The proposed behavioral health hospital would increase access to inpatient and intensive outpatient care in the Greater Boston area.
Tufts Medicine and Acadia Healthcare have formed a joint venture to build a 144-bed behavioral health facility on the site of the former Malden Hospital in Malden, Massachusetts.
The joint venture is designed to increase access to behavioral health inpatient and intensive outpatient care in the Greater Boston area. Access to care is one of the biggest challenges in behavioral health nationwide, with mental health patients boarded in hospital emergency departments for days or weeks awaiting the availability of inpatient beds.
"There is a critical need for capacity in behavioral health in the Commonwealth. Our plans to redevelop the Malden Hospital site into a state-of-the-art behavioral health hospital will help address the constraints on access to care that our healthcare providers and our patients and families face every day," Michael Dandorph, president and CEO of the Burlington, Massachusetts-based health system said in a prepared statement. "We are proud of the services that MelroseWakefield Hospital and Lawrence Memorial Hospital have provided and these plans expand upon the legacy of high-quality, compassionate care they have long delivered to patients."
The project faces local and regulatory review. Once the new facility opens in two to three years, MelroseWakefield Hospital and Lawrence Memorial Hospital in Medford will consolidate their inpatient behavioral health services at the new hospital. There will be a net gain of 86 inpatient beds.
The new behavioral health hospital represents a $65 million investment and will replace the former Malden Hospital, with a smaller footprint than the existing structure. Tufts Medicine and Acadia Healthcare are both contributing to the investment. The project will create 9 acres of conservation land and open space.
The top executive of Franklin, Tennessee-based Acadia Healthcare hailed the partnership with Tufts Medicine. "Acadia is extremely pleased to be partnering with a premier integrated healthcare system like Tufts Medicine, who shares in our mission and values," Acadia Healthcare CEO Christopher Hunter said in a prepared statement. "We look forward to creating this modern, patient-centered facility that will provide life-saving services to individuals and families throughout the region. The new hospital will also be a center of excellence for teaching the next generation of clinicians and staff so we can serve the community for many years to come."
Information about community engagement for the project is available online. A community meeting about the project is scheduled for July 19 at 6 p.m. in Malden City Hall.
For Forge Health patients with behavioral health and/or substance use conditions, if there is a comorbid physical condition that is included in the care plan.
New York City-based Forge Health, which provides a range of outpatient behavioral health services, takes a "full-person" approach to care, including physical health and social determinants of health.
Millions of Americans have both a physical health and a behavioral health or substance use conditions, according to the National Alliance on Mental Illness. Integrating care for behavioral health and physical health decreases fragmentation in care, and fragmentation is linked to poor health outcomes.
Forge Health offers outpatient behavioral health services and substance abuse services via telehealth and at offices located in Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, and Virginia.
Forge Health has been able to drive down utilization of medical services such as emergency room visits because the organization's care model is focused on both mental and physical health, says co-founder and CEO Eric Frieman.
"We have the ability to drive down utilization on the physical health side because we have a unified, full-person approach to care. In a treatment plan for one of our patients, just improving their mental health condition or their substance abuse symptoms is important, but it is not everything. If they have a comorbid medical condition, we include that as part of the treatment plan. For example, if one of our patients has diabetes, we make sure they are seeing an endocrinologist. If they are seeing an endocrinologist, they are adhering to the treatment plan; if they don't, it is time for a clinical intervention," he says.
Forge Health care model
Multidisciplinary teams are a cornerstone of the Forge Health care model, Frieman says. "We don't let any of our providers work in a vacuum or work alone. The multidisciplinary care team includes licensed mental health therapists as well as a psychiatrist or a psychiatric nurse practitioner. We also have care coordinators who helps patients coordinate their care with physical health providers and address social determinants of health. The care team works together on each patient's care. There are weekly clinical rounds and care team members are available to discuss and coordinate care for patients."
The care coordinator plays an essential role, says John Rodolico, PhD, chief science officer at Forge Health. "The therapists and psychiatrists on the multidisciplinary team cover a lot of bases, but they cannot cover everything. The care coordinator coordinates anything that falls outside the main hub of the team."
The clinicians and care coordinators share the responsibility of addressing the social determinants of health for patients, Frieman says. "We have community partners. We have a vetted list in each of our markets of nonprofits, community organizations, and government agencies. We assist our patients in getting connected to the right service."
Data analytics are an essential element of the Forge Health care model, Frieman says. "Everything that we do is electronic. So, we have the ability to track data such as progression of treatment. We have standard evaluation tools that allow us to track a patient's symptoms such as their depressive symptoms, their trauma symptoms, and their addiction symptoms. We can look at that data and see how a patient's condition progresses over time. Based off that evaluation and tracking of data, we can re-evaluate our treatment plans if necessary."
Forge Health uses four primary patient assessment tools: the BAM or Brief Addiction Monitor for substance use disorder, the PHQ-9 for depression, the PCL-5 for trauma, and the GAD-7 for anxiety.
