In the emergency room setting, agitated patients with delirium experience higher rates of hospital admissions and adverse events, researchers say.
Agitated patients represent a small but challenging portion of emergency department visits, researchers at an urban Level 1 trauma center found.
The researchers, who published their study this month in Annals of Emergency Medicine, screened 43,838 ER patients and found 1,146 (2.6%) were in an agitated state.
Agitated patients can require significant levels of care in the emergency department setting, the researchers wrote.
"We found that severe agitation occurs frequently in the ED, and often requires both chemical sedation and physical restraint to control the patient to allow a comprehensive medical evaluation and to protect medical providers and the patient from injury."
Acute states of agitation can be deadly, the researchers wrote. "Injuries and sudden deaths have been reported among agitated persons during attempts to restrain and care for them in both custodial arrests and medical stabilization."
None of the agitated patients in the Annals of Emergency Medicine research project died.
Data collected in the research project shows characteristics of agitated patients and their care:
84.6% of agitated patients required physical restraint
72.3% required sedation with an intramuscular injection
1.8% required physical restraint and sedation
16% had clinical events that required intervention such as mild hypoxia treated with supplemental oxygen
7% experienced an adverse event—either intubation or hypotension
23% had delirium symptoms
Delirium danger
Delirium is a serious condition for agitated patients, the researchers wrote.
"The rate of clinical and adverse events was much higher in patients with delirium symptoms, with a two-times-higher rate of intubation, two-times-higher rate of hypotension, and two-times-higher rate of hospital admissions."
Excited delirium syndrome, an acute form of delirium associated with extreme physical violence, is particularly problematic.
The American College of Emergency Physicians recognized excited delirium syndrome in 2009. For a diagnosis of excited delirium syndrome under the ACEP guidelines, a patient must exhibit at least six of 10 potential symptoms, including pain tolerance, sweating, agitation, lack of tiring, and unusual strength.
The Annals of Emergency Medicine researchers found that the histories and vital signs of delirium patients were similar, which indicated that different rates of complications for the patients could be caused by the nature of agitation associated with delirium. "This supports the theory that excited delirium syndrome may represent a condition that is higher risk than typical agitation," they wrote.
The stakes are high for excited delirium syndrome patients, the researchers wrote.
"Because the estimated mortality rate of patients with excited delirium syndrome may be as high as 16.5%, it is critical to identify treatments or interventions that may curb the metabolic derangements of patients with suspected excited delirium syndrome."
Recommendations
While more research is necessary to develop comprehensive best practices for the treatment of agitated patients, the researchers highlight several care guidelines.
In a minority of agitated patients, the condition is linked to a medical illness and performing a timely assessment is crucial, the researchers wrote. "Rapid assessment is imperative because previous research has demonstrated that up to 1% of similar patients ultimately require critical care resources while in the ED."
Oral sedatives are probably not appropriate for many agitated patients because they may not be rapid-acting enough or feasible for distraught patients who struggle with compliance.
If parenteral sedation is required, intramuscular injections can accomplish faster sedation than establishing an intravenous line for an agitated patient.
For physicians, nourishing core professional values such as curiosity and love of knowledge could ward off burnout.
The practice of medicine has changed in ways that are damaging the professional identity of physicians and fueling burnout, a cardiologist and medical school professor says.
Knowledge is at the heart of the physician identity, says John E. Brush Jr., MD, FACC, a cardiologist at Sentara Healthcare in Norfolk, Virginia, and professor of medicine at Eastern Virginia Medical School in Norfolk.
"Physicians study hard to become who they are. They became board certified specialists by taking exams that certify that they have the requisite amount of knowledge to call themselves specialists. But the current practice environment has blown physicians off course," Brush told HealthLeaders Media this week.
Among physicians, automation and business-like relationships in clinical settings have eroded the veneration of scientific knowledge and the desire to apply knowledge that benefits patients, he says.
"Medicine has become so automated and transactional that physicians have forgotten about that central mission and have lost their sense of professional identity."
Dehumanizing effects
Several factors practice environment have become dehumanizing for physicians, Brush wrote in a recent JAMA Cardiologyarticle.
