Safety protocols for ED patients with psychiatric illness require balancing the creation of a safe space with maintaining a therapeutic and humane environment.
An emergency department safety protocol detailed in a new journal article is designed to keep patients with psychiatric illness from suffering self-harm.
Patients with psychiatric illness can spend lengthy periods of time in emergency departments waiting for psychiatric evaluation or transfer to an inpatient psychiatric facility. Earlier research found that the mean length of stay (LOS) for psychiatric patients in emergency departments awaiting an inpatient bed was 16.5 hours and LOS for psychiatric patients in EDs awaiting transfer to another facility was 21.5 hours. Other research has found that busy and crowded EDs are not well-suited to boarding psychiatric patients for lengthy periods of time.
The new journal article, which was published by The Joint Commission Journal on Quality and Patient Safety, includes two key data points.
In the year before the safety protocol was put in place at Massachusetts General Hospital in Boston, there were 13 episodes of attempted self-harm by 4,408 at-risk psychiatric patients, with six of those episodes resulting in actual self-harm
In the year after the safety protocol was put in place at the hospital, there were six episodes of attempted self-harm by 4,523 at-risk psychiatric patients, with one of those episodes resulting in actual self-harm
Although the safety protocol did not result in a statistically significant reduction in the number of attempted self-harm events and number of actual self-harm events, the safety protocol had a clinically significant impact, the journal article's co-authors wrote.
"With a very small number of events, it is challenging to demonstrate statistically significant changes; however, these reductions do have substantial clinical significance. With thousands of at-risk patients receiving ED care each year, the impact of improving their safety is substantial. These patients are among the most vulnerable in our healthcare system, and preventing even one episode of self-harm is a critical patient care goal," they wrote.
How the safety protocol works
Earlier research has shown that hanging is the most common form of attempted suicide in hospitals, and EDs have several lanyards such as sheets and call cords as well as anchor points such as bars and IV poles. In addition, emergency room patients or visitors may have dangerous items such as prescription drugs and sharp objects.
To reduce the danger of self-harm in EDs among patients with psychiatric illness, a multidisciplinary task force at Massachusetts General Hospital crafted four primary elements in the safety protocol.
1. Safe bathrooms: Several episodes of self-harm had been attempted in bathrooms, so the safety protocol called for the creation of "safe bathrooms." Characteristics of safe bathrooms included shatterproof fixtures and mirrors, paper wastebasket liners, and minimal lanyard risks.
2. Patient observers: After conducting research, the task force concluded that one observer with adequate visibility could monitor as many as three patients. The task force also recommended hiring dedicated ED patient observers rather than using observers who were hospitalwide.
Patient observers received a significant level of training that featured a mandatory three-week orientation and annual retraining. The patient observers learned about safety issues such as suicide risk, possession of dangerous items, and risk of harm to others.
The task force also created a check list tool for patient observers. The check list included safety concerns such as elopement risk and observation goals such as constant vigilance, safe bathroom usage, and making sure there were no dangerous objects in the environment.
3. Personal belongings: The task force determined patient belongings should be removed and stored securely. Possession of cell phones was only allowed if the case was removed to ensure dangerous items could not be hidden inside. Patient requests to keep personal belongings were allowed on an individual basis under review by nursing staff.
4. Clothing search or removal: Patients at risk for self-harm were encouraged to change into safe clothing.
Forcible disrobing of a patient was determined to be appropriate in cases of extreme risk and was based on an individual risk assessment conducted by the ED physician with the option of consultation with psychiatry staff. Forcible disrobing is inherently risky, the journal article's co-authors wrote. "Forcibly changing a patient is considered a physical restraint, and, practically, to change an unwilling patient, physical restraint is often used. Therefore, patients who are forcibly disrobed must meet restraint criteria, specifically that there is risk to the immediate physical safety of the patient or others."
The lead author of the journal article, Abigail Donovan, MD, an associate psychiatrist at Massachusetts General Hospital and assistant professor of psychiatry at Harvard Medical School in Boston, told HealthLeaders that forcible disrobing is a complex issue.
"The risk of self-harm compared to the risk of forcible changing is based upon an individual assessment at the time of presentation. That assessment must include an understanding of current suicidality, a thorough history of prior suicide attempts, a current mental status exam, and a review of additional risk factors, including substance use, current intoxication, impulsivity, prior behavior in healthcare settings, and an understanding of the individual's trauma history. To forcibly change an individual, the risk of imminent self-harm must outweigh the risks of forcible changing, which can be substantial," she said.