The data analytics associated with these patient assessment tools are helpful both internally and with external healthcare provider partners, Rodolico says. "These are analytics that are used across the field, particularly the PHQ-9, PCL-5, and GAD-7, which are used across many organizations. So, these analytics can be used not only internally but also externally with other providers. For example, a first-responder can come in and be very high on the PCL-5. They go through the Forge Health program. At the end of that care, they can have a dip in their PCL-5 score, but they still need to be monitored. If everyone signs off, we can give the PCL-5 data to the clinician to whom we have handed off the patient. That way, the new clinician can see the improvement and where the patient needs to go in care."
Unique aspects of Forge Health
Streamlined care delivery is a hallmark of Forge Health, Frieman says.
"The behavioral health care industry is filled with point solutions, which is not how our model works. We have created a one-stop-shop for behavioral health. So, if a patient comes to us and they have a mental health issue and a substance use disorder, we can effectively treat that patient for both conditions without having to coordinate care with outside providers. With other providers, they may only be able to treat mental health conditions and have to coordinate with a substance abuse provider. With our multidisciplinary care teams, we have the ability to provide psychotherapy as well as evaluation and medication management services. We do it all in-house," he says.
Forge Health has a mature approach to virtual care, Rodolico says. "Forge Health has been ahead of the curve on virtual care. Many behavioral health organizations have adopted virtual care since the beginning of the coronavirus pandemic because they were forced to operate virtually. Our executive group has been looking to the future, and we were doing virtual care long before COVID-19 struck us."
Having the ability to provide high-quality care in-person or virtually is important at Forge Health, Frieman says. "The ability to have a hybrid model is critical for us. Patients can receive care in-person or via telehealth modalities. Having the ability to do both is a somewhat unique offering at Forge Health. Sometimes, patients want visits in-person; sometimes, patients want hybrid visits; sometimes, patients only want to be virtual."
Unlike many behavioral health organizations, Forge Health does not rely on grant funding to finance care, Frieman says. "We are in-network with every major health insurance company. We take Medicaid, Medicare, Veterans Affairs benefits, and TRICARE for active-duty military. There are no grants and no self-pay. All services are paid by someone's health insurance. In general, we are fee-for-service, but we also have value-based arrangements."
At the AdventHealth Post-COVID Clinic, new patients are evaluated by primary care, behavioral health, and physical therapy staff.
An extensive patient evaluation process is one of the distinguishing characteristics of a new long COVID clinic at Central Florida-based AdventHealth.
There are coronavirus "long haulers" among COVID-19 patients who have experienced mild, moderate, and severe infections. In one study of COVID-19 patients hospitalized with severe acute respiratory infection, functional impairment was found in 53.8% of patients four months after hospital discharge. Long COVID symptoms include cough, shortness of breath, anxiety and depression, cardiac issues, and fatigue.
AdventHealth opened the health system’s Post-COVID Clinic in March. Determining whether patients have long COVID and characterizing their symptomology requires an exhaustive evaluation process, says Dwayne Gordon, MD, an AdventHealth Medical Group internal medicine physician and lead physician of the Post-COVID Clinic, which is based at AdventHealth Orlando.
"These patients are universally difficult to diagnosis. You have to determine whether a patient has long COVID, which is not a crystal-clear condition. With long COVID, a patient can present in numerous ways. It can be weakness. It can be forgetfulness. It can be shortness of breath. It can be a chronic cough. It can be anxiety, depression, or insomnia. A key question is: Did your symptoms start before or after you had COVID? So, delineating the timeline is part of diagnosing long COVID. We try to determine whether someone has had onset of new symptoms or significant worsening of chronic symptoms after COVID. Some people had anxiety before they contracted COVID, but it can get significantly worse after COVID," he said.
To qualify for care at the Post-COVID Clinic, a patient must have a confirmed COVID diagnosis and coronavirus symptoms for at least three months.
The patient evaluation process at the clinic is conducted in two phases—an intake telephone call with a registered nurse followed by a 90-minute in-person evaluation, Gordon says. "We conduct an intake interview before patients come to the clinic. That intake includes getting basic information about when the patient was diagnosed with COVID, their initial symptoms, and their current symptoms."
If the intake interview indicates a patient probably has long COVID, an in-person visit is scheduled, he says.
"For example, a patient could have been infected with COVID in 2020. We would ask about presenting symptoms, we would ask whether they were vaccinated before infection, we would ask whether the patient was hospitalized, we would ask whether they required oxygen, we would ask whether they required inpatient rehabilitation, and we would ask whether they required home oxygen. Then we would talk about their current symptoms. We also have a couple of forms for patients to fill out—the GAD-7 for general anxiety disorder screening and the PHQ-9 for depression screening. We get a SLUMS score to see whether there is evidence of memory loss or dementia. We screen all of our patients to see whether they have sleep-related disorders such as insomnia and obstructive sleep apnea. We go over their past medical history in detail, including medications and past surgeries. We also talk about their social history. Are they currently employed? Are they unemployed because of long COVID symptoms?"
The in-person evaluation also includes a complete physical therapy screening.
