The ICU Survivor Center at Indiana University Health Methodist Hospital has treated about 100 COVID-19 patients who survived ICU-level care.
Indiana University Health is using an ambulatory post-ICU care clinic to treat COVID-19 patients who survived ICU care and are experiencing coronavirus symptoms after hospital discharge.
According to an article published by The BMJ, about 10% of all people who have COVID-19 become so-called long haulers, with symptoms that persist for weeks or months after the acute phase of their illness. The number of long haulers could be much higher among hospitalized COVID-19 patients. In an article published in the Journal of the American Medical Association, 87.4% of hospitalized COVID-19 patients reported the persistence of at least one symptom.
Since June 2020, the ICU Survivor Center at Indiana University Health Methodist Hospital in Indianapolis has treated about 100 COVID-19 patients who survived ICU-level care. The patients are experiencing a range of symptoms, according to Sikandar Khan, DO, medical director at the ICU Survivor Center and a research scientist at the Regenstrief Institute in Indianapolis.
60% of patients have had physical function issues such as muscle weakness or difficulty with balance
44% of patients have had sleep problems
38% of patients have had post-traumatic stress disorder symptoms
Other symptoms include fatigue, headache, anxiety, and depression
"Some are very fatigued even six months after hospital discharge. They may be having headaches. They might be having a lot of difficulty with sleep. So, virtually all of our patients have some complaint in terms of their general well-being and effects on quality of life," Khan says.
ICU Survivor Center care model
The ICU Survivor Center is an interdisciplinary clinic, Khan says.
"The goal of the clinic is to maximize the recovery of critical illness survivors. We know from scientific literature that patients who survive critical illness have symptoms of post-intensive care syndrome, which can be physical function problems, mental health challenges, and cognitive issues such as changes in memory. All of this leads to a quality of life impairment," he says.
The ICU Survivor Center's staff includes pharmacists, pulmonary critical care specialists, chaplains for spiritual support, ICU nurses, social workers, and rehab specialists. The ambulatory clinic also has referral partners such as psychiatrists and neuroscience faculty.
COVID-19 patients receive care similar to that given to other ICU survivors, Khan says. "It is a lot of the same specialties because we see the same burden in patients who have survived critical illness with COVID-19. These patients have fatigue, muscle weakness, muscle pain, headaches, and autonomic nervous system impairments such as palpitations and shortness of breath. These patients see me as well as a few of the specialists who are focused on rehab such as physical rehab and cognitive rehab."
The ICU Survivor Center also is treating COVID-19 patients with telemedicine, he says. "Our first preference is a video visit if a patient wants to have telehealth services. With video, you can really engage with the patient. If patients are not equipped with a camera—either on their phone or their computer—we will do phone visits. With the phone visits, we will usually recommend that they come in for one in-person visit, so we can get a full assessment."
The primary feature of the Moms2B program is a two-hour educational and interventional session held on a weekly basis.
A community-based interdisciplinary intervention program in Ohio has improved pregnancy and infant outcomes in neighborhoods at high risk for infant mortality, a recent research article shows.
The Centers for Disease Control and Prevention (CDC) defines infant mortality as the death of an infant in the first year of life. According to the CDC, the top five causes of infant mortality in 2018 were birth defects, preterm birth and low birth weight, maternal pregnancy complications, sudden infant death syndrome, and injuries such as suffocation.
A co-author of the recent research article who is the founder of the Moms2B community-based interdisciplinary intervention program at The Ohio State University Wexner Medical Center in Columbus told HealthLeaders that infant mortality is a significant problem in the United States.
"It is a critical measure of the health of our neighborhoods, our cities, our states, and our country. We lag way behind the other developed countries in our infant mortality rate. Most concerning is that two-to-three times more Black babies die in the United States as White babies," said Patricia Gabbe, MD. In addition to founding Moms2B, Gabbe is a professor of pediatrics and obstetrics and gynecology at The Ohio State University College of Medicine.
The recent research article, which was published by Maternal and Child Health Journal, features data collected from more than 2,000 primarily non-Hispanic Black women and their infants. There were 675 pregnancies that had been exposed to the Moms2B program and a control group of more than 1,300 pregnancies.
The study includes three key data points:
Pregnancies exposed to Moms2B were less likely to result in a neonate with low birth weight than the control group, 9.45% versus 12.00%, respectively.
Moms2B participants had an infant mortality rate of 0.75%, and the control group had an infant mortality rate of 1.67%
Moms2B participants had a preterm birth rate of 10.9%, and the control group had a preterm birth rate of 12.7%
"The biggest contributor to infant mortality in our Black families is very preterm birth. So, the Moms2B program's emphasis on promoting a healthy pregnancy is designed to get moms to a full-term pregnancy," Gabbe said.
Primary elements of Moms2B
The Moms2B program was launched in 2010, with Gabbe and an infant mental health specialist as the only staff members. "We started with two pregnant women at a church in a high-risk, high-crime neighborhood. In 2019, we had almost 800 moms. Last year, even with the pandemic, we had 629 moms. It is a testimony to how much interest and need there is for this program. We now have a staff of 25," she said.
The current staff includes child development and parenting specialists, community navigators and health workers, dietitians, fatherhood leaders, lactation counselors, nurses, obstetricians, pediatricians, and social workers. Moms2B now has sites in eight Columbus neighborhoods.