Safety protocol tips
A multidisciplinary team acting on solid research should be involved in the creation of a safety protocol for ED patients with psychiatric illness, Donovan said. "The varied perspectives of members from different disciplines are critical for developing a comprehensive and thoughtful initiative. We also advise using a root cause analysis of self-harm events to identify high-risk areas specific to the individual hospital or care setting as the starting point for a safety protocol."
It is extremely challenging to balance the creation of a safe space with maintaining a therapeutic and humane environment that also maintains the dignity of patients, she said. "At each step, we tried to ask ourselves, 'What would I want care to look like for my mother? For my child? For myself?' We felt that if we designed a protocol that we could feel good about for our loved ones' care, then we were on the right track."
'The secret sauce is having the right people with the right training,' Lifespan executive says.
At health systems and hospitals, adopting a crisis command culture has operational benefits during the coronavirus pandemic, a pair of experts say.
Across the country, health systems and hospitals have established incident command centers to manage the challenges of the pandemic. At Northwell Health last spring, incident command leadership was a key element in the health system's response to the hottest hot spot in the first coronavirus patient surge.
The crucial aspect of crisis command culture is the ability to make good decisions quickly, says Stephanie Mercado, CEO and executive director of the National Association for Healthcare Quality in Chicago.
"Decisions in healthcare—especially those related to any type of policy or procedure—have often been decided by committee and consensus with long timelines. Before the pandemic, it could take months or years to change a policy. The pandemic has shown everyone in healthcare that they need to be more flexible. They need to be more agile. Good decisions can be made on a much shorter timeline than what was previously thought," she says.
With a crisis command culture, it is possible to make good decisions on policies without putting them through a lengthy process of review and editing by multiple committees, says Nidia Williams, PhD, vice president of quality and safety at Providence, Rhode Island–based Lifespan. The health system operates several hospitals including an academic medical center and has about 17,000 employees.
"We cannot give people editing power after most people who are the key stakeholders have already said a policy is ready to go. We must streamline the decision-making process for policies. Now, we have policies that would have taken weeks if not months to approve that can be approved in hours. It is possible to approve policies in hours and still do it well. We can get more done faster—that is the lesson from crisis command culture," Williams says.
Rapid cycle improvement is an important aspect of crisis command culture decision-making, Mercado says. "We must make a decision at a point in time, but it does not have to be something decided upon forever more. Rapid cycle improvement tells us that we can go back and reevaluate decisions that were made when we have new information or circumstantial change, so we can improve decisions."
Trust and attitude are indispensable ingredients in rapid decision-making, Williams says. "A lot of it comes from trust that you have the right people playing the right roles in making decisions. It is also attitudinal. We tell ourselves we do not have the luxury of time. We do have the luxury of having everyone's talent. … We have learned that we can do the best that we can, and it can be enough so that you are not waiting for perfect before you do what you have to do."
Capitalizing on talent
In addition to rapid decision-making, a pivotal part of crisis command culture is elevating talent over hierarchy in filling key roles in incident command centers, Williams says. "The secret sauce is having the right people with the right training."
At Lifespan and other health systems, quality and safety staff are well-suited for leadership positions in incident command centers, she says.
"I am the patient safety officer at the health system. I started out as the incident commander and planning section chief at the health system–level incident command center in March. My direct superior, who is the executive vice president of quality and safety, is the person who co-led the opening of our alternative hospital site at the Rhode Island Convention Center. Now, the planning section chief at our academic medical center—Rhode Island Hospital—is my quality and safety director. We are playing important roles," Williams says.
Quality and patient safety staff have the appropriate training and experience to succeed in incident command centers, she says. "We have to document and archive our decisions over time. In addition, some of our analysts for quality and safety are most uniquely suited for not only documentation and archiving but also the analysis and reporting of our COVID-19 data both internally and externally."
The skill sets of quality and patient safety staff are an excellent fit in incident command centers, Mercado says. "The skills and competencies that those individuals have are very well-suited to provide systems, processes, and structure and order to an otherwise chaotic situation. Quality professionals do this kind of work all day, every day in their ordinary jobs; but when it comes to the pandemic, they are contributing on an order of magnitude."
Assigning quality and patient safety staff to top incident command center roles is an example of elevating skill sets over hierarchy in a crisis command culture, Williams says.
