The Teletherapist Network is member-driven and emphasizes quality over quantity.
A private online network for therapists is designed to provide professional and social support as the field transitions to teletherapy during the coronavirus pandemic and beyond.
Mental health conditions have been among the top diagnoses treated through telemedicine since the beginning of the pandemic in March 2020. In August 2020, mental health conditions accounted for 48.93% of all telehealth diagnoses, according to claims data tracked by FAIR Health.
The Teletherapist Network was launched in July 2020 with 100 members and currently has about 120 members. Once the roster hits 200 members, a wait list will be implemented. The membership fee for the network is $24.99 every two weeks.
The goal of the Teletherapist Network is to create a vibrant, socially engaged, and knowledgeable community of therapists, the network's founder told HealthLeaders.
"I created the network as a way for clinicians to join and develop relationships with each other. I wanted us to get to know each other's clinical strengths and weaknesses, then take advantage of the community aspect and collective knowledge of a private group that interacts on a personal and professional level," says Kathryn Esquer, PsyD, MBA, MA, a clinical psychologist at Family Practice Center, PC, in Selinsgrove, Pennsylvania.
The pandemic spurred creation of the network, she says.
"In March 2020, we had to switch to telehealth, which became a primary way to get healthcare, including mental healthcare. I struggled to find a quality group of peers from whom I could get information and best practices from. I found a lot of Facebook groups that were semi-private. There was a lot of information there but not quality connections or a high degree of trust in the information that was being shared. I wanted to make sure that we had quality connections, not just another large forum with impersonal posts," Esquer says.
The Teletherapist Network is well-suited to help therapists deal with the upheavals associated with the pandemic and other events over the past year, she says. "We as mental health providers have helped our clients through a pandemic shutdown with isolation, through political unrest, and through a social justice movement while experiencing these events ourselves. It's a very tricky situation, and it is something we have never seen before in our field. We are going through events with our clients on a large-scale level."
The network's tightly knit community enables peers to guide each other through the professional challenges of tumultuous times, Esquer says. "In therapy, it is important to recognize what we as therapists bring into a therapy session. The only way to do that is to look inward and to seek consultation with our peers—to seek trusted licensed clinicians who can help us see where we might be biased or where we may be missing things with our clients. The more personal perspectives we bring into a therapy session, the more pitfalls we could have."
Teletherapist Network offerings
The network allows members to connect professionally and personally in a range of ways, Esquer says. "Over the past year, there has been a need for community among therapists, with social support, mental health support, and clinical support. None of us have experienced a mass transition to telehealth all at once. So, the group power and support on the network has been tremendous."
Daily discussions: In a post forum, members have daily discussions about personal challenges and developments in the field of mental health. "We talk about what we are struggling with in the moment in our own mental health. We offer personal and professional support. The daily discussions on professional topics can range from favorite HIPAA-compliant email platforms to addressing political topics during a therapy session when the client's views do not match your own views," she says.
Social hours: Twice per week, members gather virtually to connect on a personal level or to discuss professional issues.
Crowdsourcing: In an example of the network's emphasis on quality over quantity, members routinely share their exposure to new research articles and clinical information such as best practices generated at professional societies. "Instead of having one person having to stay up to date on the best practices coming out from all of the different research areas, we are crowdsourcing and sharing information with each other," Esquer says.
Live events: Twice a month, members gather virtually for two kinds of member-driven live events. A live consultation event features an unstructured discussion, where members can talk about client cases in a private and confidential manner. The other member-driven live event is a "rumble," where members discuss and debate a controversial issue in mental healthcare.
Outside speakers: At least once a month, the network hosts a virtual event featuring experts from inside the therapy field as well as experts associated with operational aspects of therapy practices. So far speakers have included clinical directors discussing therapy best practices, accountants addressing therapy practice tax considerations, and lawyers presenting information on contracts.
Teletherapy best practices
Besides discussing the Teletherapist Network, Esquer tells HealthLeaders about four best practices to determine whether a client is a good candidate for teletherapy. They follow below:
1. Client preference: A client should be asked whether he or she wants teletherapy as opposed to in-person sessions, and teletherapy should never be forced on a client. If you only offer teletherapy, you should have referrals ready for clients.
2. Technology considerations: Therapists should find out whether a client has the infrastructure to conduct teletherapy sessions such as a reliable Internet connection and access to a computer or smartphone. The client's ability to use electronic devices and to navigate the online platform should also be assessed.
3. Telecommuting location: The client should have a private and confidential space to conduct a teletherapy session. Ideally, the client should have a room where the door can be closed, so they can feel confident that what they say is private and confidential.
4. Clinical presentation: Teletherapy is not appropriate for some mental health conditions. "Teletherapy can help treatment progress, or teletherapy can be a barrier to treatment progress. For example, clients with agoraphobia who are afraid to leave their home may be contraindicated for teletherapy—you might be enabling them to not leave the home," Esquer says.
Health systems can use data from the new study to target medical conditions and specialties that had the highest rates of deferred care.