"Physicians are now spending more time with computers
and less time with patients. They are pushed to provide greater productivity but are burdened with increasing administrative tasks, leaving little time for reflection and study. They have become homogenized into providers, a term that signifies how transactional medical care has become."
Digital innovation is threatening to overtake the reliance on physician knowledge and reasoning for medical judgment, Brush wrote.
"This is the digital age of dizzyingly rapid innovation involving digital health, big data, precision health, and artificial intelligence. Disruptive innovations could revolutionize how clinical problems are solved."
Brush told HealthLeaders that two developments have had particularly profound impacts on the practice environment: electronic medical records and the drive toward more productivity measured by relative value units.
"These factors have had a dehumanizing effect on medical practice. These factors have also distracted physicians from their central mission—to use specialized knowledge to improve the health of their patients."
Battling burnout
Reconnecting with devotion to knowledge can help physicians regain their sense of professional identity and curb burnout, Brush told HealthLeaders.
"Having a firm idea of identity can re-humanize physicians and give them a renewed sense of mission. Remembering the love of knowledge and renewing the sense of curiosity and wonder of science can provide a beacon—a true north—that can re-orient physicians and help them avoid burnout."
Knowledge and professional identity are essential to warding off physician burnout, he says.
"A firm appreciation of knowledge and a clear sense of professional identity can give them resilience. Physicians need to have the courage to stand firm against the distractions of modern medicine and nurture their love of knowledge. A renewed love of knowledge can be the cure for physician burnout."
Diagnoses have tripled over the past 25 years, mainly as the result of increased detection of small papillary thyroid cancers. Is it time for a less-aggressive approach?
A pair of physician researchers are urging the adoption of less intensive detection and treatment of thyroid cancer.
Total thyroidectomy is the most common surgical procedure for thyroid cancer, accounting for 80% of operations. It is also the highest-risk surgical treatment, with potential complications including hypoparathyroidism and risk of injury to the recurrent laryngeal nerves.
In the New England Journal of Medicinethis week, H. Gilbert Welch, MD, MPH, of Dartmouth College and Gerard M. Doherty, MD, of Dana Farber Cancer Institute say the prevalence of total thyroidectomy procedures and the potential for harm are unjustifiable.
"The basic problem is the belief that more is always better—particularly in the treatment of cancer," Welch told HealthLeaders Media this week.
The primary surgical alternative to total thyroidectomy is thyroid lobectomy, which removes about half the thyroid gland.
Thyroid lobectomy has several advantages over total thyroidectomy, the researchers wrote.
"This surgery carries a lower risk of nerve damage, avoids the risk of hypoparathyroidism altogether, and preserves thyroid tissue—for many patients, obviating the need for permanent thyroid hormone-replacement therapy."
Data for the 25-year risk of death from thyroid cancer also indicate the preferability of thyroid lobectomy, Welch and Doherty found. "First, the risk of death from thyroid cancer is extremely low (roughly 2% over 25 years), and second, that risk is unaffected by the choice of procedure."
Removing less of the thyroid gland makes more sense than total thyroidectomy procedures, Welch says. "More is just that—more—and carries more harm. In the whole vs. half thyroid question, half is as good and produces less problems."
Overzealous detection
This year, more than 50,000 Americans are expected to receive a thyroid cancer diagnosis. Over the past 25 years, diagnoses of thyroid cancer have tripled—mainly as the result of increased detection of small papillary thyroid cancers.
Welch and Doherty say there is overdiagnosis of thyroid cancer.
"Despite [the] dramatic rise in incidence, mortality due to thyroid cancer has remained stable, which suggests that there is widespread overdiagnosis—detection of disease that is not destined to cause clinical illness or death."
The researchers call for less aggressive detection activity. "Efforts to reduce thyroid-cancer detection are clearly warranted—for example, refraining from screening for cancers and from biopsying small thyroid nodules."
Treatment should take an equally conservative approach, the researchers wrote.
"We support the option of active surveillance for selected patients with small papillary thyroid cancers, but we recognize that some patients will prefer to have their cancer removed. In such cases, the question becomes how much thyroid to resect."
Changing standard of care
Welch and Doherty say the preference for total thyroidectomy is at least partly due to insufficient knowledge.