"Most of the C-suite does not take on command center structure roles—even at the affiliate hospitals. At our academic medical center's incident command center, the section planning chief is the director of clinical excellence and patient experience. So, she is a quality and safety professional first and foremost, but she has a key crisis command center role at our biggest hospital," she says.
Incident command center metrics
During the pandemic, a primary metric for incident command centers is whether they are reporting COVID-19 data to state and federal agencies on a timely basis, Williams says.
"That data is important because if you miss a day or a series of days, your CEOs and presidents and other top executives will get an email that the reporting has not been submitted. This reporting is tied to our reimbursement from the Federal Emergency Management Agency and the Cares Act, for example," she says.
For health systems and hospitals, the reporting requirements related to the pandemic include the following data sets:
How many coronavirus-positive patients are in hospitals
How many people have tested positive for the coronavirus
How many people have been given a coronavirus test
How many coronavirus patients are in ICU beds
How many coronavirus patients are in medical beds
Critical staffing shortages in hospitals
There is significant reporting about COVID-19, the population Lifespan is serving, and the health system's resources, Williams says.
"There are personal protective equipment numbers such as how many masks you have and how many gowns you have. We must report how many beds we have available to reflect our capacity. When you turn on the news at night, and they tell you how many people tested positive that day or the positivity rate that day, that information is coming from individual organizations like ours submitting data every day," she says.
In a wide-ranging address today, the president of the American Medical Association highlighted multiple challenges posed by the coronavirus pandemic.
In an address to the National Press Club today, American Medical Association President Susan Bailey, MD, called for a coordinated and comprehensive federal response to the coronavirus pandemic.
At the beginning of her address, Bailey highlighted the epic proportions of the pandemic. She said the country is experiencing 1 million new COVID-19 cases per week and recently "reached the grim milestone" of losing 4,000 lives to the coronavirus in a single day.
"Some areas of the country are experiencing record case surges that are flooding emergency departments and intensive care units. In other areas, first responders are having to make agonizing choices about whom to treat for routine health emergencies to ease overcrowding at local hospitals. With hospitals stretched at or near their breaking point, some are even forced to treat patients in cafeterias, hallways, and conference rooms," she said.
State and local authorities are not adequately equipped to cope with the pandemic without federal help, Bailey said.
"While safe and effective vaccines are at-hand, the distribution mechanisms at state and local levels have been slow, inconsistent, and severely hampered by unrealistic expectations and a lack of coordination at the federal level. This inaction at the highest level of our government has placed yet another daunting burden on the shoulders of state and local officials who lack the resources, sufficient guidance, and the support they need to handle a health emergency of this magnitude on their own."
So far, the government response to the pandemic has been woefully fragmented, she said. "Leaving state and local officials to shoulder this burden alone without adequate support from the federal government is not going to work. Fifty different strategies across 50 states will continue to sow confusion and slow the process."
The incoming administration of President-Elect Joe Biden should focus on three areas as soon as possible, Bailey said.
1. National strategy: "I call upon the incoming Biden administration to implement a national strategy and provide states and local jurisdictions with additional resources, guidance, and support to enable rapid distribution and administration of vaccines," she said.
2. Coordination with states: "The AMA urges the Biden administration to talk with states to identify gaps in vaccine distribution and to work collaboratively to address areas of concern," she said.
3. Defense Production Act: "We call for the new administration to develop a more robust national strategy for continued COVID-19 testing and production of [personal protective equipment] by tapping into the full powers of the Defense Production Act," she said.
Pandemic big picture
Bailey said the pandemic has exposed five troubling elements of U.S. healthcare that must be addressed.
1. Importance of science: There needs to be heightened adherence to science and science-based decision making in areas related to healthcare, she said. "Whether you are a physician like me or a journalist, or whether you simply post your ideas on Facebook or Twitter, all of us share some responsibility for stopping the spread of disinformation and for creating an environment where science and evidence rule the day. We must insist that our elected officials affirm science, evidence and fact in their words and actions."
The federal government's key scientific institutions such as the Centers for Disease Control and Prevention and the Food and Drug Administration should not be subjected to political pressure, Bailey said. "Politics have no place in a pandemic; and never again should scientists, researchers, or physicians feel the weight of intimidation or have the integrity of our work questioned."
2. Access to affordable care: All Americans should have access to affordable healthcare services and health coverage, she said.