The evaluation process helps to establish a care plan, Gordon says. "After patients get evaluated by physical therapy, behavioral health, and myself, then we establish a comprehensive care plan. Many patients require physical therapy for generalized weakness. They might require occupational therapy because they are dropping things or are unable to do activities of daily living such as bathing, cooking, and dressing."
Staffing, referrals, and research
It is crucial for long COVID clinics to have multidisciplinary care teams, Gordon says. "When it comes to being multidisciplinary, we have a primary care physician, a behavioral health team, and a physical therapist. Patients get a comprehensive evaluation by all three of those disciplines. We also partner with subspecialists who we can make referrals to—we have AdventHealth pulmonologists and cardiologists. We also have a registered nurse, who helps with social work, and a practice manager."
Having a multidisciplinary clinic is a key to success, he says. "One thing we have learned, and we talk about regularly is the involvement of multiple departments—everything from marketing to research to behavioral health to primary care to physical therapy and beyond. We have all of these departments represented at a weekly meeting because long COVID is complex. You have to have a social worker, you have to have a nurse, you have to have medical assistants, you have to have doctors, you have to have your physical therapists. If you do not have those components, then you are going to fall short because these patients take a significant amount of time and resources."
The Post-COVID Clinic is conducting research to increase the understanding of long COVID with the AdventHealth Transitional Research Institute. One study that is already underway is examining how long COVID affects patients with diabetes. Researchers will observe changes to organs, such as the heart, lungs, liver, kidney, pancreas, and spleen following a COVID diagnosis in people with and without diabetes to determine how COVID and any related inflammation may impact organ function in diabetics.
Behavioral health dimension
Behavioral health services are an important element of the Post-COVID Clinic, Gordon says. "Some people have significant anxiety and depression. They not only require counseling but also may require medications. They can get counseling from us, then we transition them to outpatient counseling for modalities such as cognitive behavioral therapy, where they get help coping with the stressors of long COVID."
Insomnia is common among coronavirus long haulers, he says. "There can be multiple reasons for insomnia, including sleep disorders such as sleep apnea. They might get two or three hours of sleep per night. For these patients, we work on a medication regimen, and we work on sleep hygiene counseling that includes handouts for best practices to get a restful night."
Insomnia contributes to brain fog among long COVID patients, Gordon says. "It is well known that if you have insomnia, then your ability to think clearly is going to be impaired."
Forgetfulness and dementia are being observed in relatively young coronavirus long haulers, he says. "The majority of patients who are scoring for memory loss and dementia in the SLUMS evaluation are between 30 and 55 years old. It is highly unusual to see the scores that we are seeing in that age range. It is uncommon to do a SLUMS evaluation for people in this age range—this evaluation is typically done in the elderly population because that is when you tend to see forgetfulness."
The coronavirus pandemic has worsened healthcare workforce woes that were already plaguing healthcare workers before the public health emergency.
The American Hospital Association (AHA) says there is a three-pronged approach to current healthcare workforce challenges—addressing well-being, supporting behavioral health, and preventing workplace violence.
Healthcare worker burnout has reached crisis proportions during the coronavirus pandemic and workforce shortages are widespread among nurses, physicians, and other clinical roles across the country. The health and the sustainability of the healthcare workforce are in jeopardy.
The AHA recently released Part 1 of a three-part series of reports on the strained healthcare workforce. The first installment is titled "supporting the team," and it focuses on addressing well-being, supporting behavioral health, and preventing workplace violence.
The pandemic has driven the healthcare workforce in an alarming direction, says Elisa Arespacochaga, MBA, vice president of clinical affairs and workforce at AHA.
"At its core, healthcare is people providing care for people. We need a talented, engaged, and diverse workforce to be able to do that effectively. Unfortunately, the healthcare field just like other fields across the country is facing mounting workforce challenges, including some critical staffing shortages that could jeopardize access to care. Some of these challenges come from longer term trends such as the demographic shifts of having fewer young people and more people who are on Medicare. The bottom line is the pandemic exacerbated the problems and took a toll on the healthcare workforce," she says.
The pandemic has worsened burnout, Arespacochaga says. "We knew before the pandemic that the impact of burnout was not only taking a toll on the physical and mental health of our workforce, but also was contributing to challenges related to patient outcomes, people leaving the workforce, and recruiting. Over the past two years, COVID has just amplified all of these challenges."
The pandemic has increased the need for behavioral health services for healthcare workers, she says. "COVID-19 has been a huge emotional and physical strain for our healthcare workforce. Our healthcare workers are incredibly resilient, but the ongoing impact of the pandemic has taken a toll on their ability to recover and to be resilient."
The pandemic has also increased workplace violence incidents, Arespacochaga says. "We knew before the pandemic that healthcare workers were among the highest rates of injuries from workplace violence. We are there to care for people in their most extreme circumstances, and sometimes there is violence. However, the pandemic has made workplace violence worse. We have seen a marked increase in violence against hospital employees, and it does not seem to be slowing down."
Supporting healthcare workers
The new AHA report includes initiatives and strategies associated with the organization's three approaches to supporting the healthcare workforce.