"Surgeons may underestimate their own complication rates, particularly if they rarely perform the operation. Furthermore, low-volume surgeons may be unaware of new practice guidelines, since thyroid surgery represents a small part of their practice."
Surgeons also appear to be clinging to an outdated view of thyroid cancer risk, the researchers wrote.
"Conventional practice pathways and surveillance strategies were designed for patients with higher-risk disease. It is hard for providers to de-intensify care. To do less for today's patients than for the patients of the past may make clinicians feel exposed."
A less intensive approach to thyroid cancer also could increase patient anxiety, and primary care can play a key role in alleviating concerns, Welch and Doherty say.
"Primary care practitioners can help by educating patients about the heterogeneity of the conditions we call 'cancer,' as well as by shepherding patients through a system that was designed for more advanced disease."
Several research studies over the past four years have drawn similar conclusions. The field is moving toward widespread acceptance of the overdiagnosis problem, Welch told HealthLeaders.
"Both the American Thyroid Association and the American College of Radiology now recommend that small thyroid nodules not be biopsied. And thyroid cancer doctors are now beginning to offer active surveillance—just like urologists do for low-risk prostate cancer."
IU Health has a five-pronged strategy for hip and knee implant procurement, featuring pricing, contracting, physician engagement, vendor relations, and value.
Transparency and competition have become driving forces in the procurement of hip and knee implants at IU Health.
The approach has cut the cost of hip and knee implants at the Indianapolis-based health system by 25%.
"We have an open market that encourages competition between vendors," says Anthony Sorkin, MD, medical director of statewide orthopedic strategic service line.
IU Health's Orthopedic-implant Procurement Enhancement (OPEN) program has a five-pronged approach to lowering implant costs.
1. Pricing
The primary ingredient of the OPEN program is a red/yellow/green implant pricing board that is posted in IU Health orthopedic units, with red representing the most expensive implants and green representing the least expensive implants.
IU Health has 15 acute-care hospitals. Orthopedic surgeons at nine of the facilities have been participating in the OPEN program.
The pricing board is a powerful transparency tool, Sorkin says. "You create transparency for both the surgeons and the vendors, then you allow the vendors to do their job, which is to promote sales in a constructive environment."
Reducing implant pricing can achieve significant cost savings, he says. "For a standard procedure, whether it is a hip or a knee, about 80% of the costs are in the operating room. A significant part of that 80% cost in the operating room is the implants."
2. Contracting
Three-year contracts without re-bidding provisions are often financially disadvantageous, Sorkin says.
"In a three-year deal, like with any other commodity, the value of that commodity can and will decrease, while the health system is held to the contracted price."
The OPEN program has flexible three-year contracts for vendors, with rebidding allowed in six-month intervals. The rebidding process has stirred competition and put downward pressure on prices, Sorkin says.
3. Physician Engagement
For more than a year after launching the OPEN program, one-on-one meetings were held with surgeons about their performance metrics, surgical supplies and implants, says Megan Brown, an analyst in the clinical value analytics group at IU Health.
Physicians were given metrics based on their surgeries and patients, including overall cost, length of stay, and metrics for quality and performance improvement. "We would provide the surgeons with their implants from the surgical logs as well as all of the items that were used in the surgical procedure," Brown says.
"They were very surprised by the cost of a lot of the items they were using."
Meetings were also held on a quarterly basis with each surgeon and key members of the surgeon's operating room team, Brown says. "We would meet with the surgeon and operating-room leaders such as the manager, orthopedic or resource coordinator, or nurse circulator. We would talk about the utilization of products and what the items cost."
In addition to cost awareness, surgeons also have a financial incentive to embrace the OPEN program's drive for cost efficiency, Sorkin says.
"IU Health decided to allow gain-sharing with the surgeons. It's not much money, but it created a general attitude among the staff that they are involved in the process of value-based care, and that helped pull everybody along."
Gain-sharing is based on costs from admission to discharge, with an average cost figure established for the nine IU Health hospitals that perform hip and knee replacements. Surgeons ranking in the top 25th percentile for low cost receive a 20% gain-sharing payment from cost savings achieved in their procedures.