"As certain provisions of relief packages from the beginning of the pandemic expire, many Americans are still facing tremendous difficulties and hardships—some dealing with the loss of a job or a business. … In this new year, we urge the federal government to take necessary measures to protect not only lives but livelihoods at risk—measures such as a second enrollment period for the Affordable Care Act."
3. Addressing health inequities: The pandemic has revealed widespread inequity in the U.S. healthcare system, Bailey said.
"The data from COVID-19 is painfully clear. Communities of color have been disproportionately impacted by this pandemic because of systemic inequities that are rooted in racism. Heart disease, diabetes, and other chronic conditions that have led to devastating consequences for African American, Latino, and Indigenous communities … have also made them more susceptible to the dangers of COVID-19. The road ahead demands that our health system acknowledge these inequities and work to integrate new policies to level the playing field in all communities."
4. Improving public health: The country's public health infrastructure has been "gutted," she said. "In the last 13 years, we lost 40,000 jobs at the state and local public health agencies, with the local health department workforce shrinking about a quarter. We are seeing the impact of this disinvestment play out today in the slow vaccine rollout we are witnessing. Marginalized and minority communities and people living in rural areas have also suffered the consequences of this disinvestment for too long."
5. Global nature of health: The United States needs to work with other countries to address future outbreaks of disease, Bailey said.
"We cannot act as if our country exists in isolation. We must recognize the global community of health providers and healthcare institutions—and lead these efforts as we are called to do. Global alliances in healthcare are critical in helping prevent future threats before they sweep our planet. We applaud the incoming administration's commitment to rejoin the World Health Organization."
Pandemic impact on physicians
The pandemic has taken a heavy toll on physicians, Bailey said during a question-and-answer session after her address.
"The frontline doctors who are in the emergency rooms and the specialists who work in the ICUs have been running on fumes for a long time. … But on the other side, there are doctors who are having to close their practices because they don't have enough patients to see because of local shutdowns combined with fears among patients about going out into public," she said.
Physician burnout and suicide are significant concerns during the pandemic, Bailey said. "There is burnout. Many are aware of Dr. Lorna Breen—the physician in New York who committed suicide last year. We do not have good numbers on what has happened with the suicide rate among physicians and other healthcare workers during the pandemic, but I am sure it is not going down."
Many people are reluctant to be vaccinated for reasons including misinformation and cultural barriers.
Clinicians need to take a multipronged approach to communicating with their patients about coronavirus vaccination, a Yale New Haven Health expert says.
With the COVID-19 pandemic raging across the country, vaccination is a key implement in the public health toolbox. 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.
There are four best practices clinicians should follow when communicating with people to encourage them to get coronavirus vaccination, says Richard Martinello, MD, medical director of infection prevention at Yale New Haven Health in New Haven, Connecticut.
1. Cast vaccination as part of wider infection prevention strategy
"Not only with coronavirus vaccination but also with flu, sometimes we focus on the act of getting vaccinated as being the preventive effort. While vaccination is a key part of our overall public health strategy to prevent disease, it is only one part of a multifaceted approach to keep people healthy," Martinello says.
While the pandemic is wreaking havoc nationwide, clinicians should communicate that vaccination is only one of several preventive measures, he says. "Wearing a mask, social distancing, and getting vaccinated are key components for people to achieve their goals. Oftentimes, that can be a more productive conversation than one of simply saying, 'We need you to get vaccinated.'"
2. Tap into patient values and goals
It important to understand a patient's values and goals, then to communicate how vaccination is aligned with those values and goals, he says. "What do they want for themselves? What do they want for their family? Then, as physicians and others in healthcare, what we need to do is think about how to frame what we think are the right actions for the patient in the context of what their goals are."
For example, many people feel the coronavirus pandemic has constrained their independence and ability to lead a "normal life," Martinello says.
"Right now, some of us have a sense that our freedoms are being squelched. Doing what we can to decrease coronavirus transmission in our communities such as vaccination can allow us to regain those freedoms that we value—freedoms like being able to fly on a plane without having to worry about infection or the freedom to go out to a restaurant without having to worry," he says.
3. Hold open conversations
To have productive conversations about coronavirus vaccination, clinicians need to be good listeners, Martinello says. "One of the first things we need to do is to listen to patients' questions."
It also is important to dispel misunderstandings about vaccination delicately, he says. "We need to respect that patients may have some deep-seated views; and we need to recognize that if they are accessing non-factual information, we have to be very cautious about how we approach those individuals to try to bring them around to understand the facts."