Addressing well-being
Dealing with burnout requires a cultural shift, not just a checklist of tasks to complete
Planning to engage key stakeholders in well-being initiatives should include front-line and core managers
When there are gaps in resources, prioritize needs and seize on opportunities to launch pilot initiatives
Address self-care through training during onboarding and continuing education programs
Supporting behavioral health
Seek to have a culture of psychological safety where healthcare workers feel safe to speak out and seek treatment for mental health or substance use disorders
Share stories about mental health or substance use disorders—try to normalize mental illness
Integrate physical and behavioral health services, which has been shown to boost employee satisfaction
Prevent workplace violence
There should be an assigned leader who fosters workplace safety initiatives
There should be accountability protocols for all leaders and those protocols should be shared with the staff
Reporting of workplace violence should be encouraged, with a zero-tolerance organizational expectation about violent behavior
Create an interdisciplinary threat assessment team to identify opportunities to mitigate threats
Conduct ongoing education and training programs, including simulation training
Allcove centers provide a range of services to young people, including mental health screening, short-term therapy, primary care, and addiction treatment.
In California, Stanford Children's Health is helping to open allcove centers, which is a new model for prevention, early detection, and treatment of mental illness in young people.
Millions of American children and young adults experience mental health conditions, and access to care is a challenge. In 2020, 13.01% of Americans aged 12 to 17 reported experiencing a major depressive episode in the previous year, according to Mental Health America. The mental health of high school students has deteriorated during the coronavirus pandemic, with 37% of students reporting they experienced poor mental health in 2021, according to the Centers for Disease Control and Prevention.
The status of mental health for children and young adults is raising alarm, says Steven Adelsheim, MD, director of the Stanford Center for Youth Mental Health and Wellbeing.
"Prior to the pandemic, we were already facing a crisis in terms of access and support for children's mental health issues. There were increasing rates of youth suicide and struggles to have access to care in terms of enough qualified providers to meet the needs of young people. With the pandemic, the challenges have increased, including the growing number of young people needing mental health support. We have higher rates of anxiety, higher rates of depression, and more young people coming into emergency rooms for suicidal ideation and suicide attempts," he says.
Adelsheim and his colleagues at the Stanford Center are playing a leading role in the creation of allcove centers across California. With support from Santa Clara County Behavioral Health Services, two allcove centers opened in Santa Clara County in June 2020. There are plans to open five more allcove centers, with as many as three opening by the end of this year.
The allcove model
Allcove centers are designed to play an important role in the behavioral health continuum of care for young people, Adelsheim says. "We have seen a lot of national attention on school mental health services. The allcove centers become the community place for young people 12 to 25 to come in and get early care. So, we are trying to create a public mental health continuum of early support from school mental health to allcove centers to even early psychosis programs that have grown exponentially across the country since the federal government made the investment through the federal 10% set-aside for early psychosis programs."
Mental health services available at allcove centers include screening and short-term therapy, he says.
"Generally, it is a short-term therapy model, so staff help young people feel comfortable if they are having a breakup in a relationship, or sexual orientation questions, or bullying, or some other type of challenge. They do not have to wait until things become severe. Most of the time, we see young people and families accessing mental health services through emergency rooms at times of crisis. The idea with the allcove centers is they are places that are comfortable enough for young people to come in for an early mental health visit with a licensed therapist and be able to access short-term support. Family therapy is available. Group services are available."
If young people need a higher level of mental health care, allcove center staff can connect them with other behavioral health providers.
Other services provided at allcove centers include primary care, education and employment support, addiction treatment, and peer support, Adelsheim says. "We are looking at a range of supports for young people. Some services support building resiliency and wellness. Other services provide mental health support. We also have integrated support with primary care clinicians who can provide sexual health services for young people as well as general medical services. In addition, we have peer support services. Every young person who comes in to an allcove center is met by a peer support specialist—someone who is close to their age who may have a lived experience with a mental health issue. The peer support specialist can help a young person learn about the services that are available at the allcove center."
Allcove centers have been designed and developed by young people for young people, he says. "Each allcove center has an active youth advisory group that is involved in decisions about the services that are provided. The youth advisory group is involved in the hiring of the staff."
The physical characteristics of allcove centers are designed to create a welcoming environment for young people, Adelsheim says.
"They all have a space called The Cove, which is a warm and welcoming place for young people where they can be together and be able to interact with each other in a comfortable way. One of the ideas is to be able to come in for a moment of pause. Young people can be alone, without really being alone. … The colors and the design are set up to create a level of comfort for young people in terms of the space itself. We try to create a space that is not as clinical as one might see in a typical mental health clinic. There are areas for young people to do creative things and snacks are available. There are art supplies available."
Launching allcove centers
At this stage of the allcove center initiative, the facilities have relied on a range of financial support, he says.
"We are working with the state of California on funding models to be able to provide Medicaid as well as commercial insurance support for the centers. We are doing that work through a partnership with the state Mental Health Services Oversight & Accountability Commission. The centers that opened in Santa Clara County started with some funding from California's millionaire tax for mental health. Santa Clara County also used some of their innovation funds for their two centers. In addition to the state pilot funds, communities are also pulling together other funds from their own mental health services. We are also working with managed care networks to talk about how we can build in the capacity for early and upfront support. There is also some foundation support. The goal is to create a financial model that will allow for broader sustainability over time."