4. Vendor Strategy
Sorkin says IU Health's approach to vendor engagement is uniquely capitalistic. "What we wanted to do was to open the market to all vendors, then let them freely compete."
IU Health's vendor-engagement strategy for hip and knee implants has been nationwide. "We had all of the vendors come together, and we talked with them all at the same time in a large room," Sorkin says.
"We had 11 vendors in the room from across the country. If we had picked a winner, we would have had one happy company and 10 very unhappy companies. This way, all of the vendors were engaged."
The OPEN program has been a win-win-win, with physicians, vendors and the health system all generating benefits, he says.
"The surgeons' engagement has increased significantly, and the vendors are happy to have the opportunity to sell their products, so their engagement has increased. We met our metrics, so the health system is happy. We took a situation where all three parties were in some way disappointed; and now that we are more than a year into our program, all three appear to be doing well."
Having multiple vendors and implants available to surgeons gives physicians flexibility to pick the best implants for individual patients, Sorkin says. "This allows our physicians to not be forced to either use a product from a company they are not familiar with or to limit the products that are available to them based on patient needs."
There is variability in patients that requires flexibility in implant selection, he says.
"A hip replacement in a very active 55-year-old is very different from a hip replacement in a very inactive 75-year-old. All patients are different, so it seemed to make sense to us at IU Health that we should create and foster an environment where the surgeons can do what they are trained to do, which is demand-match products and technology to the various patients."
Price transparency has led to cost-cutting among both vendors and surgeons, Sorkin says. "No vendor wants to be red. … No surgeon wants to be known as the high-cost provider."
5. Value
The OPEN program is allowing IU Health to capitalize on a growing market without sacrificing quality, Sorkin says.
"The OPEN program is critical for us because the Medicare population is exploding. So, we need to learn how to have the highest-value care, with value being quality over cost. One of the ways we are trying to achieve that is we are looking to decrease the denominator while having no effect on the numerator."
In terms of vendor strategy, the free-market approach has been a crucial element for generating value in the OPEN program, he says.
"We told all of the vendors that we wanted all of them to participate, that this was not about winning or losing, and that we were not setting a price. We did not tell them that they had to hit a price in order to participate. We just asked for their best price, and we showed them how the red-yellow-green [pricing system] would look."
Open competition fosters good partnerships, Sorkin says.
"Everybody else wants to pick a winner—that is the take-home message. Whenever you pick one or two winners, you are going to create ill-will no matter how you do that."
The other six hospitals do not perform hip and knee procedures
The AMGA's proposed 14-metric measurement set and proposed changes to Medicare's quality measures draw largely favorable reviews.
Recently proposed quality measure changes are generally steps in the right direction, an Electronic Health Record Association official says.
A pair of quality measure changes were proposed this month. The Centers for Medicare & Medicaid Services (CMS) have proposed changes as part of the Medicare Physician Fee Schedule for 2019, and the American Medical Group Association (AMGA) has proposed a 14-metric measurement set.
The proposed CMS changes would alter measures in the Quality Payment Program, which features the Merit-based Incentive Payment System (MIPS) and advanced alternative payment models. The proposed changes to MIPS are modest, says Ida Mantashi, chair of the Electronic Health Record Association's Quality Measurement Workgroup.
"I was surprised that the measure changes were not huge. The measures that have been proposed for removal are not that highly used—we were expecting some of them to go away," she says.
The CMS proposals include eliminating MIPS process-based quality measures that clinicians have called low-value or low-priority, according to CMS. The proposed changes to MIPS are designed to elevate the importance of measures that have a more significant effect on health outcomes, CMS says.
Mantashi applauded CMS for maintaining quality measures for specialty practices. "Some specialties have so many little measurements that they can't go to fixed measures. … I hope CMS never gets rid of the measure functionality for the specialty practices."
Evaluating AMGA measures
The AMGA, which is based in Arlington, Virginia, has proposed quality measures that are designed to reflect value in care and to lessen administrative burden.