Seeking common ground is a prime strategy to encourage skeptical people to get vaccinated, Martinello says. "One strategy to approach that conversation is to think about aspects that we may agree about. If someone has deep-seated feelings and concerns that lead them not to want to get vaccinated, we need to find aspects of that conversation where we can have information that we agree upon."
4. Overcoming cultural barriers
Some minority groups, particularly African Americans, are suspicious of the medical community because of a history of injustice such as the infamous Tuskegee syphilis study that began in the 1930s.
"This is an area where we need to have a great deal of humility and patience. We need to recognize that we may not completely understand the concerns that our patients have leading to their reluctance to get vaccinated. Trying to dig into those concerns can be very helpful to better understand where that reluctance is coming from," Marinello says.
The safety of the coronavirus vaccines should be emphasized, he says. "If someone is concerned that they are being experimented on with these vaccines, we can acknowledge that these vaccines have been produced very quickly and made available to the public in a rapid fashion. If that is the concern, we can provide a better understanding as to why these vaccines were made available so quickly."
First, this conversation can focus on the history of vaccine technology, Marinello says. "There has been a great deal of research over decades in the development of new vaccine technologies. From a scientific and pharmaceutical perspective, we were prepared for this virus and positioned to prepare vaccines in a rapid fashion."
Second, the conversation can turn to how the coronavirus vaccines were developed, he says. "From a development perspective, these kinds of vaccines usually go through a very systematic and serial process to come to market. In the case of the coronavirus vaccines, there was so much investment that the developers of the vaccines were able to overlap those steps and do things concurrently rather than in a serial fashion. That helped make these vaccines available so quickly."
Third, it is important to emphasize that minority populations are not being singled out for experimentation and that minority populations will be getting equal access to vaccination, Martinello says.
"It is helpful for minority patients to understand that these vaccines are being widely used among different sorts of people. It is helpful to tell these patients that there are a lot of efforts to ensure equity and justice in the way the vaccine is being distributed. We are not only trying to have the greatest good for the greatest number of people. We are also making sure that communities that may not have had adequate or equal access to vaccines in the past will have access to these vaccines so their communities can stay healthy."
Like many fields in telehealth, teletherapy has experienced significant growth during the coronavirus pandemic, a teletherapy CEO says.
Teletherapy is likely to experience growth and other significant changes in 2021, the CEO of a teletherapy provider says.
Last March, when the coronavirus pandemic took hold in the United States, telehealth visits increased 50%, according to Frost and Sullivan. With in-person medical visits associated with the risk of coronavirus infection, virtual visits have emerged as a safe and effective way for patients to meet with their healthcare providers in many circumstances.
Trip Hofer, MBA, CEO of New York City-based teletherapy provider AbleTo has four predictions for teletherapy in 2021.
1. Upward growth trajectory
In 2021, there will likely be a continuation of the increased patient adoption of teletherapy that was seen in 2020 because of the COVID-19 pandemic, Hofer says.
"The coronavirus pandemic has been a horrific event; but for telehealth, the pandemic has advanced the industry by five years to a decade. People who were not used to telehealth have been exposed to it. We probably will see a dip in teletherapy in 2021 as people go back to office settings, but a lot of people have become comfortable with these services. As a result, the trend in 2021 is likely to be continued growth," he says.
2. Startups, mergers, and acquisitions
Teletherapy is drawing a significant amount of investment dollars, which will drive market changes this year, Hofer says.
"In 2021, you are going to see more teletherapy startups come into the market. You also are going to see more M&A activity this year because money is flowing in and larger organizations such as health plans are seeing opportunities to bring teletherapy in-house," he says.
3. Targeting outcomes
This year, there is going to be increased focus on teletherapy outcomes—both clinical and financial, Hofer says. "There is recognition that teletherapy is increasing patient access, but health plans are getting more focused on what they are getting for that access."
AbleTo works mainly with health plans, and they ask for a spectrum of data, he says. "One data point is patient satisfaction—health plans want to know whether patients are satisfied with the services they are receiving. They want to see utilization data—how much was a service utilized and how often. They also want to see data for clinical outcomes."
In teletherapy, examples of clinical outcome measurement tools include the DASS 21 and the PHQ-9.
Health plans also are interested in return on investment and financial outcomes, Hofer says.