There have been discussions to open allcove centers in other states, Adelsheim says. "They can connect with us through our website, allcove.org. We have information available to share with communities that are interested in rolling out this model. We have a technical support team whose role is helping interested communities think about what it would take to start a model like this. Opening a center often begins with developing a youth advisory group because the youth voice is important to developing services and to helping communities pull together the service delivery partners."
For financially distressed rural hospitals, affiliation with other hospitals was linked to a lower risk of closure compared to being independent, researchers found.
For financially distressed rural hospitals, affiliations with other hospitals lower the risk of closure; but for financially stable rural hospitals, affiliations with other hospitals increase the risk of closure, a new research article found.
Several factors have made rural hospitals more exposed to financial distress than urban hospitals, the new research article says. Compared to urban hospitals, rural hospitals struggle to attract and retain clinicians. Rural hospitals face higher fixed costs than urban hospitals because of lower patient volumes. Compared to patients at urban hospitals, patients at rural hospitals are more likely to be uninsured or covered by public insurance.
The new research article, which was published by JAMA Health Forum, examines data collected from 2,237 rural hospitals from 2007 to 2019. The study compared closure risk for independent hospitals, hospitals that were already affiliated with other hospitals in 2007, and hospitals that became affiliated after 2007.
The study has several key data points.
140 (6.3%) of the rural hospitals closed by 2019
The number of rural hospitals that were independent decreased dramatically over the study period, falling from 68.9% in 2007 to 47.0% in 2019
For financially distressed rural hospitals in 2007, affiliation was linked to a lower risk of closure compared to being independent (adjusted hazard ratio 0.49)
For financially stable rural hospitals in 2007, affiliation was linked to a higher risk of closure compared to being independent (adjusted hazard ratio 2.36)
For financially stable rural hospitals in 2007, for-profit ownership was linked to a high risk of closure (adjusted hazard ratio 4.08)
On average, affiliated hospitals had more beds than independent hospitals
Hospitals that were already affiliated in 2007 were more likely than independent hospitals to have maternal and neonatal care (71.7% versus 61.1%)
Hospitals that were already affiliated in 2007 or became affiliated after 2007 were more likely than independent hospitals to have mental and/or substance use disorder (MSUD) treatment and surgical care (80% versus 74%)
Overall, the percentage of rural hospitals in financial distress increased from 25.0% in 2007 to 30.2% in 2019
"The results of this cohort study suggest that affiliations may be associated with lower risk of closure for some rural hospitals in financial distress. However, among initially financially stable hospitals, an increased risk of closure for hospitals associated with affiliation and proprietary ownership raises concerns about the association of affiliation with closures in some circumstances," the study's co-authors wrote.
Interpreting the data
Rural hospitals experienced significant changes from 2007 to 2019, the study's co-authors wrote. "Approximately 6% of rural hospitals that were open in 2007 have now closed. Affiliations and financial distress have increased substantially, whereas market shares have declined. Downsizing was observed across the board in terms of decreases in number of beds and total volume of inpatient stays. During the study period, rural hospitals decreased maternal and neonatal, MSUD, and surgical inpatient services."
Some rural hospital closures may have been business decisions that were not aligned with community needs, the study's co-authors wrote. "Notably, hospitals that became affiliated during the study period had a higher rate of financial distress at the end of the study period, as well as a greater reduction in total inpatient volume and market share than independent hospitals, suggesting that these hospitals may have not performed well even after joining a system or merging with another hospital. Additionally, private for-profit ownership was associated with closure among financially stable hospitals."
Some financially distressed affiliated rural hospitals may have reduced risk of closure because affiliation provides access to more resources, the study's co-authors wrote. "Among financially distressed hospitals, affiliations were associated with a lower risk of closure compared with being independent. This finding did not hold in the subanalysis of hospitals that were independent in 2007, suggesting the protective association may have been associated with mature affiliations (i.e., hospitals already affiliated in 2007)."
Clinician compensation growth and productivity from 2020 to 2021 are comparable to levels seen before the coronavirus pandemic, according to AMGA data.
The coronavirus pandemic had significant impacts on clinician compensation and productivity in 2020. Patient service volumes decreased, with some clinicians furloughed and declines in office visits and elective surgeries.
The AMGA 2022 Medical Group Compensation and Productivity Survey is based on data collected from 383 medical groups that employ 183,000 clinicians. The survey features several key data points.
Median clinician compensation increased 3.7% from 2020 to 2021, compared to a 0.1% increase from 2019 to 2020
Compensation per work unit (wRVU) fell in 2021—clinicians were compensated 11.0% less for each individual unit of work in 2021 than they were in 2020
Productivity increased sharply—median total wRVUs increased by 18.3% from 2020 to 2021, compared to a 10.2% decrease from 2019 to 2020
The compensation increase indicates compensation growth is nearing pre-pandemic levels, Fred Horton, MHA, president of AMGA Consulting, told HealthLeaders. "You could say that should make up for two years of compensation, but there were guarantees put in place for 2019 to 2020 and productivity has not come all the way back. We are approaching the pre-pandemic compensation levels with the 3.7% rate of compensation escalation."