The AMGA measurement set features both process measures such as cancer screening and outcome measures such as hospital readmission rates:
Admissions for acute ambulatory sensitive conditions composite
HbA1C poor control
Depression screening
Diabetes eye exam
High blood pressure control
CAHPS, health status, and functional status
Breast cancer screening
Colorectal cancer screening
Cervical cancer screening
Pneumonia vaccination rate
Pediatric well-child visits through age 15 months
In general, Mantashi gives the AMGA measurement set a positive review.
"They did a good job putting this list together. It is not an easy task to account for all of the directions and needs in healthcare. They have done a good job of bringing everything under the same umbrella," she says.
However, the AMGA measurement set is a poor fit for many specialty practices, says Mantashi, director of product management at Boca Raton, Florida-based Modernizing Medicine.
"The problem with 14 measures is that if you are in a specialty, you are going to have a very hard time reporting all 14. For example, dermatologists don't have readmissions."
The federal program's financial incentives have encouraged the development of care models that help keep frail patients out of emergency rooms and inpatient wards.
Medicare Advantage is a hotbed of innovation in efforts to improve care for seriously ill patients, researchers say.
"The financing structure of Medicare Advantage makes it a fertile testing ground for new payment and care delivery approaches, including value-based payment models," the researchers wrote in their report published this month by the Duke Margolis Center for Health Policy.
The financing of Medicare Advantage health plans includes a pair of incentives that support innovation:
Health plans receive per-member per-month payments. If enrollees' cost of care is less than their capitated payments, the health plan keeps the savings.
Health plans receive bonus payments for high-quality care as determined by the Centers for Medicare & Medicaid Services' Star Ratings program
To demonstrate Medicare Advantage's capacity to enable innovative care for seriously ill patients, the Margolis Center researchers focused on care models developed by three health services firms that contract with Medicare Advantage health plans.
The researchers found that the companies—Aspire Health, Landmark Health, and Turn-Key Health—have care models for the seriously ill that share four primary commonalities.
1. Eligibility requirements
The firms analyze claims data from Medicare Advantage health plans to ensure that enrollees meet eligibility requirements for their services.
The analysis goes beyond identifying diagnoses and gauging utilization. Predictive analytics are used to target patients who are likely to incur increasing utilization and costs as their illnesses progress.
"Without rising risk of high-cost care encounters, there is little potential savings to be gained from the intervention," the researchers wrote.
2. Health assessments
The companies' care teams conduct and maintain health assessments of patients that help form comprehensive understandings of health status and risk factors such as safety concerns in the homes of patients.
The health assessments generate a wealth of data, the researchers wrote. "The information recorded in these assessments may then be used to inform risk stratification within patient cohorts, to prioritize resource needs for patients, and to tailor care plans."
3. Aggregated data
The assessment data is combined with claims data in computer programs that monitor patient health status and risk level.
Dashboards and reporting from the combined data are used to monitor several measures, including patient engagement, quality of care, utilization, and clinical outcomes. The information helps care teams decide whether interventions can avoid high-cost encounters such as emergency room visits.
4. Home health
Health services are delivered in a patient's home or residence facility.
Access to services from the companies is extensive, the researchers wrote. "All of them provide round-the-clock accessibility to patients, which is critical for quickly addressing patient concerns and needs in order to prevent or divert emergency visits and hospital admissions."
Expanding innovative care models beyond Medicare Advantage
The researchers say Medicare Advantage's innovative care models for the seriously ill face three expansion hurdles: rural economics, workforce training, and inflexibility in traditional Medicare.
The home health approach at Aspire Health, Landmark Health, and Turn-Key Health is costly in rural areas, where the distance between patient homes can be great. Travel costs limit the financial viability of the models.
For these care models, clinical leaders are particularly difficult to find because they must have both clinical and management training. The researchers say management training should be added to medical school curricula and post-doctoral education.
If traditional Medicare embraces these care model, innovation-stifling standardized rules would likely be adopted, the researchers wrote. "Those rules would necessarily limit the flexibility of the models to meet the needs of patients."
The researchers make three recommendations to promote care models for the seriously ill:
Incentivize the care models for traditional fee-for-service Medicare patients such as expanding the Independence at Home demonstration program to support care models with interdisciplinary teams focused on seriously ill patients
Study more serious illness care models to generate data on utilization, quality, and cost
Support workforce training that better prepares providers for practicing medicine under alternative payment models
After building a global reputation for providing complex, specialized care, the health system is building a care model that is designed to better meet the needs of the communities it serves.