For example, he says a large share of AbleTo's service offerings is for individuals who have a mental health need and a physical comorbidity. For a patient who is depressed and has had a heart attack, AbleTo can treat the depression, which can lower total cost of care by reducing emergency room visits and hospitalizations, Hofer says.
4. Regulatory environment
Licensure requirements are more restrictive in behavioral health than in physical health, Hofer says. "For example, nurses have compact state licensure; where if they get licensed in one state, they can get licensed in dozens of other states. We don't have that in mental health—if you are licensed in one state you can only practice in one state. Multistate licensure is onerous. On average, our therapists have two state licenses."
During the pandemic, the Centers for Medicare & Medicaid Services have relaxed the licensing requirements for behavioral health, so professionals can practice across state lines. "My hope is that CMS is going to continue to allow us to do that because it is going to provide more access for patients," he says.
If CMS ends the cross-state licensure waiver for behavioral health professionals in 2021, it is unlikely that the federal agency will make the change abruptly, Hofer says.
"I predict that CMS will continue to allow behavioral health professionals to practice across state lines for at least a period of time after the pandemic. What is most concerning is continuity of care for the patient. For example, if a therapist is licensed in Massachusetts and is treating a patient in New Hampshire then CMS ends the licensure waiver, all of a sudden the patient can lose continuity of care. I think CMS is very concerned about that."
To maintain continuity of care, CMS is likely to allow therapists to continue treating patients across state lines as long as services are needed, he says.
With new Medicare fee-for-service reimbursement, Brigham Health plans to expand its Home Hospital program.
The Centers for Medicare & Medicaid Services' (CMS) recently announced the Acute Hospital Care At Home waiver is a huge step forward for home-based hospital care, the leader of the Brigham Health Home Hospital program says.
In the United States, the hospital at home model was pioneered by Johns Hopkins Medicine, which launched a program in 1994. The coronavirus pandemic has spurred adoption of the care model, including the launch of virtual hospital at home programs.
In November, CMS announced the creation of the Acute Hospital Care At Home program during the coronavirus public health emergency to help health systems and hospital increase care capacity during the pandemic. Six healthcare organizations were designated as the first participants in the Acute Hospital Care At Home program, including Boston-based Brigham Health.
The Brigham Health Home Hospital program has been shown effective in reducing cost of care.
In a randomized controlled trial published a year ago in the Annals of Internal Medicine, the adjusted mean cost of Home Hospital acute care episodes was 38% lower for home patients compared to control patients receiving traditional hospital care.
HealthLeaders recently discussed the new CMS hospital at home waiver and Brigham Health Home Hospital with David Levine, MD, MPH, MA, medical director of strategy and innovation for Brigham Health Home Hospital, and an assistant professor of medicine at Harvard Medical School. The following is a lightly edited transcript of that conversation.
HealthLeaders: What is the impact of getting Medicare fee-for-service reimbursement for hospital at home care?
David Levine: This is the change that we all have been waiting for. It is an enormous step forward for the field because it opens the care pathway to large numbers of patients who have Medicare as their only insurance.
For our program, we have been in a very fortunate position, where our population health team has supported our Home Hospital work at the enterprise level and our hospital has supported our Home Hospital work significantly. However, we have been constrained budgetarily. When you cannot bill for most of your services and you must rely on a fixed budget from central sources, that constrains the size and scope of your program. So, we are excited that we will be able to recoup much of the care costs from delivering care to patients. It will allow us to expand the program.
HL:What are your plans to expand Brigham Health Home Hospital?
Levine: We consider ourselves to be an innovation shop in home hospital care. So, we are continually adding sensors, new technologies, and different care pathways. Having a stable revenue source for our program allows us to expand in a very stable and guaranteed way.
On one end, we are continuing our innovation pathways and pursuits. That means different kinds of patients will be able to get Home Hospital care than before. We will hopefully be able to increase the quality, safety, and patient experience of the care that we deliver through new technologies and new care pathways.
On the other end, we are going to be able to offer this care to more people. Previously, our Home Hospital program was always full—it was capped because as soon as we discharged a patient, we took on another patient. We did not have a large care team to take care of all the patients who wanted Home Hospital care. With a more stable revenue source, we will be able to expand this offering to more patients.
HL: What was your previous cap on Home Hospital patients and what are your plans to increase the number of patients in the program?
Levine: A year ago, our cap was four patients. With COVID-19, we expanded to nine patients, and I am hoping we will be at 12 to 16 patients soon.