The 3.7% compensation increase from 2020 to 2021 compares favorably to compensation growth before the pandemic, he said. "On an annual basis, we normally see compensation increases of 1.7% to 3.0%. So, we are seeing a larger increase."
The increase in productivity offset the decrease compensation per wRVU, Horton said. "Based upon where productivity came in, it more than made up for the reduced compensation per work RVU. It made up for it in aggregate at an increase of 3.7% in compensation. So, even though we have a decreased compensation per work RVU, we have more than enough units in the marketplace to offset that decrease and still produce on average a 3.7% compensation increase for providers."
Two factors drove the 18.3% increase in median total wRVUs from 2020 to 2021, he said. "The first piece is a return of approximately 90% of the 10.2% decrease in median total work RVUs from 2019 to 2020. So, we almost returned to the productivity that we saw before the pandemic. The second piece, which is about 8% to 9% of the 10.2% decrease in median total work RVUs from 2019 to 2020, represents new values that were assigned to the evaluation and management (E&M) codes on an RVU basis. The RVU values went up for all of the E&M codes—the Centers for Medicare & Medicaid Services changed the RVU values on the E&M codes in 2021."
AMGA expects compensation and productivity to stabilize in 2022, Horton said. "Overall, we should be able to see more stable metrics—whether it is compensation, compensation per work RVU, or productivity. One of the things we have seen historically is that productivity tends to be relatively flat. We have seen large changes mainly because the coding weights changed. There should be the same underlying visit volume as we get back to pre-pandemic levels. I do not anticipate that there are going to be significant increases in productivity going forward."
Chief medical officers and chief nursing officers recently participated in a HealthLeaders virtual roundtable that focused on healthcare workforce issues.
The CMO/CNO panel at the HealthLeaders Healthcare Workforce of the Future virtual roundtable tackled a range of issues, including worker retention, adjusting care models, and using telehealth to address workforce shortages.
Workforce shortages have become a pressing issue for the clinical operations at health systems, hospitals, and physician practices across the country. The HealthLeaders Healthcare Workforce of the Future virtual roundtable was designed to focus largely on solutions to workforce shortage problems.
Strong leadership is essential to promote worker retention at healthcare organizations, panelists said.
"When you talk about retaining workers, you must have strong leadership in place. We need to develop local leaders and have a good succession plan for top leadership. When you have a good practice environment and clinicians feel empowered to come to work and do their job, that starts at the top of the organization," said Crystal Beckford, MHA, chief nursing officer and vice president of patient care services at Luminis Health's Doctors Community Medical Center in Lanham, Maryland.
"Leadership is crucial. There is a saying, 'People do not leave jobs—they leave managers,'" said Greg Kasper, MD, MBA, vice president of medical affairs-metro region at Toledo, Ohio-based ProMedica.
Employee engagement fosters worker retention, he said. "To succeed in retention, you need to engage the frontline staff. Often times, it is as simple as asking them, 'What do you want? What are you looking for?' Obviously, pay is usually an answer, but that is difficult right now with the financial constraints that healthcare organizations are under. Retention should be more than just pay, and engagement and purpose are very effective keys. Brainstorming solutions in open houses can go a long way to retain staff."
Avoiding rigid schedules is an effective retention strategy, Beckford said. "To retain workers, you must be flexible. Whether it is eight hours, six hours, or four hours, we must have flexibility in our work schedules and flexibility in our programs. If someone only wants to work over the summer, we need to have flexible workforce programs that make that possible. We need to support staff in the way they want to work, so they see your organization as the preferred place to work."
To retain workers, healthcare organizations need to be sensitive to the values of different generations of workers—Baby Boomers, Generation X, and Millennials—said Deana Sievert, DNP, MS, chief nursing officer at The Ohio State University Wexner Medical Center in Columbus, Ohio. "One of my colleagues on the East Coast came up with a great idea—getting a generational mentor. Get a Millennial mentor. Get a Generation X mentor. Talk with them and find out what you could be doing differently to meet the needs of the generations. While core things such as pay are generally the same for generations, you can do little things for each one of the generations and meet them where they are."
Adjusting care models
One way to address workforce shortages in the inpatient setting is to change care models to ease pressure on nursing and physician staffing, panelists said.
"We know we need to be careful with our nurse-to-patient ratios. But one of the things that we have the opportunity to explore is related to infusing some of our other disciplines into the inpatient care teams. For example, we know that in our current practice we have tried hard to increase mobility for our patients. One of the best people for mobility care are our physical therapists and the physical therapy assistants. So, we are looking to change the model not just for nurses and physicians but also looking at other disciplines and infusing them into the inpatient care models," Sievert said.