The primary feature of the Moms2B program is a two-hour session held on a weekly basis at each Moms2B site. The sessions begin with a "sister-brother circle," Gabbe said. "The men hear the same lessons on breastfeeding, good nutrition, co-parenting, and anger and emotional management. Then, our sessions break up into three groups: a Dads2B group that works with a fatherhood leader, a parenting group for women, and a pregnancy group for women."
Childcare is provided during the two-hour sessions so participating adults can focus on the program.
Gabbe said the two-hour sessions have several educational and interventional elements, including the following:
Nutrition: All moms get a healthy meal during the two-hour session and can take a meal home. As is the case for all lessons, food preparation and nutrition lessons are accompanied by short and colorful handouts. Moms are connected to the federal Supplemental Nutrition Program for Women, Infants, and Children (WIC), as well as food banks. Once a month, Moms2B brings a Mid-Ohio Foodbank truck to its sites, so moms can go home with fresh foods and staples.
Breastfeeding: For infants, breastfeeding is protective. "Our moms initiate breastfeeding in the hospital about 80% of the time. When we started, it was about 50%," Gabbe said.
Safe sleeping: Moms2B models safe sleeping techniques for infants. For example, one interactive exercise consists of placing a crib filled with inappropriate items in the center of the sister-brother circle. The moms and dads are then asked which items should not be in the crib. "In the end, you end up with an empty crib with a baby flat on their back," she said.
Reproductive health: Moms2B provides education about several different methods of birth control. "Our team has developed a game called Repro Bingo, where you call out different methods of birth control and show what is effective and what is not effective," Gabbe said.
Smoking cessation: Moms2B conducts smoking assessments with moms and dads. The organization also has a partnership with a Columbus Public Health program called Baby and Me Tobacco Free. "We do not want our babies to go home where the mom or dad are smoking," she said.
Stress reduction: Moms2B teaches moms stress reduction techniques. "Sometimes, we blow bubbles to reduce stress, and we teach moms how to take deep breaths to relax," Gabbe said.
Return on investment
The Moms2B program has an annual budget of about $1.6 million, with the funding drawn from Medicaid, the Governor's Office of Faith-Based and Community Initiatives, and The Ohio State University Wexner Medical Center, Gabbe said.
"The cost per baby is about $2,000, said Gabbe. "That is a small investment to save a baby and to save a mom. We are focused on achieving equity in health—equity in the population of moms and babies. So, we are making a modest investment given what we are trying to achieve."
Moms2B generates a positive return on investment, she said. "When I do a cost-saving analysis, Moms2B saves money. This investment reduces healthcare costs that have been devoted to infants who are born premature and spend a lot of days in a NICU."
A new automated contact tracing system precisely tracks healthcare workers' movements in hospitals.
In the hospital setting, automated contact tracing is far superior to manual contact tracing, a California-based hospital's chief medical officer says.
Since the beginning of the coronavirus pandemic, the healthcare workforce has been strained by coronavirus infections and workers sent home to quarantine after unsafe exposures to infected patients and colleagues. There have been more than 400,000 cases of COVID-19 among healthcare workers, according to the Centers for Disease Control and Prevention.
Methodist Hospital of Southern California adopted automated contact tracing in November. "With automated contact tracing, which we do with SwipeSense, we can get contact tracing information in about five minutes. It is a total game changer," says Bala Chandrasekhar, MD, CMO of the Arcadia, California facility.
Before the hospital started using automated contact tracing, the manual process took about two weeks and imprecision often resulted in healthcare workers being sent home for testing and isolation unnecessarily, he says.
The manual process had been administered by the hospital's Occupational Health Department. "The problem with the manual process is that it is very time consuming. I had one doctor come to me at the beginning of the pandemic who said, 'I just got contacted from occupational health that I had an exposure two weeks ago. What am I supposed to do?' I said, 'At two weeks, there is not much that you can do.' That was very unsatisfactory," Chandrasekhar says.
The two-week lag period in manual contact tracing could lead to the spread of coronavirus infection, he says. "A healthcare worker could be carrying the virus for a while and be asymptomatic, then expose other healthcare workers, patients, or their family."
And relying on the memory of staff members about exposures to infected patients and coworkers is imprecise, he says.
"With a manual contact tracing process, it is difficult to risk stratify. With COVID-19, the CDC says an unsafe close contact is someone who has had at least a 15-minute exposure within six feet of the infected person over a 24-hour period. The manual process cannot get you that information reliably. So, you might unnecessarily call people and tell them they have been exposed. If it is a healthcare worker, they are out of work in quarantine or isolation. That is a problem because we need healthcare workers during the pandemic—we cannot send a bunch of people home unnecessarily. It creates more of a crisis."
How automated contract tracing works
The SwipeSense technology uses badges to collect data on the movements of healthcare workers in the hospital, Chandrasekhar says.
"It is a radio frequency tag that you wear with your ID tag. The badge tracks where you have gone in the hospital; so, when it comes to contact tracing, we can easily figure it out in a very short period of time. Although data is collected continuously, contact tracing only gets turned on when there has been an unsafe exposure to an infectious disease. So, we are not actively tracking everybody all the time."