HL: Did Brigham Health Home Hospital have to be modified to participate in the CMS Acute Hospital Care At Home program?
Levine: The largest change is that the CMS Acute Hospital Care At Home waiver requires that a nurse either see the patient in person or by video at least once a day.
Our program is at the leading edge of using mobile integrated paramedics, who have a higher level of training than regular paramedics. We use mobile integrated paramedics quite frequently; oftentimes, they will see one of our patients twice a day along with a physician visit. That way of caring for patients does not fulfill the requirement of at least one daily touch by a nurse, so we have altered our practice to include a nurse visit daily. We will likely be having split visits—in the morning, the patient may be seen by a paramedic, and in the afternoon the patient may be seen by a nurse, or vice versa.
HL: What kind of special training and skills do mobile integrated paramedics have?
Levine: These are paramedics who build additional skills in acute care medicine such as administering more kinds of medications. For example, paramedics usually do not administer antibiotics, but mobile integrated paramedics do. Our paramedics can do more procedures such as putting in a Foley catheter, which is not something that paramedics usually do but we do it in the hospital, so that is a skill that our paramedics learn.
Mobile integrated paramedics also develop social and emotional skills. They function almost like a community health worker or a social worker. Finally, there is care coordination training.
The fundamental aspect is that paramedics are well trained, and they are often underutilized. They have intense expertise in the home. They have intense expertise in acute management. They have expertise in medication reconciliation. So, adding very thoughtfully to their skill set has been a boon to our program.
HL: What do you think the future holds for the hospital-at-home care model?
Levine: I am extremely enthusiastic about the future of home hospital care. We have been seeing an explosion in the number of programs and the use of this care model throughout the country. The CMS waiver has taken the next step to helping these programs to thrive and spread.
Presently, the CMS waiver is only authorized through the public health emergency; but, hopefully, we will be able to formalize the waiver in a rule that is much more permanent and final.
We need more next steps. We definitely need to see other payers follow CMS' lead. We need to see commercial fee-for-service payers to follow CMS' lead. We need to see Medicaid agency's follow CMS' lead—CMS has already signaled that change. We need to see the full fee-for-service structure embrace home hospital care.
The mindfulness program at an Ohio-based medical center has been expanded to include short videos for healthcare workers during the coronavirus pandemic.
A mindfulness program for healthcare workers at The Ohio State University Wexner Medical Center has decreased burnout and significantly increased resilience and work engagement, a recent research article found.
Burnout is one of the top challenges facing clinicians and other healthcare workers nationwide. In a report published in September 2020 by The Physicians Foundation, 30% of more than 2,300 physicians surveyed cited feelings of hopelessness or having no purpose due to changes in their practices related to the coronavirus pandemic. Research published in September 2018 indicates that nearly half of physicians across the country were experiencing burnout symptoms.
The recent research article, which was published by Global Advances in Health and Medicine, highlights the impact of the Mindfulness in Motion (MIM) program at The Ohio State University Wexner Medical Center in Columbus, Ohio. "Mindfulness is described as a nonjudgmental, present-moment awareness with non-reactivity to introspective perceptions," the study's co-authors wrote.
The study includes three key data points.
As measured by the Maslach Burnout Inventory, there was a 27% reduction in MIM participants meeting burnout criteria.
As measured by the 10-item Connor-Davidson Resilience Scale, which rates resiliency on a scale from 0 to 40, there was a significant increase in resilience. After participating in MIM, mean resilience scores rose from about 29.2 to about 31.6.
As measured by the Utrecht Work Engagement Scale, which rates work engagement on a scale from 0 to 6, there was a significant increase in work engagement. After participating in MIM, mean work engagement scores rose from about 3.9 to 4.3.
MIM was launched in 2008, starting with the nursing staff in the medical center's surgical intensive care unit. The program has since been expanded to all staff members at the facility, the lead author of the recent research article told HealthLeaders.
"We have environmental workers, we have respiratory therapists, we have nurses, and we have physicians and many other job titles. So, we have the whole healthcare teams understanding the stresses of other staff members," said Maryanna Klatt, PhD, a professor in the Department of Family and Community Medicine at The Ohio State University College of Medicine in Columbus.
