.
In geriatric patient populations, predictors of high emergency department utilization include specific diagnoses such as chronic pulmonary disease and multiple comorbidities, recent research shows.
The country's burgeoning number of seniors account for about 15% of the population but they contribute to more than 21% of total healthcare expenditures. Relative to younger Americans, seniors use emergency rooms more, have longer stays in the ED, and utilize more resources and interventions in the ED.
The research findings, published recently in Annals of Emergency Medicine, indicate that interventions should be tailored for seniors who are frequent users of the ED, the researchers wrote.
"Programs designed to meet the needs of geriatric patients across the continuum of care may be helpful to address the unique needs of geriatric patients to maintain physical and mental health. This may be especially important in care venues outside of the ED and inpatient setting."
The research features data collected from more than 1.2 million geriatric patients. Frequent users of the ED were defined as patients who visited an ER six or more times over the course of a year.
5.6% of the geriatric patients qualified as frequent users
The frequent users accounted for 19.9% of visits to an ED
The most common comorbidities were diabetes without complications (25.8%), chronic pulmonary disease (21.5%), renal disease (19.1%), congestive heart failure (16%), and peripheral vascular disease (15.1%)
The strongest predictors of high ED utilization were pain-related diagnoses, injury-related visits, and high numbers of comorbidities
"Overall, we found vulnerable patients with likely complex medical, psychosocial, and functional issues associated with increased utilization patterns," the researchers wrote.
Reducing geriatric frequent users of the emergency department
The findings suggest possible interventions to improve care for seniors who are frequent ER users, the lead author of the research, Edward Castillo, PhD, MPH, told HealthLeaders.
"Geriatric frequent users are different than other frequent user populations, so interventions need to be designed for this specific population. To be successful, these interventions will likely need to have a multidisciplinary staff that can identify senior-specific needs through screenings, coordinate appropriate care and resources for the patient when they leave the ED, and follow up to be sure their needs are being met," he said.
Postacute care is part of the solution, said Castillo, who is an associate adjunct professor in the Department of Emergency Medicine at the University of California, San Diego. "Once appropriate needs are identified, outpatient and home health services can be used to avoid ED visits and hospital admissions for some conditions and some patients."
With the broadest reach to patients, the primary care setting is well-suited for identifying and assessing depression.
The primary care setting is the most appropriate venue for the screening and early treatment of depression, according to the lead author of an article published recently in the New England Journal of Medicine.
Depression is one of the most common behavioral health disorders in the country, with the estimated lifetime risk of a major depressive episode set at about 30%. Suicide, which is associated with depression more than 50% of the time, has become more prevalent in recent years and is now the 10th leading cause of death for Americans.
"Primary care settings offer the broadest reach in terms of patients seeking care, and therefore are the optimal place to conduct screening for depression and suicide," Lawrence Park, MD, medical director of the Clinical Research Unit at the National Institute of Mental Health's Experimental Therapeutics and Pathophysiology Branch in Bethesda, Maryland, told HealthLeaders last week.
Although the primary care setting is well-suited to detect depression and suicidal ideation, there are challenges for clinicians to overcome, he said.
"One must be aware of not only depression, but all possible medical and mental health conditions. So, the primary care provider needs to be expert at detection and diagnosis across a broad range of diseases. Because depression is so common, we recommend the use of a brief screening tool for depression—and suicidal thoughts and behaviors—for all primary care patients."
If a patient presents signs of depression, primary care clinicians must weigh several options, Park said.
"When depression is suspected, primary care providers should conduct follow up assessment to determine the severity of the condition, safety evaluation, and consider interventions. Therapeutic interventions may include close monitoring of the patient's condition, initiation of psychotherapy and/or medications, referral to a mental healthcare provider, or hospitalization."
Primary care's depression niche
For treatment of depression, the primary care setting is only appropriate for patients with mild and moderate conditions, Park said.
"In primary care, there is a scarcity of healthcare resources. Primary care providers lack the time and support to comprehensively care for all aspects of the depressed patient. From our perspective, primary care is ideally placed to perform the critical screening function for depression and suicidal thoughts and behaviors. If quick and efficient screening is done on all patients, primary care providers can devote additional time for assessment to those with positive screens."
In cases of severe depression, interventions include the assistance of mental health specialists, time-consuming treatments such as psychotherapy, and higher levels of care such as emergency department evaluation, he said.
Avoiding primary care pitfalls
To provide optimal care for depressed patients, primary care physicians should have easy access to mental health resources, Park said.
"Many primary care settings have incorporated an embedded mental healthcare professional into their practices. Without adequate mental healthcare support, primary care providers may be reluctant, or unable, to conduct accurate screening and assessment of depression and suicidal thoughts and behaviors, or they may not be able to appropriately manage these conditions when they are identified."
Primary care clinicians also face a significant clinical challenge when managing depressed patients, he said.
"Primary care physicians should rule out underlying medical conditions that may cause or exacerbate depression, and they should distinguish between bipolar depression or major depressive disorder—unipolar depression—as both situations would have important therapeutic implications."