The automated contact tracing technology can tell whether a healthcare worker has had an unsafe exposure according to the CDC guidelines, he says. "We have complete information about everybody who has been in contact with an infected person, and we can risk stratify. Anybody who has had only casual contact with an infected patient or healthcare worker does not need to be notified or go into quarantine."
So far, Methodist Hospital of Southern California has used automated contact tracing for 41 patients and 114 healthcare workers.
Among COVID-19 patients hospitalized with severe acute respiratory infection, lung and functional impairments were found in half of them four months after discharge.
Many coronavirus patients hospitalized with severe acute respiratory infection experience significant respiratory, functional, and psychological symptoms four months after hospital discharge, a recent research article found.
Gary Rogg, MD, an attending physician in internal medicine and co-director of the Post-COVID-19 Recovery Program at Westchester Medical Center in Valhalla, New York, says coronavirus "long haulers" can have a range of long-term symptoms. Those symptoms include cough, shortness of breath, anxiety and depression, cardiac issues, constitutional symptoms such as numbness and tingling, deconditioning, and hair loss.
The recent research article, which was published by JAMA Network Open, features data collected from 219 patients at an academic hospital in Northern Italy. The researchers measured lung impairment, functional impairment, and posttraumatic stress symptoms.
Measurement of lung function impairment was based on diffusing lung capacity for carbon monoxide (DLCO). Lung function impairment was considered present if the DLCO level was less than 80% of expected value. Severe lung function impairment was considered present if the DLCO level was less than 60% of expected value.
DLCO was less than 80% of the expected value in 51.6% of patients
DLCO was less than 60% of the expected value in 15.5% of patients
Functional impairment was found in 53.8% of patients
Posttraumatic stress symptoms were found in 17.2% of patients
"We found that a significant proportion of survivors of COVID-19 experienced respiratory or functional impairment four months after hospital discharge, with clinically relevant psychological consequences," the study's co-authors wrote.
Among hospitalized patients with severe acute respiratory infection, coronavirus long haulers are relatively common, the lead author of the study told HealthLeaders.
"In our study, we confirmed that a relevant proportion of patients still complains of COVID-19 symptoms months after the acute phase of their illness. The most frequent symptoms were fatigue and reduced tolerance to exercise," said Mattia Bellan, MD, PhD, Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy.
The severity and duration of COVID-19 symptoms after hospital discharge poses challenges to many patients and requires further research, Bellan said. "These symptoms have an impact on the quality of life of these patients since they often have the perception of being generally unwell. Whether these sequelae will persist over time is a major public health issue that needs to be assessed in the future."
CommonSpirit Health has a large and diverse physician enterprise, with more than 5,800 employed physicians, about 1,100 ambulatory care sites, and 21 value-based organizations.
Large health systems with far-flung physician practices benefit from creating a shared culture and utilizing effective communication strategies, the new physician enterprise leader of CommonSpirit Health says.
The Chicago-based health system has an expansive physician enterprise across 21 states. The organization has more than 5,800 employed physicians, about 1,100 ambulatory care sites, and 21 value-based organizations.
In December, CommonSpirit Health announced that Thomas McGinn, MD, MPH, had joined the organization as system executive vice president of physician enterprise. McGinn is succeeding Bruce Swartz, who retired in November.
Before joining CommonSpirit Health, McGinn served as the deputy physician-in-chief and senior vice president of physician network operations at New Hyde Park, New York–based Northwell Health. While at Northwell Health, he was also the founding chair and a professor at the Department of Medicine at the Zucker School of Medicine at Hofstra/Northwell in Hempstead, New York. Before working at Northwell Health, he was chief of the Division of General Internal Medicine at Mount Sinai Medical Center in New York City.
HealthLeaders recently had a conversation with McGinn about the challenges of managing a large physician enterprise. The following is a lightly edited transcript of that discussion.
HealthLeaders:What is your vision for physician enterprise leadership at CommonSpirit Health?
Thomas McGinn: The fundamental vision is to look at each of our medical groups and communities, then try to come together under one culture and one mission. That mission-driven culture should enhance efficiency and quality.
A first step is standardizing communication across different communities. We put forward our message about who we are, what we are doing, and what are our priorities. You cannot underestimate the importance of well-timed communication that is both supportive and defining.
Then, we have a lot of issues we are looking at across the board on creating standards. For example, quality standards such as blood pressure measurements in Tacoma, versus blood pressure measurements in Houston, versus blood pressure measurements in Fargo. It seems like a basic thing, but how you measure blood pressure and how you collect that data has a standard across our footprints. We have our quality standards that we are setting that people are following. We are benchmarking those standards and have dashboards for them.
We also have operational performance standards that we have created. There are all the basics such as revenue cycle, then we have interesting targets such as virtual health. In virtual health, we went from zero before the pandemic to about 20% of our volume now in virtual care. The standards for virtual care being created across the health system include what percentage of volume should be virtual.
There are also cost standards such as staffing ratios and provider incentives.
HL:What are two of the top goals in your new position?