Telemedicine utilization by condition and medical specialty during the early phase of the coronavirus pandemic sheds light on deferred care, a new research article shows.
At the beginning of the pandemic, use of telemedicine surged as many clinicians turned to the technology to continue to see patients in a safe manner. Despite the uptick in telemedicine use, overall medical visits dropped substantially, which raises concern about deferred care, the new research article says.
The study, which was published today by Health Affairs, is based on data collected from 16.7 million Medicare Advantage and commercial insurance beneficiaries.
The researchers examined data for in-person and telemedicine outpatient care from Jan. 1, 2020, to June 16, 2020. Jan. 1 to March 17 was designated as the "pre-COVID-19 period" and March 18 to June 16 was designated as the "COVID-19 period."
The study generated several key data points:
30.1% of total outpatient visits were provided through telemedicine during the COVID-19 period, which amounted to a 23-fold increase in telemedicine use over the pre-COVID-19 period
Despite the increase in telemedicine visits during the COVID-19 period, overall outpatient visit volume fell 35.0%
During the COVID-19 period, at least half of clinicians in six specialties used telemedicine at least once: endocrinologists (67.7%), gastroenterologists (57.0%), neurologists (56.3%), pain management physicians (50.6%), psychiatrists (50.2%), and cardiologists (50.0%)
During the COVID-19 period, specialties that generally require in-person visits provided at least one telemedicine visit at a relatively low level, including orthopedic surgeons (20.7%), ophthalmologists (9.3%), physical therapists (6.6%), and optometrists (3.3%)
Specialties that conducted a larger percentage of total visits via telemedicine in the COVID-19 period had a smaller decrease in total visits per week from the pre-COVID-19 period to the COVID-19 period. During the COVID-19 period, five specialties conducted about half of total visits through telemedicine: psychiatry (56.8%), gastroenterology (54.5%), endocrinology (53.1%), social work (50.8%), psychology (49.1%), and neurology (47.9%).
On average, conditions for which a larger percentage of total visits were conducted through telemedicine in the COVID-19 period had a smaller decrease in total visits per week from the pre-COVID-19 period to the COVID-19 period. Conditions with the highest percentage of total visits provided through telemedicine in the COVID-19 period included mental illnesses such as bipolar disorder (55.0%), anxiety (53.9%), and depression (52.6%). For these conditions, total visits per week fell 11% or less from the pre-COVID-19 period to the COVID-19 period.
Some common chronic conditions had relatively low use of telemedicine and significant drops in total visit volume. For hypertension, 38.1% of visits were conducted through telemedicine and total visits fell 23.0%. For diabetes without complication, 33.9% of visits were conducted through telemedicine and total visits fell 30.6%.
There was low use of telemedicine visits for eye conditions, which was associated with large drops in total visits. For cataracts, 1.2% of visits were conducted through telemedicine and total visits fell 61.2%. For glaucoma, 2.6% of visits were conducted through telemedicine and total visits fell 52.2%.
Healthcare providers could use the research article's findings to target areas with the highest rates of deferred care, the study's co-authors wrote.
"Health systems could allocate resources to patient outreach efforts such as telephone calls or reminder messages, prioritizing patients whose conditions saw the largest drop in visit volume. Furthermore, additional clinical capacity could be allocated to specialties with the largest backlogs of deferred care. Finally, health systems could prioritize chronic illness populations, who were more likely to have deferred care, for targeted population management," they wrote.
Interpreting the data
The data indicates that several specialties stand out for deferred care during the coronavirus pandemic, study co-author Michael Barnett, MD, MS, told HealthLeaders.
"Ophthalmology definitely seems to be the hardest hit. There are plenty of chronic eye conditions that require regular checkups, including glaucoma and many retinal diseases. Other specialties with the largest backlog of deferred care include otolaryngology and dermatology," said Barnett, an assistant professor in the Department of Health Policy and Management at Harvard T.H. Chan School of Public Health in Boston.
During the early phase of the pandemic, specialties with the least telemedicine engagement such as optometrists, physical therapists, and ophthalmologists appear to have been ill-suited for the switch to telehealth, he said. "Our hypothesis is that these specialties rely heavily on in-person contact and may also have had the least infrastructure and cultural preparedness to transition to telemedicine among all specialties."
The relatively low use of telemedicine for common chronic conditions such as hypertension and diabetes without complication along with a significant decline in total visit volume for these conditions raises alarm, Barnett said.
"It is concerning, especially because we worry that the most disadvantaged populations are probably the ones with the most deferred care and highest need to maintain continuity of care. We do not have data yet to know about the magnitude of deferred care that may have led to worsening chronic illness control, but we think it is a very important public health concern to monitor."
The MGMA's leader says physician practices should be on the frontline of COVID-19 vaccination.
Many of the country's physician practices have been left out of the coronavirus vaccination effort, a new survey indicates.
Although the development of coronavirus vaccines has proceeded more rapidly than most public health experts predicted at the beginning of the pandemic last spring, vaccination efforts have been relatively slow in many states. For example, California is recasting the administration of vaccine after an inefficient rollout.