Cleveland Clinic is launching an ambitious population health initiative designed to augment its world-class inpatient care, the organization's new chief of population health says.
"For Cleveland Clinic,we anticipate that as we manage population health well, we will create additional capacity for highly complex care. Some of our facilities are running close to capacity," says Adam Myers,MD, MHCM, FACHE.
Myers is also serving as director of Cleveland Clinic Community Care, a new population health approach at Cleveland Clinic. The approach features several elements of the organization, including primary care internal medicine, primary care pediatrics, family medicine, the organization's clinically integrated network of more than 6,000 physicians,Express Care,and the Center for Value-Based Care Research.
Prior to joining Cleveland Clinic, Myers served as the chief operating officer at Texas Health Physicians Group, a physician organization affiliated with Arlington-based Texas Health Resources.
HealthLeaders Media spoke recently with Myers. Following is a lightly edited transcript of that conversation.
HLM: What are some of the fundamental approaches to population health at Cleveland Clinic?
Myers: One is to help the healthcare system transition from volume to value.
Two is to focus on health, not simply on treatment of disease. For a long time, this has been a portion of what the Cleveland Clinic has done, but we can augment that quite a bit—not just for the folks we call patients but also for the communities we serve.
Three is creating additional access for patients and partnering with our community colleagues in addressing thesocial determinants of health.
Finally, we intend to work on enhancing the reliability of the primary care we deliver.
HLM: How does Cleveland Clinic plan to expand its population health efforts?
Myers: Initially, we are going to address the communities where we already live and work—northeast Ohio and other areas where we have physician practices in Florida. Ultimately, as we create a population health model, our hope is that it will propagate. Everyone is trying different approaches to population health and each community has its own opportunities and challenges. … We hope to come up with an approach that can be adopted elsewhere.
HLM: Describe a primary population health challenge at Cleveland Clinic and how the health system plans to address it.
Myers:Just like every other place, Cleveland Clinic faces finite resources. The changes in payment structures are underscoring the finite resources. However, we are determined and well-resourced to address this challenge.
We will be building teams around primary care providers—pharmacists, advanced practice providers, social workers, nutritional counselors, and behavioral medicine support to round out the team, so that the members of our teams can work closer to the top of their licenses.
HLM: Describe how your dual role as chief population health officer and director of Cleveland Community Care is designed to work.
Myers:I have the strategic and directional role of population health that will work with our primary care-focused efforts and our specialty institute partners. Then there's Cleveland Clinic Community Care, which is the operating nuts and bolts of primary care for the communities we serve.
HLM: What is Cleveland Clinic's approach to addressing social determinants of health?
Myers: Rather than assume what each community needs, Cleveland Clinic Community Care will partner with municipalities, community organizations, businesses, churches, existing healthcare teams in the communities, and other health systems to address the needs defined by both stakeholders and focused healthcare analytics. Our approach to social determinants will be tailored to communities.
At the Stephanie Tubbs Jones Family Health Centerin the east side of Cleveland, we found that getting to appointments was a real struggle. Transportation was very difficult. We made a simple intervention that was a value-add intervention for the community. We provide 30 to 50 patient transportation opportunities per day.
The Cleveland Clinic does not intend to directly meet all of the community needs for social determinants of health. It's just not possible. We also do not intend to replace or displace the other support systems that are in our communities. We need to stand alongside what already is in place, find the remaining gaps, and work to either close gaps ourselves or help resource closure of gaps.
NCH Healthcare System has generated several benefits from disease prevention and wellness programs with its employees, including $27 million in health plan savings.
A Florida health system's disease prevention and wellness efforts are generating a healthy return on investment.
NCH Healthcare System has changed the focus of the Naples-based health system from a "repair shop for disease" to prevention and wellbeing, says Chief Medical Officer Frank Astor, MD, MBA.
"There are going to be changes in healthcare, but we think this is the right thing to do. Keeping a very healthy population is going to help us no matter what the future brings," Astor said last week during the HealthLeaders Population Health Exchange in Coeur d'Alene, Idaho.