McGinn: The underlying challenge in each of our communities is the evolution toward an integrated delivery network. Creating an integrated delivery network often comes down to the concept of network integrity. So, we are looking at each of our markets and trying to understand key elements that are missing across the care continuum. One of the biggest challenges in almost every market is the absence of a solid primary care base, which is a common problem among health systems. Most health systems grew out of hospital acquisition, and hospitals tend to have specialists, so there is an inverse proportion of specialty to primary care.
Virtual care is another top goal. We want to maintain the volume of our virtual care and to evolve virtual care into each type of specialty. We need to figure out how to use virtual care in specialties such as pediatrics, surgery, and rehab.
HL: How do you promote value-based care in an integrated delivery network?
McGinn: We need to go into each market and look at it through the lens of how our delivery network is doing rather than how our hospitals are doing. It is an evolutionary process, and each market is in a different stage of evolution in creating an integrated delivery network. You do not have to own everything in every market. You can develop partnerships in areas such as primary care and nursing homes, but partnerships need to be strategic and you need to monitor all of the pieces to make sure they are working.
I use the term ecosystem. Each patient lives in a healthcare ecosystem, and it is usually three or four ZIP codes. You want to know all the pieces in that ecosystem; and you want to pay attention to them, so you know how patients are navigating their healthcare ecosystem. Whether you own all of the pieces of the ecosystem or not, you want to understand how it works.
HL: What are the keys to building and strengthening provider networks?
McGinn: There are a lot of different pieces that go into this puzzle. One major piece is building a culture that people feel they belong to. Another major piece is interconnectivity and having the IT infrastructure so that referrals can happen in a seamless way, which can be a challenge when you have medical groups with different electronic medical records. It can take hard labor to fix IT infrastructure issues.
You need to have people who work to connect clinicians. You need to have people who are physically visiting doctors' offices—even doing social events or virtual events. There are a lot of different tactics that you have to use to bring doctors together to enhance network integrity.
Equity has been a longstanding issue in U.S. healthcare, but the coronavirus pandemic has heightened concern by exposing glaring disparity problems. In particular, African American and Hispanic people have experienced a disproportionate burden of illness and mortality during the pandemic.
Disparity is a major issue in sepsis care and outcomes, the president and CEO of the Sepsis Alliance recently told HealthLeaders.
"Sepsis is a huge burden on everyone. It is the No. 1 cause of death in hospitals. It is the No. 1 cost of hospitalization. It is the No. 1 cause of readmission to hospitals. Sepsis is a huge public health crisis. Then you magnify this crisis on certain minority communities, and you have something that is really dire," said Thomas Heymann, MBA.
The Sepsis Alliance has created a Sepsis and Health Equity Fact Sheet that highlights many racial, ethnic, and socioeconomic disparities related to sepsis. The fact sheet includes the following sepsis disparities:
Black and other nonwhite people have nearly twice the incidence of sepsis as whites
Non-Hispanic black children admitted to an emergency room are less likely to be treated for sepsis than non-Hispanic white children
Native Hawaiians have almost twice the burden of sepsis mortality compared to whites
Black children are 30% more likely than white children to develop sepsis after surgery
Children with severe sepsis or septic shock who are black or Hispanic are about 25% more likely to die than non-Hispanic white children
Adults below the poverty line have more than three to four times the risk of dying of sepsis compared to adults whose family income is at least five times the poverty line
"We understand equity as a systemic problem, so we cannot do a scatter-shot approach, which is what we had been doing in being more reactive than proactive in this area. Seeing the COVID-19 disparity data really brought it home to us. We got some funding to conduct a sepsis inequity literature review, and we saw startling differences in access, care, and outcomes," Heymann said.
Sepsis Alliance pledge
The San Diego-based organization adopted the following pledge last month: "Sepsis Alliance is committed to fostering equity, diversity, and inclusion (EDI) in our work and in the sepsis care community."
The Sepsis Alliance also adopted a three-point EDI plan.
1.Expand public education and provider training to close racial and ethnic gaps in sepsis awareness and ensure culturally responsive sepsis care: Goals for this part of the EDI plan include adding at least five new subject matter experts from communities of color to the organization's roster of presenters annually and providing implicit bias instruction in Sepsis Alliance Institute courses.
2.Pursue advocacy initiatives that further EDI goals and act as an EDI leader in healthcare: Goals for this part of the EDI plan include creating an industry EDI pledge by spring 2021 and creating an industry EDI reporting platform by spring 2021.
3. Boost diversity within the Sepsis Alliance to better reflect the communities that the organization serves: Goals for this part of the EDI plan include incorporating EDI into the Sepsis Alliance charter and conducting annual EDI training for the Sepsis Alliance's staff, board of directors, and advisory board.
Understanding and addressing sepsis disparities
Several factors are driving sepsis disparities, Sandy Cayo, DNP, vice president of clinical performance and transformation at the New Jersey Hospital Association and a member of the Sepsis Alliance Equity, Diversity, and Inclusion Steering Committee told HealthLeaders.
There is relatively less awareness about sepsis in minority populations compared to white Americans. In the Sepsis Alliance's most recent annual survey on sepsis awareness, only 5% of black respondents could identify the four most common sepsis symptoms and 18% of white respondents could identify the symptoms.
There is a higher incidence and severity of underlying health factors among minority populations. African Americans and Hispanics often have more comorbid conditions including diabetes, hypertension, and respiratory problems such as chronic obstructive pulmonary disease.