The new survey, which was released this week by the Medical Group Management Association (MGMA), is based on data collected from Jan. 21 to Jan. 24. The data was collected from 400 medical practices that are already vaccinating patients or are planning to vaccinate patients.
The survey features four data points:
71% of physician practices reported they were unable to obtain coronavirus vaccines for patients
85% of independent physician practices reported they were unable to obtain coronavirus vaccines for patients
45% of hospital or health system-owned physician practices reported they were unable to obtain coronavirus vaccines for patients
The majority of physician practices that have been able to get coronavirus vaccines report limited supply and only being able to vaccinate 1% or less of their patients
Prescription for physician practice involvement in COVID-19 vaccination
Physician practices should be the primary place for coronavirus vaccinations after the first phase of vaccination for frontline healthcare workers and people over 75, says Halee Fischer-Wright, MD, president and CEO of the MGMA, which is based in Englewood, Colorado.
"Physician practices are uniquely suited for the role. They have patient registers, they have methodology to keep track of vaccines, and they already have vaccine systems set up for their patients as evidenced by administration of flu vaccine, shingles vaccine, and other vaccines. This is not a new process for physician practices. It is already well established," she says.
Patients expect physician practices to play a major role in the vaccination effort, Fischer-Wright says.
"Cutting physician practices out of the entire supply chain has created issues in the sense that patients are already calling and utilizing practice resources to ask about where to get vaccine, how to get vaccine, when to get vaccine, and whether to get vaccinated. Practices are already answering those questions. It would be much more effective to take that time and resources and convert it to getting patients into practices to get vaccinated."
Physician practices involved in coronavirus vaccination should not be limited to primary care practices, she says.
"Any practice that handles chronic disease should also be involved. For example, nephrology practices would be a great place to get your vaccine if you are on dialysis or have end-stage renal disease. If you have congestive heart failure, your cardiology practice would be a great place to get your vaccine. If you have cancer, your oncology practice would be a great place to get your vaccine. Some of the most vulnerable people who are in most need of the vaccine are in medical specialty care."
Physician practices well-suited to address vaccination hesitancy
Physician practices are trusted sources of information, and they can have a positive impact on addressing vaccination hesitancy, Fischer-Wright says.
"We still have a significant population of people who do not want to get the vaccine because they do not trust it. For example, studies have shown that more than 40% of nursing home workers are turning down the vaccine because they do not trust the people who employ them and they do not trust the vaccine. You can address that by having nursing home workers get the vaccine from their personal physicians, where there is an establishment of trust."
Many patients are not getting cancer screening during the pandemic because of concern over potential infection at healthcare settings.
Decreased rates of cancer screening during the coronavirus pandemic could lead to a significant increase in cancer mortality, a cancer expert says.
People have been deferring care during the pandemic due to fear of contracting the coronavirus in healthcare settings. For five kinds of cancer, reduced cancer screening linked to the coronavirus pandemic has likely led to thousands of delayed cancer diagnoses, according to an IQVIA Institute report. For the three-month period ending June 5, 2020, the IQVIA Institute estimates there could have been more than 80,000 delayed positive diagnoses for breast, cervical, colorectal, lung, and prostate cancer.
Delays in cancer diagnoses lead to increases in cancer mortality, says Justin Klamerus, MD, president of Karmanos Cancer Hospital and Network, a division of the Karmanos Cancer Institute in Detroit. Karmanos facilities are owned by McLaren Health Care—a health system based in Grand Blanc, Michigan.
"The earlier stage that a cancer is diagnosed, the greater the likelihood that it can be cured. If you look at breast cancer, before the pandemic 92% of women who were diagnosed with breast cancer could be expected to be cured. That number is directly correlated to the stage of diagnosis. If you have a Stage 3 breast cancer with a large mass that has grown over time, there is a lower chance of survival. With a large mass, there is a higher chance of spread to lymph nodes and a higher chance of distance spread to other organs. When breast cancer spreads to other organs, it becomes incurable," Klamerus says.
Prevention is the No. 1 goal in cancer care, but screening is crucial, he says. "When we cannot prevent a cancer, identifying and diagnosing at the earliest stage in almost every cancer leads to a higher likelihood of a cure."
In the Karmanos network, screenings for all cancers were down 17.2% in the fiscal year ending October 2020 compared to the 2019 fiscal year. Mammograms were down 16.8% and colonoscopies were down 20.4%. Roughly 107,000 patients were screened for these cancers at Karmanos in 2019, versus 89,000 in 2020.
The early signs of the impact of decreased screening are troubling, Klamerus says. "Anecdotally, what we are seeing is that patients are presenting with more advanced stages of disease. They are avoiding symptoms that would normally lead to having tests done or seeing a doctor. Patients are avoiding that care because of the concerns over COVID-19."
Klamerus fears that the decrease in cancer screening linked to the coronavirus pandemic will lead to a significant increase in cancer mortality.