Adjusting care models can be tied to having clinical staff work at the highest point of their licensure, she said. "When we talk about getting nurses to work at the highest point of their licensure, off-loading some responsibilities to some of our other disciplines is a very good strategy. We haven't always been good at that, and we haven't always been wise at allowing more people into the inpatient space as an every-moment partner. They have been transactional—they come in and they perform their care, then they leave the unit. We have to think differently about how we use other disciplines and incorporate them into our inpatient care team."
In adjusting care models in the inpatient setting, leaders need to adopt unconventional approaches, Beckford said. "We are going to have to think about care models in a way that is totally different from how we have thought about them in the past. The physical therapists are there, the occupational therapists are there, the respiratory therapists are there. But we are experiencing a worker shortage across the board. So, we must look more at roles that do not exist today or have been tried on a smaller scale. For example, we are looking at nurse extenders for documentation—that could definitely save nurses time and a non-nurse could help with that."
Telehealth solutions
Telehealth offers opportunities to address workforce shortages, panelists said.
"We are all struggling with workforce shortages, and in the rural areas it is particularly tough. You cannot recruit physicians to work in rural areas. It is hard to find ICU nurses to work in rural areas. We need to leverage our relationships between rural hospitals and hospitals in urban areas with telehealth. Using telehealth in this way is not limited to physicians. You can do it with nursing and respiratory therapy, for example," Sievert said.
Respiratory therapy is a great example where telehealth can address workforce shortages, Kasper said. "Any time you have that kind of role that requires an experienced, highly skilled individual, you can apply telehealth as a solution. We were looking at respiratory therapy in a remote ICU during COVID surges—with a goal of managing an ICU patient remotely from our tertiary and quaternary referral centers. You need a lot of ancillary skills to evaluate the patient locally, but much of the care can be done remotely. We were using telestroke monitors to remotely and accurately evaluate patients. As long as the patient had appropriate lines and monitors in place, they were able to be managed remotely in many situations."
Telehealth can be a vital workforce resource even in urban areas, said Jeanette Nazarian, MD, vice president of medical affairs and chief medical officer at Howard County General Hospital, which is part of Baltimore-based Johns Hopkins Medicine. "My hospital is in a very populated county close to two large quaternary health systems in Baltimore, and we still struggle to get some of the specialty services. The irony of COVID is, as horrible as the pandemic has been, it forced people to move into virtual realms in ways that we would have never been able to persuade people was acceptable in the past."
Using telehealth has allowed Howard County General Hospital to offer several specialty services, she said. "We have telehealth for ophthalmology. We have telehealth for rheumatology because the rheumatologists do not come to the hospital anymore. The most important area where we are using telehealth because it was a crisis is for pediatric psychiatrists—we did not have any available in the hospital. There are a whole bunch of pediatric psychiatrists at Hopkins, so we started doing virtual visits with the pediatric psychiatrists. We worried that parents would be in an uproar that their kids were not seeing a doctor in person, but they did not care. They just wanted their kid seen."
Telehealth is also cost-effective, Nazarian said. "We have tried to use telehealth in areas where we have low volumes and paying someone to provide that coverage is exorbitant and does not make sense."
The HealthLeaders Exchange is an executive community for sharing ideas, solutions, and insights. Please join the community at this link. To inquire about attending a HealthLeaders Exchange, email us at exchange@healthleadersmedia.com.
At Bon Secours Mercy Health, clinicians serve on Clinical Transformation Committees and Physician Resource Optimization teams.
The supply chain subsidiary of Cincinnati-based Bon Secours Mercy Health has two formal ways for clinicians to participate in the supply chain function.
At health systems and hospitals, supply chain departments play a gatekeeper role in the acquisition of medical devices and supplies, particularly for new products. Physicians and nurses can play formal or informal roles in this decision-making.
At Bon Secours Mercy Health, the supply chain function is administered by a wholly owned subsidiary, Advantus Health Partners. Clinicians from the health system play two formal supply chain roles: Clinical Transformation Committees and Physician Resource Optimization (PRO) teams.
Clinical Transformation Committees
These committees meet to make supply chain decisions for specific specialties, says Jimmy Chung, MD, MBA, chief medical officer of Advantus Health Partners.
"These committees have voting members who are clinicians from each of our hospitals as well as operational leaders such as operating room directors and cath lab directors. These committees make decisions at a group setting at the system or ministry level. This is work that a lot of health systems would like to achieve because at many health systems decisions are made at the hospital level. If you have a health system that has 10 to 20 hospitals, you can imagine 10 to 20 different processes, and supply chain trying to listen to all of them. In terms of strategy, that situation is very difficult," he says.
Clinical Transformation Committee attendees can be as many as 200 people to participate in discussions, but the voting members are generally the key leaders and clinicians from the hospitals, which is usually less than 30 people. "We have created centralized Clinical Transformation Committees at the ministry level that make decisions where there is opportunity for standardization and reduction of unnecessary variation. This brings the best value for our patients," Chung says.
Physician Resource Optimization teams
PRO teams function under the clinical operational leadership at Bon Secours Mercy Health, Chung says.