There are also "overlaying factors" such as lack of insurance and mistrust of providers that cause people of color to either not seek treatment soon enough or not get the proper treatment when they present to a healthcare provider with signs and symptoms of sepsis.
"There have been studies that show that when people of color show up in emergency rooms, providers may not listen to them in the same way they might listen to their white counterparts. So, they may not be believed," she said.
To address sepsis disparities, healthcare providers need to elevate their awareness of equity issues and bias, Cayo said. "We need to put a lens of equity on how we approach care. We need to look at whether there is bias inserted and whether we could have eliminated it or addressed it."
Healthcare providers also need to communicate openly and regularly about equity and bias, she said. "It is important that we start talking about equity and bias. We are talking about it more than ever this year. We need to have these conversations upfront—it cannot be just for diversity and inclusion officers. All clinicians need to have equity and bias awareness as a priority in their approach to care."
Transitioning services to telemedicine and federal assistance through the Paycheck Protection Program were pivotal for primary care practices in 2020.
Primary care physicians (PCPs) have endured daunting challenges during the coronavirus pandemic, but a combination of business savvy and external support has helped many of them to keep serving patients, a new report says.
Particularly in the early phase of the pandemic last spring, primary care practices experienced dramatic reductions in patient volume as patients avoided medical offices due to fear of coronavirus infection. Two Florida-based practices interviewed for the new report experienced deep reductions in patient volume during the early weeks of the pandemic, with one practice reporting a 60% decrease and the other practice reporting a 75% decrease.
The new report, which was published by the Urban Institute with funding from the Robert Wood Johnson Foundation, is based on a review of published data that documents PCP pandemic experiences and interviews with 16 PCPs. The size of the physician practices that were interviewed ranged from a solo practitioner to a practice that employs 370 physicians. The practices operated in 10 states: California, Florida, Georgia, Massachusetts, Michigan, Missouri, New Jersey, North Carolina, Texas, and Virginia.
PCPs have faced major challenges during the pandemic, the report says. "The PCPs we interviewed provide a window on how the COVID-19 pandemic has challenged our already-fragile system of primary care. These have included threats to their financial viability, particularly for smaller, independent PCP practices, and difficulties delivering quality care while ensuring safety for their patients, clinicians, and staff."
However, the PCPs interviewed for the report found ways to overcome their difficulties. "These PCPs have proven to be capable and nimble business owners, quickly shifting to new modes of care delivery. They have also taken advantage of government and community support to sustain their ability to serve their patients," the report says.
But perseverance has come with a considerable negative consequence. "These efforts have taken their toll, and many report a significant level of burnout that could have long-term implications for our nation's system of primary care," the report says.
Struggle for survival
Most PCPs reported severe financial pressure in the early phase of the pandemic.
In addition to the financial hit from reductions in patient volume, several PCPs discontinued offering "non-essential" services such as physicals to reduce potential coronavirus exposure for patients and staff. Discontinuation of these services was a drain on revenue. "Most PCP respondents reported dramatically reduced revenue in the early phases of the pandemic. For example, a Massachusetts doctor reported that his practice experienced a 40% decline in revenue," the report says.
PCPs also reported significant difficulty in securing adequate personal protective equipment (PPE) during the pandemic. "Most reported that acquiring necessary PPE has been difficult, if not impossible, at multiple points during the pandemic. This was particularly true for the smaller practices, which must compete with large health systems and hospitals for supplies," the report says.
Acquiring PPE contributed to higher costs during the pandemic, PCPs reported.
The financial woes required many PCPs to cut costs, the report says. "Several PCPs reported that they reduced their own salaries, imposed staff furloughs, pay cuts, or implemented a combination of these tactics."
Transition to telemedicine
Nearly every PCP interviewed for the report had shifted a significant level of services to telehealth, which not only increased safety during the pandemic but also boosted revenue. "A Missouri doctor told us that, without telehealth, they would be under 50% capacity. The practices also reported that purchasing the necessary technology and engaging with telehealth vendors was relatively affordable," the report says.
Reimbursement rules have been favorable for telehealth during the pandemic. During the public health emergency, Medicare is reimbursing telehealth visits at the same level as in-person visits. "Several PCPs practiced in states that require private insurers to do the same," the report says.
External support
Federal assistance and community support has helped PCPs stay in business, the report says.
The most consequential external support reported was the Paycheck Protection Program (PPP) established through the Coronavirus Aid, Relief, and Economic Security (CARES) Act. PPP funding was more helpful to primary care practices than the Provider Relief Fund (PRF), which allocated $175 billion to compensate providers for decreased revenue or treatment costs associated with the pandemic, the report says.
"Recipients of PPP loans who used the funds for payroll, business mortgage interest payments, rent, or utilities can request loan forgiveness, relieving them of any obligation to pay back the funds. Of the PRF funds, the federal government distributed a large portion automatically to providers who participate in Medicare, based on their total net patient revenue. This resulted in large hospitals and health systems receiving the bulk of the money; small PCP practices have received a relatively small proportion of these funds."
While not as significant as the PPP funding, communities also helped primary care practices, the report says. "Many practices reported that they had received donations from local residents, foundations, and non-profits. Some donated PPE and provided financial assistance. One doctor reported that patients were making them masks."