"For many decades, we saw that the death rates from cancer were increasing every year. In 2016, we saw cancer death rates fall for the first time and every year thereafter it had fallen. Many of us in cancer medicine are concerned that because of the pandemic, 2020 will be a year when we see that positive trend reverse and we will see an increase in cancer death rates because of individuals avoiding screening and seeing their physicians," he says.
The decrease in cancer screenings is part of a distressing national trend of deferred healthcare services during the pandemic, Klamerus says. "Deferred care is a second pandemic, which is not uncommon when you look at the history of pandemics."
Encouraging cancer screening
Karmanos has used an "all-hands-on-deck approach" to encourage patients to undergo cancer screening, Klamerus says.
"First, we recognized that our physicians and providers who have relationships with patients needed to directly reach out to those patients. We have provided instructional materials that could be used with patients to encourage screening and to make sure patients knew that we were doing everything possible as an organization to be a safe place for care," he says.
Karmanos has used multiple outreach channels to encourage screening, Klamerus says. "We did media campaigns through social media. We partnered with our McLaren Medical Group, which are our primary care physicians, to reinforce the importance of cancer screening."
Karmanos also mobilized cancer navigators, who work in the organization's cancer centers, he says. "We had those navigators work with our screening centers to try to identify patients who had missed screening and have direct contact with them. The navigators answered questions about concerns that patients had about accessing care and emphasized the safety of the care that was being provided at our facilities."
Infection control efforts
Karmanos and McLaren have taken several steps to prevent coronavirus infections in care settings, Klamerus says. "First of all, we have worked to make sure that our buildings are safe."
"You cannot get into our buildings unless you are screened for COVID-19 symptoms including a temperature check. We have limited visitors. We have aggressive cleaning of the patient rooms in clinic and ambulatory settings as well as our hospitals. We have ended practices such as semi-private rooms in inpatient settings—those are all private rooms now," he says.
Karmanos and McLaren have also embraced technology to reduce possible coronavirus exposure. In addition to increasing the use of telemedicine visits, they have reduced traffic in their waiting rooms, Klamerus says. "We have adopted new queuing systems for waiting rooms. We keep people in the parking lot longer, contact them on their cell phones, and bring them into our buildings just before their appointments to limit crowding."
Now, there is an emphasis on vaccination, he says. "We have had robust employee vaccination programs. As of January 6, we had 65% of our employees vaccinated, and we had two more waves of employee vaccinations in the two weeks after January 6. We are aiming to get as many people vaccinated as possible as we pivot from vaccinating frontline workers to getting patients and members of our community vaccinated."
Healthcare workers who experience long-term symptoms after their acute COVID-19 illness can struggle to do their jobs.
Employers should put measures in place to support healthcare workers who suffer from long-term symptoms after experiencing acute COVID-19 illness, a recent journal article says.
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 journal article, which was published by The Lancet Respiratory Medicine, says healthcare worker coronavirus long haulers can experience symptoms that interfere with the ability to do their jobs. "The barriers to returning to work are often low energy, cognitive symptoms, and affective symptoms. For example, a middle-aged, critical care nurse with years of both clinical and academic experience described having poor focus during patient encounters, forgetting names of essential medications, and debilitating fatigue after a typical workday," the co-authors wrote.
Recommendations to help healthcare worker coronavirus long haulers
A multidisciplinary team should be created to develop return-to-work strategies for healthcare worker coronavirus long haulers, the co-authors wrote. "This team might include individuals with specialism in neurology, psychiatry, psychology, pulmonology, physiatry, and other subspecialties, in collaboration with primary care staff."
Employers can take several actions to support coronavirus long haulers in their workforces, the co-authors wrote. "Examples include reintroduction into the workforce in phases, limiting shift schedules that disrupt natural circadian rhythms, mandating breaks to avoid post-exertional neurological symptoms, partnering with other workers to facilitate oversight while multitasking, and gradually increasing responsibility and workloads. Although these measures might be costly in the short term, they might also allow for a previously healthy, skilled healthcare professional to continue working long term."
Shift changes and easing workloads are effective strategies to get healthcare worker coronavirus long haulers back to work, the lead author of the journal article told HealthLeaders.
"In our experience, it does seem that reduced work hours and a flexible schedule avoiding night shifts to promote rest and recovery works best to prevent debilitating post-exertional fatigue. The creation of a backup or supervision system for employees returning to work might also be useful to avoid coverage gaps in the event of post-exertional fatigue while work hours are being gradually increased. Most importantly, we recommend dialogue between employers, employees, and occupational health about what is helpful on an individual basis," said Nathan Praschan, MD, MPH, a senior resident at Massachusetts General Hospital/McLean Hospital Adult Psychiatry Residency.
Employers should support healthcare worker coronavirus long haulers to help ensure adequate staffing during the pandemic, he said. "We think supporting healthcare workers struggling with long-term sequelae of COVID-19 as they return to work will help maintain the workforce as it continues to handle the pandemic. Not only that but also failing to do so would amount to moral injury among healthcare workers and contribute to burnout."
A new survey finds that concern over side effects is the top reason for coronavirus vaccination hesitancy.