Championed by President and CEO Allen Weiss, MD, NCH has launched prevention and wellness programs for its own employees and the surrounding community. A series of employee initiatives, which are generating impressive results, started a decade ago:
2009—Biometrics and preventive health screens such as colonoscopy and mammography
2010—Personal health assessment, coaching, diabetes education, and nicotine testing
2011—Stopped hiring smokers
2014—Annual labs, biometrics, health-related classes, and health deductible buy down for healthy activities
Starting in 2014, NCH started offering employees financial incentives to promote health consciousness and healthy lifestyles. The incentives—health reimbursement accounts (HRAs)—are being used to lower insurance costs for employees who participate in NCH's health plan.
"HRA dollars were used to buy down deductibles at the health plan," Astor says.
NCH and its employees have generated significant health and financial gains from their prevention and wellbeing efforts:
Lowered body mass index, blood pressure, waist circumference, and lipids
Overall program satisfaction is 98%, with 40% satisfied or very satisfied with offerings
At the NCH health plan, costs have decreased 7.8% annually over the past five years, with no increase of employee premiums for the past four years
The decrease in healthcare spending has saved the health plan $27 million over the past three years
Number of days lost to injury has dropped from 381 in 2015 to 226 in 2016
Employee engagement has been a key to NCH's success in promoting prevention and wellbeing within the health system, Astor says. "Our employees became active, engaged, and happy with the new activities and lifestyle."
Community wellness
NCH is anticipating similar gains from the health system's prevention and wellbeing initiatives in Naples and surrounding communities, Astor says.
"We decided to have a life radius around NCH that involved engaging political and local government institutions, and civic organizations. We helped build an environment where we had parks, green areas, and bike paths."
Engaging communities has required a high level of outreach work, Astor says. "We went beyond the scale of a hospital or healthcare system, involving schools, faith-based organizations, supermarkets, and restaurants."
At NCH, a crucial element of building and sustaining wellness gains is adoption of the Blue Zones approach to health, he says. The approach includes moving naturally, having a positive outlook, eating wisely, and belonging socially such as connecting with loved ones.
"We are going to sustain these changes with Blue Zones. We started with biometrics, a change in philosophy, and the deductibles. The Blue Zones effect can maintain our gains and keep the population healthy," Astor says.
A team of researchers and clinicians explores new frontier for telemedicine and finds opportunities to provide high-quality care.
A virtual vascular clinic can conveniently deliver high-quality care that generates high patient satisfaction scores, researchers say.
To create a pilot study of a virtual vascular clinic, the researchers established imaging-equipped satellite clinics linked to a health system. The satellite clinics were conveniently located for patients, who had virtual visits with vascular surgeons at the satellite locations.
"Synchronous telemedicine with point-of-care ultrasound is effective in evaluating common vascular conditions. Virtual care may be used for management of patients with chronic vascular disease," the researchers wrote in an article published in the Journal of Vascular Surgery.
From October 2015 to August 2016, 55 patients were treated at the pilot virtual vascular clinic. The patients had telehealth visits with a surgical provider via Skype for Business, clinical data was entered into the health system's electronic medical record, and the satellite facilities that the patients visited for their Skype session provided imaging and laboratory services.
The conditions of the patients included both arterial problems such as aneurysm and venous problems such as varicose vein.
91% of the patients reported they would highly recommend a virtual physician visit to a friend or colleague
100% said their virtual visits were more convenient than traditional office visits
100% said they were given clear information about their health during the virtual visits
100% said they could communicate effectively with their surgical provider
Multiple benefits
For vascular care, virtual office visits have several advantages over traditional office visits, the researchers wrote.
"The use of telemedicine with point-of-care ultrasound testing shortens access times for the patients and maintains quality of care because of increased availability of laboratory testing and clinic space at the satellite locations," they wrote.
Having results from imaging and laboratory immediately at the satellite locations enabled interpretation, diagnosis, and management of patient conditions closer to their homes, the researchers wrote.
"The immediacy of test results also enables the referring physician to prescribe a comprehensive management of the patient's disease, leading to greater efficiency, less wait time, and faster service," they wrote.