Primary care practice forecast
Reimbursement looms large for primary care practices in the second year of the pandemic, the lead author of the study told HealthLeaders.
"Many practices continue to rely on telemedicine for a significant portion of services, so continued adequate reimbursement will be important. Over the longer term, some practices may be more willing to enter into capitated arrangements with payers, in which they agree to treat patients for a pre-set amount each month, regardless of the number of services delivered," said Sabrina Corlette, JD, research professor, founder, and co-director of the Center on Health Insurance Reforms at Georgetown University's McCourt School of Public Policy.
After the coronavirus crisis has passed, Corlette predicted there will be three dominant trends at primary care practices. "I suspect the trend toward consolidation and acquisition will continue, more practices will be open to taking on capitated forms of payments, and the delivery of services via telemedicine will be here to stay."
At Cedars-Sinai, a volunteer team of experienced physicians is placing central and arterial lines in COVID-19 ICUs.
A volunteer "COVID Line Team" at a Los Angeles–based medical center has boosted the efficiency of placing central and arterial lines in COVID-19 ICUs and taken pressure off busy critical care teams.
During coronavirus patient surges, hospital ICUs often become inundated with severely ill patients. The COVID Line Team at Cedars-Sinai Medical Center has increased the efficiency of placing central and arterial lines in coronavirus patients and freed up precious time for the dedicated ICU clinical staffs.
The COVID Line Team was formed in March 2020 during the first coronavirus patient surge in Los Angeles, says the team's leader, Evan Zahn, MD, director of the Guerin Family Congenital Heart Program at Cedars-Sinai's Smidt Heart Institute.
"I sent out emails to departments where I thought the expertise was located. We had a remarkable response. We got several physicians from anesthesia, who are obviously good at placing lines. We got pediatric intensivists. We have a wonderful procedural center here, and those clinicians are super talented and have participated in a big way," he says.
With elective procedures on hold during the first coronavirus patient surge, Zahn was able to recruit nearly 20 physicians to work on the COVID Line Team, and they were able to place lines in COVID-19 ICUs around the clock. "We had anesthesiologists with tremendous skill not practicing. I was not scheduling elective cases with babies. We had the time to provide a 24/7 service, and we were heavily utilized," Zahn says.
The COVID Line Team has generated several advantages, he says.
With experts who are efficient at placing lines, there are quicker procedure times. "The bedside nurses tell us that when they have a line that is challenging, it can take an hour or hours for an ICU clinician to get the line in. For the COVID Line Team, it is very unusual for any line to take more than 10 or 15 minutes," Zahn says.
The speedy procedures free up time for ICU nurses. "They are standing there assisting us in placing lines for only a few minutes, so they can get back to taking care of patients," he says.
The COVID Line Team reduces the exposure of ICU clinicians to the coronavirus. "When we walk into an isolation room, we protect the junior house staff and junior physicians from coronavirus exposure. Similarly, the ICU medical team does not have to do the donning and doffing of personal protective equipment to perform the procedure. They can be figuring out a strategy to care for the patient rather than doing the mundane tasks of putting in these lines," Zahn says.
The COVID Line Team has been able to keep complications minimal. "We are a highly trained, highly experienced group that has been doing these procedures for many years. These are patients who are quite ill, and they cannot afford to have line complications. Our line complication rate has been almost nonexistent because we have such an experienced group of operators," he says.
Practice makes perfect
Utilizing the medical center's simulation center was one of the keys to success for the COVID Line Team, Zahn says.
"We did not just show up as a line team. Before we started placing lines in the ICU, we spent several days in our simulation center, which was set up to look exactly like an ICU. We worked out exactly where each piece of equipment would go and exactly how we would go into the isolation room. As with all technical things, the more planning you do, the more efficient you are," he says.
The simulation work has eased the process of adding new members to the COVID Line Team, Zahn says. "Once we had our simulation set, we created instructional videos and virtual reality for COVID lines that we could use to train our new members quickly. They could do the simulation work, watch a couple of procedures, and be ready to go."
The simulation center was also pivotal in training the COVID Line Team how to operate with cumbersome personal protective equipment, he says. "Walking around with the kind of PPE we wear to do these procedures is not a normal thing, and none of us were really experienced in that part of this work. The simulation center was invaluable. The line part was easy for us. But how you do this work and stay safe and keep the nurse safe and minimize your time in the room while maximizing your efficiency can all be achieved through simulation."
Logistics and supply chain
Robert Wong, MD, a pediatric cardiac anesthesiologist, has led the logistical effort to keep the COVID Line Team well organized, Zahn says.
"He puts out a monthly schedule for the COVID Line Team physicians. Through some of his technicians, he organizes all of the supplies, so we have all of the lines and the accessories you need to get them in. Robert has organized a supply chain, so that whenever we go to a COVID ICU, all of the supplies are readily available."
COVID Line Team metrics
The COVID Line Team has been tracking a limited set of metrics to assess quality of care and staffing issues, Zahn says. "We did not set out to do this as an academic exercise. It was much more a call to arms, and we followed very simple quality metrics that we felt were important to track."