A new survey highlights people's attitudes about coronavirus vaccination and suggests good strategies for healthcare providers to communicate with patients about getting coronavirus vaccines.
Vaccination hesitancy among the American public is one of the primary challenges facing the coronavirus vaccination effort across the country. Vaccination is widely viewed as essential to controlling the coronavirus through herd immunity, which occurs when a large proportion of a population develops resistance to an infection.
The new survey was conducted in December by Denver-based Welltok and Ipsos, a Paris, France-based market research company. The online survey features information collected from 1,000 U.S. adults nationwide.
The survey includes several key findings:
The Top 3 desired sources of information on coronavirus vaccines were healthcare providers (86% of survey respondents), health insurance company (81%), and pharmacy (79%)
69% of survey respondents said they would get the vaccine when it became available to them
64% of survey respondents said they wanted reminders for second doses of the vaccine
Among survey respondents who said they would not get the vaccine, 64% cited side effects as the cause of their vaccination hesitancy
82% of people who were immunized for influenza this year intend to get the COVID-19 vaccines
51% of people who did not get the flu shot this year intend to get the COVID-19 vaccine
Age was strongly correlated with intent to get vaccinated: 82% of people 55 and over planned to get vaccinated, 65% of people 35 to 54 planned to get vaccinated, and 58% of people 18 to 34 planned to get vaccinated
"The COVID-19 vaccines offer a ray of hope for many, but just because vaccines are available doesn't mean everyone will get the shot. Getting people vaccinated against COVID-19 will require personalized and consistent outreach," the survey report says.
Healthcare provider messaging about coronavirus vaccination
Clinicians and other healthcare providers are well-positioned to be a trusted source of information about the coronavirus vaccines, Welltok Chief Strategy Officer April Gill told HealthLeaders.
"Healthcare providers see their patients year over year. Healthcare providers track your progress as a human being from a medical standpoint, and they help patients determine when something is wrong. So, they have to be a trusted source of information about patient health," she said.
Healthcare providers can ease people's concerns about coronavirus vaccination side effects, Gill said.
"You need to be able to assure people that vaccinations are not new and explain that vaccines go through a vigorous process of clinical trials and testing before they are released to the public. In addition, patients can be told that the side effects associated with the COVID-19 vaccines are similar to the side effects for other vaccines—they are relatively mild. The side effects include some redness or swelling at the injection site, fatigue, and muscle aches that typically resolve themselves within a few days."
To encourage younger people to get coronavirus vaccination, healthcare providers can appeal to their relationships with family members, she said. "Young people need to know that when they interact with older people in their family, they are putting those people at risk if they do not get the vaccine. This is part of focusing on values and focusing on what people want to do in their lives. Focusing on what is important to young people such as spending time with older family members is critical."
For healthcare providers, the top methods of communication preferred by survey respondents were personal email, phone calls, text messages, postcards, work email, and social media posts.
"Based on the survey data, there is plenty of information indicating that messaging should be conducted in multiple channels so that you can reach as many people as possible. Healthcare providers should be using every channel at their disposal to get vaccination messaging out," Gill said.
Healthcare providers should also vary their messaging to appeal to specific populations, she said. "For example, older patients are going to have different motivations and things that they are considering than younger patients such as being able to spend time with grandchildren and enjoy their retirement. For younger patients who may feel invincible, clinicians can tell them how vaccination is important to protect the people they care about."
An emergency department social medicine team improves care for complex patients and supports emergency room clinical staff.
An emergency department social medicine (EDSM) team at a San Francisco-based hospital has improved the care of patients with psychosocial needs.
Treating patients with behavioral health issues such as substance abuse and social challenges such as homelessness pose several difficulties in emergency departments. For example, ED clinicians are under time pressure to treat patients with acute medical conditions and ED staff typically have limited links to community-based organizations.
The EDSM team at Zuckerberg San Francisco General Hospital and Trauma Center was detailed recently in an article published by the Journal of the American Medical Association. The EDSM team at the hospital includes a patient navigator, social workers, care coordination nurses, a pharmacist, physician consultants, and specialists in transitional care, substance use, and quality improvement.
The journal article features four key data points:
From October 2017 to March 2020, the EDSM team conducted nearly 4,000 consultations to assess and coordinate care for patients, which prevented 567 admissions and 127 readmissions
More than 1,100 patients were given discharge medications at no charge and received pharmacist education about their medications before discharge
For patients treated by the EDSM team, mean ED length of stay was 345.8 minutes, which was just slightly higher than the 344-minute length of stay of all other ED patients
60-day ED utilization decreased 5.8% for patients treated by the EDSM team
Medications were provided free of charge to ED patients with barriers to medication access to promote safer discharge to the community.
The EDSM team worked closely with the ED staff, the journal article's co-authors wrote.