"The function of the PRO teams is to look at specific initiatives that may be heavily influenced by the way physicians practice. They deal with physician preference items—these items are generally high-priced products such as orthopedic implants. The spend for these items can be in the tens of millions of dollars for an organization our size. The challenge with physician preference items is that there are many vendors in the industry; and with a health system such as ours with 50 hospitals, each hospital and its surgeons all like to do things their way. You end up with 30 or 40 different contracts with different vendors. That leads to a lot of waste, a lot of unnecessary variation, and potential safety issues," he says.
PRO teams, which are relatively new at Bon Secours Mercy Health, are ad hoc groups of clinicians, Chung says. So far, there have been several PRO teams in the cardiac area, there is one PRO team for orthopedic work, and one PRO team created for the spine category. A PRO team is being formed for vascular work. "They are mostly designed to be ad hoc, but they can continue to do initiatives as they come up in the same category or the same specialty," Chung says.
Typically, a PRO team will have eight to 10 physicians, he says. "They are generally meant to reflect each of our hospital markets."
PRO teams can be used to reduce the number of vendors for products such as implants, Chung says. "We may go to a PRO team with a situation in orthopedics where we are working with 40 vendors; but based on our use pattern, market shares, and clinical quality research, we think that we can reduce the number of vendors to five or six. We present this scenario to the PRO team physicians, who analyze the data. If they approve the move, we have a process for that standardization activity. If there are any specific clinical needs that are not met, the PRO team will let us know so that we can then get any outlier products."
Selecting physicians to play supply chain roles
The clinicians who serve on the PRO teams and the Clinical Transformation Committees tend to be physician leaders, Chung says.
"In general, the PRO teams have physicians who can serve as leaders and content experts. These physicians tend to have leadership responsibilities. They can be held accountable for initiatives at their local level. In the Clinical Transformation Committees, we have looked for physician leaders. We look for physicians who may not have the highest volume for a product but are aligned with the direction where we would like to go to provide the highest value to our patients. These physicians tend to be well known in the hospital markets—they are validated by the market chief clinical officers," he says.
Ideally, physicians who work in these supply chain roles have business savvy, but other qualities are also important, Chung says.
"We would love to have all physicians who work with the supply chain to have an understanding of how health systems work and how the business of healthcare works. But we can't ask for that. Every physician does not have those skillsets. We look for physicians who are open-minded and are open to the idea of teamwork. We look for physicians who are engaged and dynamic. We look for physicians who are willing to work with peers to work toward improvement in healthcare quality and value," he says.
Researchers find that 98% of emergency medicine residents are working in urban areas of the country.
Emergency medicine residents are disproportionately located in urban areas of the country, which is contributing to an emergency physician "desert" in rural America, a new research articlesays.
Earlier research on clinically active emergency physicians found that the number of emergency physicians increased by more than 9,000 from 2008 to 2020. However, 92% of emergency physicians were located in urban areas, with only 6% located in large rural areas and 2% located in small rural areas.
The new research article, which was published by Annals of Emergency Medicine, identified emergency medicine residents in the 2020 American Medical Association (AMA) Physician Masterfile and compared 2020 to 2008 data. The researchers also compared the number of Accreditation Council for Graduate Medical Education-accredited emergency medicine residency programs from 2013 versus 2020.
There were nearly 7,000 emergency medicine residents in the 2020 AMA data set. The overwhelming majority of the emergency medicine residents (98%) were located in urban areas, with 6,850 of the clinicians in urban areas, 114 in large rural areas, and 23 in small rural areas.
The number of residency programs increased significantly, from 160 in 2013 to 265 in 2020. However, the new residency programs were disproportionately added in states that already had a high number of programs.
In California, the number of residency programs increased from 14 to 22
In Florida, the number of residency programs increased from 5 to 19
In Michigan, the number of residency programs increased from 11 to 25
In New York, the number of residency programs increased from 21 to 31
In Ohio, the number of residency programs increased from 9 to 18
In Pennsylvania, the number of residency programs increased from 12 to 21
Several, mostly rural, states had no emergency medicine residency programs in 2013 or 2020: Alaska, Hawaii, Idaho, Montana, North Dakota, South Dakota, and Wyoming.
"The number of emergency medicine residency programs has increased; most new programs were added to the states that already had emergency medicine residency programs. There is an emergency physician 'desert' in the rural United States, lacking both residents and residency training programs," the co-authors of the new research article wrote.
Telehealth could help address the shortage of emergency medicine physicians in rural areas, the co-authors wrote. "One potential means of bringing emergency physician care to these rural areas without necessarily bringing the emergency physicians there could be an expansion of telehealth infrastructure and increased uptake of telehealth in the rural areas where emergency physician care is most needed."
Having emergency medicine residents work in rural areas is an attractive option to relying on telehealth, they wrote. "Increased emphasis on and availability of rural rotations for emergency medicine residents could alternatively provide residents exposure to clinical sites not routinely encountered in their training and increase the rate of graduating emergency physician residents relocating to these environments. Ultimately, if we are not increasing the opportunities for residents to practice in rural, more resource-limited environments, it is likely that many will be unprepared for the unique challenges of working in these environments and subsequently more unwilling to take more jobs in rural areas."