Weekly quality meetings generated a data-driven gain early in the program, he says. "One of the things we noticed early on was that we were losing arterial lines due to thrombosis, and this was before it was widely known that these patients were hyper thrombotic. Through quality improvement, we were able to quickly heparinize lines to prevent them from clotting."
Zahn has been tracking operators, time spent in isolation rooms, and how many lines a clinician does. "I was basically asking people to stand in harm's way. I felt the responsibility of protecting the people who were risking exposure to the coronavirus, and it was important to me that nobody got over-exposed and subsequently ill. The proof is in the pudding—no one got hospital-acquired COVID on our team."
They also have been tracking utilization of central, venous, arterial, and dialysis catheters. "We noticed at a certain point that there was a marked increase in dialysis catheters, which signified that the degree of illness that we were seeing was increasing with renal failure, and we discussed this with the ICU team," he says.
Other metrics are related to staffing and physician performance, Zahn says. "We look at percentage of lines placed on weekdays versus weekends so we can meet our staffing needs. We look at the number of lines placed by junior physicians versus senior physicians to see if there is a difference in outcomes."
Many patients from socially vulnerable communities lack essential resources to achieve optimal surgical outcomes, researcher says.
Cancer surgery patients who live in socially vulnerable communities have a higher likelihood of adverse outcomes than other patients, a recent research article says.
Social determinants of health are widely recognized as a key component of healthcare inequities. "Social determinants of health such as poverty, unequal access to healthcare, lack of education, stigma, and racism are underlying, contributing factors of health inequities," the Centers for Disease Control and Prevention (CDC) says.
The recent research article, which was published by the Journal of the American College of Surgeons, is based on data collected from more than 200,000 cancer surgery patients.
The study evaluated the relationship between "textbook outcomes" and social vulnerability, which was measured using the CDC's Social Vulnerability Index (SVI). A textbook outcome was defined as the absence of complications, extended length of stay, readmission, and mortality. The SVI features 15 variables drawn from U.S. Census data, including poverty, vehicle access, and the quality of housing.
The study includes three key data points.
Patients with a high SVI ranking were more likely to experience complications than patients with a low SVI ranking: 24.0% of high-SVI patients experienced complications vs. 21.5% of low-SVI patients.
Patients with a high SVI ranking were more likely to experience 90-day mortality than patients with a low SVI ranking: 8.4% of high-SVI patients experienced 90-day mortality vs. 7.0% of low-SVI patients.
Race was also associated with adverse outcomes. White patients with a high SVI ranking had 10% lower odds of having textbook outcomes. Non-white patients with a high SVI ranking had 22% lower odds of having textbook outcomes.
"Collectively, the data strongly suggested that cancer patients from areas characterized by high social vulnerability were at higher risk of adverse postoperative outcomes independent of other measured variables," the study's co-authors wrote.
Interpreting and assessing the data
The corresponding author of the study told HealthLeaders the data features three findings.
"First, we found that patients who were black or Hispanic were disproportionately represented in high socially vulnerable communities. Second, even if you did not look at race and ethnicity, if you resided in a community that was very vulnerable, then you had a very much higher risk of having worse outcomes postoperatively. Third, if you happened to be a minority and living in a socially vulnerable neighborhood, it had an additive effect. So, those patients were in double jeopardy for having lower odds for an optimal outcome after surgery," said Timothy Pawlik, MD, PhD, MPH, surgeon-in-chief at The Ohio State University Wexner Medical Center, and chair at the Department of Surgery, The Ohio State University College of Medicine, Columbus, Ohio.
Patients with a high SVI ranking lack critical resources to lower the odds of adverse surgical outcomes, he said.
"The SVI is basically reflective of how rich the resources are in a community. If you have bad transportation, it is hard for you to get to your clinic appointment or to get to the hospital in a timely manner. If you have substandard housing, it is going to make it much more challenging after you get discharged from a complex operation to have as good a recovery compared to a patient who is discharged home to a much more affluent setting that has many more resources. For socioeconomic status, if you are discharged home into a community that is more economically deprived, it is more difficult to get the resources that you need such as food, transportation, and assistance to recover from your surgery."
Impact of race on outcomes
The study's data reflect systemic racial inequalities in the country, Pawlik said.
"We know that patients who are black or Hispanic have worse healthcare outcomes than their white counterparts, even after you control for insurance status and disease stage. The data that we present in this paper shows that even if you control for social vulnerability, black and Hispanic patients still did worse. If black and Hispanic patients are also in a socially deprived or vulnerable neighborhood, it is even more difficult for them to overcome barriers."
Addressing social vulnerability
Physicians and hospitals can take actions to address social vulnerability at the patient level, Pawlik said.
"There are good screening tools that are available to do this work. If we can identify that a patient comes from a socially vulnerable community or environment, then we can mobilize resources in the hospital such as social work, patient care managers, and patient navigators to interact with patients to get them the resources that they may need around housing, food insecurity, and transportation."
At the community level, healthcare organizations need to support efforts to build healthy neighborhoods, he said. "We need to look beyond the doors of our hospital and begin to look at systematic change in the environments in which our patients live. We need to create healthy communities because that will ultimately help us achieve better outcomes in perioperative care."
AMGA president and CEO calls on Congress to act on several of the organization's priorities, including coronavirus vaccination and promotion of telemedicine.