"At a standard time daily, the EDSM team rounded in the ED to elicit referrals from clinicians for patients experiencing homelessness, substance use, mental illness, food insecurity, intimate partner violence, and gaps in medication access, health insurance coverage, ambulatory care, and home-based services. Throughout the day, the EDSM team reviewed the electronic health records for ED patients with psychosocial needs. Additionally, ED clinicians and nurses proactively discussed psychosocially complex patients with the EDSM patient navigator by phone or in person. Once a patient referral was identified, the EDSM team integrated the psychosocial and medical aspects of care in consultation with the ED clinical team prior to patient ED discharge or admission."
Connecting patients with services
The EDSM team works with patients and ED clinicians to connect patients with services after discharge, the lead author of the journal article told HealthLeaders.
"The EDSM multidisciplinary team starts by meeting with the patient to understand his or her self-identified needs. In parallel, the team solicits input from the ED clinician on the medical issues and clinician concerns. Once a plan is created in partnership with the patient and ED clinician, EDSM team members call community-based partners including substance use treatment programs, social workers, case managers, food programs, emergency housing programs, and other community-based social services to facilitate enrollment and service delivery after discharge from the ED," said Jack Chase, MD, co-director of social medicine at Zuckerberg San Francisco General Hospital and Trauma Center.
The EDSM team works closely with staff in the San Francisco Department of Public Health and other city agencies to make community social service connections, he said.
EDSM team members also connect patients with ambulatory care providers, Chase said. These providers include primary and specialty medical care, mental health care, and substance-abuse treatment providers. These connections are made through the electronic medical record and by email to provide ongoing support, to arrange case conferences to discuss complicated patient care situations, and to facilitate referrals after discharge, he said.
Role of social medicine consultants
The EDSM teams social medicine consultants play a crucial role for patients and ED clinical staff, Chase said.
"Our social medicine consultants, soon to include a nurse practitioner in addition to physicians, employ a service-based mindset to meet the patient's self-identified needs while also providing clinical guidance, reassurance, and extra work capacity to our ED clinical colleagues. We recognize that our ED clinical colleagues are managing acute medical emergencies such as stroke, respiratory failure, cardiac arrest, and trauma while simultaneously managing behavioral health and social emergencies, including substance use relapse, psychosis, homelessness, starvation, extreme poverty, and social isolation," he said.
The EDSM team focuses on the care of patients with less acute medical issues and more prominent behavioral and social needs, Chase said.
"Our goal is to meet the patient's self-identified needs in the most efficient and successful way possible while also providing our ED clinical colleagues with a preferable alternative to admission for social needs or discharge without adequate support. To integrate a bio-psycho-social plan, key elements of this work include direct EDSM clinician to ED clinician communication and consultation, augmenting community-based services to meet a patient's needs, and care coordination with community-based clinicians to support comprehensive outpatient care."
Creating and sustaining EDSM teams
The EDSM team initiative at Zuckerberg San Francisco General Hospital and Trauma Center targeted a specific goal when the program was created, Chase said.
"Our initial vision of using a multidisciplinary team to provide more comprehensive care in the ED came from using a quality improvement mindset to understand a central problem affecting our patients and our hospital: How to meet the complex medical, social, and behavioral health needs for patients in the ED while preserving acute care services and bed space within the hospital for patients with the highest level of medical acuity."
He offered advice for how other hospitals can start an EDSM team program.
"We would recommend that hospitals start by reviewing their own patient and community data and identifying what challenges they see in relation to caring for patients with complex needs. Once data on patients' health-related social needs are defined and the reasons for unmet needs are understood, we recommend using performance improvement methodology to identify initial small tests of change to make progressive enhancements. Additionally, we recommend stakeholder engagement and team-building with community partners and existing community social services."
There are crucial elements to sustain an EDSM team program, Chase said.
"One key to success in securing support and acquiring funding has been our use of data to demonstrate effectiveness of each intervention coupled with patient stories to demonstrate the human impact of this model of care. Additional elements of our model include empowering frontline staff to drive improvement based on their own daily experiences in clinical care and creating space within the program for professional development. The latter effort supports increased training and certification to allow team members to fulfill the highest level of their licensure and credentials while building new, more sophisticated skills in the process."
The goals of the CEO include addressing infection preventionist burnout and promoting coronavirus vaccination.
The new leader of the Association for Professionals in Infection Control and Epidemiology (APIC) says the coronavirus pandemic has taught the country many hard lessons about controlling deadly pathogens.
Infection preventionists have been a vital source of expertise during the pandemic. For example, they have played a pivotal role in helping healthcare organizations to prevent the spread of the coronavirus in their facilities.
Devin Jopp, EdD, MS, began working as the new CEO of APIC in December. In previous roles, he has worked with prime healthcare stakeholders, including payers, providers, and healthcare information technology professionals. For example, he served as president and CEO at the Workgroup for Electronic Data Interchange, which focuses on enhancing the exchange of healthcare information.
In a recent discussion with HealthLeaders, Jopp talked about a range of issues related to infection preventionists during the pandemic. The following is a lightly edited transcript of that conversation.
HealthLeaders: What are your top priorities in your new role at APIC?
Devin Jopp: Right now, I want to help our members identify and share best practices in the COVID-19 response. I also want to help ensure that we do not see healthcare-associated infections rise while we pay attention to COVID-19. We need to stay focused on other things like MRSA that are out there and be on guard for new infections.