Virtual vascular surgical clinics have the potential to not only improve access for patients but also boost the market for vascular care, the researchers wrote.
"This new patient care model may improve access for patients who choose to have the convenience of expert surgical services and laboratory testing closer to home. Increased satisfaction of the patients will create new markets for patients who otherwise may not be served by vascular specialists."
Operating virtual vascular clinic
The pilot virtual vascular clinic was geared for convenience, efficiency, and quality:
Customer service representatives checked insurance coverage status of patients
Physicians ordered medical management and imaging electronically
For additional testing, patients went to their satellite location's vascular laboratory either the same day or before their follow-up visit
Patient evaluations by offsite vascular surgeons included a clinical history, a visual physical exam, a diagnosis, and implementation of a care plan
A registered nurse played the role of tele-presenter at the satellite locations and could remove sutures, assess wounds, and send photographs of incision sites
"Using secured videoconferencing technologies, telemedicine may replace traditional clinic visits, save patients time and travel, and improve use of limited surgeon and facility resources," the researchers wrote.
Call to action features respecting self-determination in the home setting, promoting safety culture, fostering learning and improvement, overhauling care coordination, and payment model reform.
"Safe care in the home setting has generally received less attention nationally than safety in hospitals, nursing homes, and ambulatory settings," says the report from the Institute for Healthcare Improvement, "No Place Like Home: Advancing the Safety of Care in the Home."
The IHI report makes a call to action. "We have yet to completely elucidate the nature and prevalence of risks in the home and create optimal ways to improve safety in this setting. Given the increasing proportion of care provided in the home, improving safety in this setting deserves urgent attention."
Home health is a growing healthcare sector. In 2016, there were more than 2 million personal care attendants in home settings, according to the U.S. Department of Labor, with the number projected to increase 40% in the next decade.
The IHI report sets five guidelines to improve home health safety:
1. Self-determination
In the home setting, self-determination and person-centered care are essential elements for safety, the report says.
"Respect for the sacredness of the home is essential to maintaining dignity. People receiving care at home may not see themselves as 'patients.' For example, people with physical disabilities who receive care at home are not ill. With this in mind, home care workers must avoid 'medicalizing' the home."
Recommendations to foster self-determination and person-centered care include boosting communication with care recipients and family caregivers.
2. Safety culture
Creating and maintaining a safety culture should be a top goal of every organization that provides home health services, the report says.
"Increasing the safety of care in the home requires more than simply collecting prevention strategies and interventions. It requires an overarching commitment to safety."
Promoting the safety of caregivers is essential, the report says.
"The culture of safety and the specific safety practices need to be inclusive, attending to the safety of care recipients and everyone who provides care. … People who provide care in the home are at risk for experiencing emotional or physical harm as they go about their work."
Recommendations to foster a safety culture include guarding the emotional and physical safety of home caregivers.
3. Learning and improvement
An effective learning and improvement system will be crucial in achieving and sustaining home health safety gains, the report says.
There is a dire need to understand and disseminate the fundamentals of home health safety, the report says. "Individuals and organizations must develop or identify effective strategies to improve safety in the home, and to accelerate change they must quickly share these strategies with peers."
The learning process has yet to begin in earnest, the report says.
"We need what we currently do not have: a robust learning system through which to learn, collect, and share data, identify effective interventions using safety science, and spread best practices about safety in the home setting."
Recommendations to support learning and improvement efforts include developing measurement and reporting capabilities.
4. Team-based care and care coordination
The expert panel that crafted the report found poor care coordination is the top clinical concern in home health safety.
"The current healthcare system does not sufficiently enable teamwork among the many professionals involved in a person's care, including nurses, therapists, physicians, social workers, managers, and administrators. Although home care workers often provide care alone, there must be a coordinated team and infrastructure to support them," the report says.
Recommendations to improve care coordination include maximizing the use of community-based resources.
5. Policies and payment models
Policy and payment model reform is needed to boost care coordination and improve service delivery, the report says.
"Current regulations and payment models often increase care fragmentation. In general, services paid via fee-for-service models tend to be siloed, leaving important needs unmet."
Recommendations for reforms include aligning payment models with key home-health goals such as care coordination and whole-person services.