In a letter this week to U.S. House of Representatives Speaker Nancy Pelosi, the leader of the AMGA presents the organization's eight priorities for 2021.
The AMGA, formerly known as the American Medical Group Association, represents more than 440 multispecialty medical groups, hospitals, and health systems nationwide. About 175,000 physicians work at AMGA member organizations.
AMGA members have been pivotal players in the country's response to the coronavirus pandemic, wrote AMGA President and CEO Jerry Penso, MD, MBA. "Our medical groups and integrated systems have been on the frontlines of this public health emergency from the beginning and have navigated the new normal to continue providing high-quality, cost-effective, and patient-centered medical care."
In his letter to Pelosi, Penso highlighted eight AMGA priorities for 2021:
1. COVID-19 vaccination
Multispecialty medical group practices are on the frontline of the pandemic and should be involved in coronavirus vaccination efforts, Penso wrote. Practices bring several strengths to the task, he wrote.
Practices have existing relationships with patients, which can facilitate vaccinations
Practices have structures and processes in place to administer vaccines
With the two vaccines approved so far requiring two doses, practices are well-suited to use existing relationships with patients to schedule, manage, and document the process of administering two shots
AMGA members should play an important role in distributing coronavirus vaccines, Penso wrote.
"Our members have the storage and staffing requirements necessary for the vaccine, but to ensure operational success, medical groups should be notified three to four weeks in advance of the number of doses they will receive. With a dedicated supply of vaccine and support, including the necessary financial support for staff, tents, and the other logistical needs to manage vaccine operations, medical groups are well positioned to quickly help vaccinate as many patients as possible."
2. Funding healthcare provider relief during the pandemic
Penso acknowledged the financial support Congress has already provided to healthcare providers through the Public Health and Social Services Emergency Fund (Provider Relief Fund) and called for more funding.
"AMGA recommends at least an additional $100 billion in new appropriations to the Provider Relief Fund during this upcoming legislative session. The increase in the number of cases, the need to cancel elective procedures, influenza season, and the current winter months create a confluence of conditions that will strain healthcare systems' ability to respond to this national crisis," he wrote.
In addition, Penso called for legislation that would make Provider Relief Fund money tax-free for for-profit healthcare provider organizations. "All providers, regardless of tax status, should receive the maximum amount of support from the Provider Relief Fund since it is intended to ensure the viability of our healthcare system."
3. Bolstering telehealth
Telemedicine growth has been one of the positive developments of the pandemic, and Congress should promote telehealth, Penso wrote. "Not only does telehealth increase access to care, it also leads to improved spending efficiency in the healthcare system."
Congress and the Centers for Medicare and Medicaid Services should take several actions to bolster telemedicine during and after the pandemic, he wrote.
Payment parity between telehealth visits (including audio-only services) and in-person visits should be ensured
Congress should approve the Temporary Reciprocity to Ensure Access to Treatment (TREAT) Act, which provides state reciprocity in healthcare professional licensing to allow them to practice across state lines during the pandemic
4. Care for chronic illness
Penso called for reforming the chronic care management (CCM) code in the Medicare Physician Fee Schedule, which reimburses clinicians for non-face-to-face care management.
"Medicare beneficiaries are subject to a 20% coinsurance requirement to receive the service. Consequently, only 684,000 patients out of 35 million eligible Medicare beneficiaries with two or more chronic conditions benefitted from CCM services over the first two years of the payment policy. Removing the coinsurance payment would facilitate more comprehensive management of chronic care conditions and improve the health of Medicare patients," he wrote.
5. Medicare sequestration cuts
Penso called on Congress to continue to spare healthcare providers Medicare sequester cuts. "Congress temporarily halted the Medicare sequester cuts through March 31, 2021. Given that COVID-19 relief and recovery efforts will go on throughout this year, Congress should approve the Medicare Sequestration COVID Moratorium Act, which would continue to halt Medicare sequester cuts until the end of the public health emergency," he wrote.
6. Closing coverage gaps in the Affordable Care Act
The Affordable Care Act should be improved to provide affordable healthcare coverage to more Americans, Penso wrote. "The COVID-19 pandemic exposed certain gaps in health insurance coverage that must be addressed in order to ensure that Americans have increased affordability and coverage. Congress must take additional actions to strengthen the Affordable Care Act by expanding subsidies, extending enrollment periods, and creating caps on premium contributions."
7. Increasing provider access to data
Congress should pass legislation that would give healthcare providers access to commercial payers' administrative claims data, Penso wrote.
"Having access to claims data plays a critical role in patient care coordination. … Not only does access to commercial claims data help providers deliver better care, but it additionally empowers the patient. Patient access to health data will only lead to better conversations with their providers and subsequently to better health outcomes. Access to data also ensures more accountability between the provider and the payer regarding a patient's care."
8. Advancing health equity
To promote health equity, Congress should act to reduce barriers to accessing medical care and social services, Penso wrote.
"It is important that Congress create legislative frameworks that address the underlying causes of inequality in the healthcare system. To that end, we support the passage of the Social Determinants Accelerator Act introduced last Congress. The legislation provides grants to assist communities with evidence-based approaches to coordinate health and social services, a key element to increasing health equity in underserved communities."