I am very much worried about burnout among infection preventionists, so I want to help prevent burnout. I also want to help recruit new infection preventionists at a time when our country really needs them.
Another one of my goals is around awareness of the need to further infection prevention in all of our care settings, especially long-term care facilities. There was a real miss in long-term care facilities in terms of not having enough infection preventionists on site before the coronavirus pandemic.
Finally, vaccines are certainly going to be important to protect our healthcare workers and the general public. I want to break down the myths and be a source of truth regarding these vaccines.
HL: Where do you think we have made the greatest strides in infection control for the novel coronavirus?
Jopp: Our understanding of the virus has grown significantly since the beginning of the pandemic. We have learned much more about how the virus is spread. For example, we have learned that spread is more airborne than through contamination of surfaces.
We have learned more about the morphology of the virus. We have learned that it is a lipid-based virus, which means that it reacts to water and soap. In the early days of the pandemic, we were worried that we would need other cleaners such as bleach to help control the virus.
We have learned that personal protective equipment and social distancing works. So, if we implement these measures, they are some of the best safeguards that we have.
We have also learned that testing and contact tracing work. When testing and contact tracing are implemented properly, it is a great opportunity for us to help turn the tide on the virus.
HL: What are the primary challenges remaining in infection control of the coronavirus?
Jopp: Clearly, vaccines are going to be an issue. I am worried about resistance, so we need to get enough of our healthcare workers to actually take the vaccines. There are concerns about how quickly the vaccines were developed, but the vaccines are based on science.
The lack of affordable PPE and availability of testing is still a concern that we must address.
The whole idea of COVID-19 fatigue, resistance to wearing masks, and engaging in social gatherings is a huge challenge for us. We must be able to overcome these challenges to control the coronavirus infection rate.
HL: How can healthcare IT play a role in control of the coronavirus?
Jopp: National surveillance is one of the big learnings that came out of the pandemic, and we need to enhance it. Electronic health record systems need to enhance the level of their data sharing.
We really need to look at how local and state health departments as well as healthcare providers share data. Now, we realize that this kind of sharing is not working at the level that it needs to be. During the pandemic, we could have been more nimble and have more accurate data if this kind of sharing was better.
We also need standardization of public health registries and to try to normalize those registries to make sure that we have accurate data and that it is reported quickly.
All of this points to the need to have true interoperability. We need to make sure that—from the patient health record all the way through to healthcare facilities and government agencies—we can communicate in a way that is seamless. We have been working on interoperability for decades, and we still have work to do.
HL: How will the coronavirus pandemic affect infection prevention efforts after the crisis has passed?
Jopp: The pandemic is going to force many organizations to do a lot of soul searching about what they could have done better. One issue is creating strategies for managing novel pathogens.
We need to create processes for disaster preparedness using pandemics as a likely scenario. Before, when we talked about disaster preparedness, we talked about earthquakes, hurricanes, and terrorism. Pandemics were not a top priority as a likely scenario, and that is certainly going to change.
We have got to improve our infection prevention infrastructure in all aspects of healthcare and outside of healthcare. Again, long-term care facilities were a real miss and more of those facilities need to have infection preventionists on staff. It cost lives to not have more infection preventionists on staff in that setting.
When you look outside of healthcare, infection preventionists are needed in fitness centers, hospitality, and travel such as cruise ships. We need to look at infection prevention in a different light.
HL: What actions would you like to see the new Biden administration take to improve infection prevention?
Jopp: The Centers for Disease Control and Prevention is crucial. We need to try to ensure that we are providing proper investment into the CDC to be sure that they have the resources to do things such as bolstering our surveillance capability and stockpiling PPE. The National Institutes of Health is another key agency. We need to try to enhance our readiness to conduct research. Providing proper funding to these agencies is a very important step.
The researchers reviewed utilization of low-value services such as imaging for non-specific back pain and arthroscopic surgery for knee osteoarthritis.
Most primary care physicians are effective at limiting the ordering of low-value medical services, a new research article says.
Earlier research found that annual spending on low-value medical services in U.S. healthcare ranges from $75 billion to $100 billion. "Primary care physicians (PCPs) have been conceptualized as potential gatekeepers for efforts to reduce low-value spending," the co-authors of the new research article wrote.
The new research article, which was published this week in Annals of Internal Medicine, analyzed Medicare Part B claims from a random sample of beneficiaries enrolled between 2007 and 2014. Examples of low-value medical services included imaging for non-specific back pain, prostate specific antigen screening for men older than 75, and arthroscopic surgery for knee osteoarthritis.
The study includes two key data points:
For most PCPs, the medical services they performed or ordered accounted for less than 9% of their patients' low-value spending, which represented less than 0.3% of their total Medicare Part B spending.
For most PCPs, referrals accounted for less than 16% of their patients' low-value spending, which represented less than 0.5% of their total Medicare Part B spending.
The data indicates PCPs are effective gatekeepers for low-value medical services, the lead author of the study told HealthLeaders.
"Our findings suggest that PCPs generally do a good job avoiding performing, ordering, or referring their patients for low-value services. For most PCPs, spending from low-value services they performed or ordered accounted for less than 9% of their panel's total low-value spending, and services they referred their patients out for accounted for less than 16% of their panel's total low-value spending," said Aaron Baum, PhD, assistant professor, Department of Health System Design & Global Health, Icahn School of Medicine at Mount Sinai Health System, New York, New York.
Spending on low-value medical services accounts for a significant amount of wasteful healthcare spending, he said. "One trillion dollars—25%—of healthcare spending is classified as waste. Of this, low-value services, which can be measured using claims data, account for upto $100 billion per year. We need to be able to measure more of the remaining $900 billion of wasted spending using readily available data sources in order to monitor and better understand the sources of wasted healthcare spending overall."
The specialties that contributed the most to low-value spending included cardiology, ambulatory surgical centers, internal medicine, orthopedic surgery, and gastroenterology, Baum said.
The leader of America's Physician Groups pushes for acceleration of the shift from the fee-for-service care model to value-based care.
The leader of a physician association focused on the transition to value-based care has written a letter to the incoming Biden administration urging adoption of three approaches to improve the U.S. healthcare system.
Led by innovations adopted by the Centers for Medicare & Medicaid Services, the country has been shifting away from the fee-for-service (FFS) care model to value-based care models such as Medicare Advantage health plans. The goal of this movement is transitioning from the FFS care model's emphasis on reimbursing medical services based on the volume of services provided to value-based care models that emphasize lowering costs and increasing quality.
The letter to the Biden administration is from Donald Crane, JD, president and CEO of America's Physician Groups. APG represents more than 300 physician groups that employ or contract with about 195,000 physicians who provide care to nearly 45 million patients.
Crane told HealthLeaders that the FFS care model is not serving the country well. "Fee-for-service is a barrier to quality improvement and is ruinously wasteful. Our citizens deserve better," he said.
Crane's letter calls on the Biden administration to take three approaches to strengthening the U.S. healthcare system.
1. Hasten shift from fee-for-service reimbursement to value-based care
The Biden administration should support adoption of budget-based prospective payment models, Crane says in his letter. "As providers and organizations continue to make investments in accepting risk and providing high quality care at a low cost for patients, supporting the movement to budget-based prospective payment models at the physician group level will provide them with the proper incentives to encourage the acceptance of risk."
Value-based care models represent a step forward in addressing social determinants of health, Crane says. "These models also play an integral role in addressing social determinants of health through initiatives centered around behavioral health, increased screening of patients for risk factors of these determinants, and other proactive methods of care. The social determinants of health-focused care that physicians in value-based models offer provide a level of financial value that must be supported moving forward."
If Joe Biden follows through on his campaign pledge to create a public option health plan, it should feature a value-based payment model, Crane says. "We are aware that a public healthcare option will be one of the avenues examined as a possibility in extending the best care possible. Should a plan for a public healthcare option be drafted, we would recommend that for physician groups a budget-based prospective payment system be utilized."
2. Bolstering Medicare Advantage
Medicare Advantage is playing a crucial role in the shift from FFS to value-based care, and the program should be actively supported, Crane says. "An integral part of the move from volume to value is supporting Medicare Advantage (MA) and the role it plays in shifting healthcare in this direction. Providers and health plans who engage in high-value, risk-based MA contracts are working diligently to improve overall quality in the MA program and should be rewarded for those efforts."
Medicare Advantage health plans should embrace budget-based prospective payment, he says. "Congress, the Centers for Medicare & Medicaid Services, and stakeholders must work together to put in place incentives that further drive the value evolution in MA just as they are working to do so in traditional Medicare. These incentives should offer both positive and negative reinforcement that will motivate MA plans to push budget-based prospective payment downstream to the physician group level."
3. Decreasing healthcare costs
To lower healthcare costs, the Biden administration should encourage the ongoing shift of care from high-cost settings such as hospitals to low-cost settings such as the home and ambulatory care, Crane says.
"Transferring more patient care to ambulatory or home settings is making life changing strides in offering increased convenience and care options for patients while lowering costs and delivering improved outcomes. Technology has also progressed to the point where virtual visits offer even more convenience for patients while still allowing providers to effectively treat those suffering from chronic conditions while monitoring their health and creating effective care plans for treatment. The advantages that telehealth services represent for those patients with issues surrounding access to care, individuals with disabilities, and the elderly have been evident during the ongoing pandemic."
Lowering drug prices is another essential element of decreasing healthcare cost, he says.
"Rising prices have had a great effect on access to much needed medicines for those suffering from chronic conditions. The effects of high prescription drug costs also have systemic consequences, with patient non-compliance because of decreased access or the inability to afford medication leading to increased costs for the healthcare system in general through unnecessary hospitalizations, emergency services, and physician visits."
Efforts to decrease drug prices should include drug importation reform, value-based purchasing, and international pricing models, Crane says.