MIM is an eight-week program, with participants meeting for a one-hour session each week. The sessions have five primary elements:
1. Reflective writing in response to a weekly prompt
2. Video on the science of mind/body interventions
3. Voluntary sharing of reflective responses
4. Experiential video on yoga/mindfulness practice
5. Closing meditation based on a weekly theme
An example of a weekly prompt to spur reflective writing is asking MIM participants about an experience they had in the prior week with a co-worker or a patient where they felt totally present, Klatt said. "They felt they were totally there, and the experience was different than day-to-day interactions."
This weekly prompt can have a profound impact, she said. "People get totally blown away. They say, 'I did not recognize the difference. It reminds me of why I went into healthcare.' But until they are prompted to remember this kind of experience, that experience just happens, and they do not note it. Without the prompt, they do not get the boost from the experience."
Klatt said a good example of a weekly theme for the closing meditation of a MIM session is presented in Week 1 of the program.
"We ask participants to watch their habits without judging them. Participants are asked to watch their habits of how they communicate with others, habits of thought, or physical habits. The first step of mindfulness is noticing. So, the Week 1 theme for the closing meditation is to begin the meditation with seeing yourself and paying attention to how you operate in the world. In the reflection at the beginning of Week 2, people share what they realized from the Week 1 meditation on their habits," she said.
Avoiding passing judgment on habits or other MIM exercises is crucial, Klatt said. "An important aspect of mindfulness is not to judge yourself. In this case, you begin by noticing a habit. Then you can choose to either keep the habit or change it."
A pivotal part of the MIM program that makes it well-suited to the hospital setting is making the weekly sessions part of the workday, she said. "By scheduling the Mindfulness in Motion sessions during the workday, it shows healthcare workers that their hospital cares about them—it shows the hospital cares about how healthcare workers are functioning. Mindfulness in Motion is not an extra thing that healthcare workers must do—it is incorporated in the workday."
Adapting Mindfulness in Motion to the coronavirus pandemic
During the coronavirus pandemic, Klatt has expanded MIM offerings beyond the eight-week program.
"To serve the whole medical center during the pandemic, I had to shift to a more condensed format. I started with 5- to 6-minute video practices. We are up to more than 19,500 views of those videos. I was shocked at how many people used the short videos. Now, we are in a patient surge situation with COVID-19 in Ohio, and I was asked to make some 2-minute videos. These videos are designed for the healthcare providers in the medical center who are overwhelmed with work to help them ground themselves and reboot when they feel they cannot go on because they are so exhausted," she said.
Klatt also has created 30-minute PowerPoint videos to explain what mindfulness is to people and how they can apply mindfulness during the pandemic. Those videos have about 4,000 views, she said.
A recent study found an unexpectedly high level of discrimination against patients, researcher says.
More than 1 in 5 adults experience discrimination in healthcare settings, a recent research article found.
After lurking in the background for decades, health equity has emerged as a top concern in the U.S. healthcare system. In earlier research, experiences of discrimination in healthcare settings have been shown to drive negative impacts on trust, communication, and health-seeking behaviors.
The recent research article, which was published by JAMA Network Open, features survey data collected from more than 2,100 U.S. adults. The study includes several key data points.
458 (21.4%) of the survey respondents reported experiencing discrimination in healthcare settings
Among survey respondents who reported experiencing discrimination, 72.0% reported experiencing discrimination in healthcare settings more than once
Racial or ethnic discrimination was the most common type of reported discrimination (17.3%), followed by discrimination based on educational or income level (12.9%), weight (11.6%), and age (9.6%)
The odds of experiencing discrimination were high for women (odds ratio 1.88)
The odds of experiencing discrimination were low for older survey respondents (odds ratio 0.98), survey respondents earning at least $50,000 in annual household income (odds ratio 0.76), and survey respondents who reported good (odds ratio 0.59) or excellent (odds ratio 0.41) health compared to poor or fair health
Non-Hispanic white survey respondents reported significantly less racial discrimination (4.0%) compared to non-Hispanic black survey respondents (54.6%) and Hispanic survey respondents (21.9%)
"The prevalence of discrimination identified in this study points to a need to examine discrimination in the healthcare system as a risk factor for other negative effects. Future work on interpersonal discrimination in the healthcare system should examine the types of discrimination we have identified herein, with the understanding that they are harms imposed on patients rather than caused by or reflective of patient demographic characteristics," the study's co-authors wrote.
Interpreting the data
The lead author of the study told HealthLeaders that the level of discrimination found in the research was higher than expected.
"The prevalence of discrimination in the healthcare system we identified (21.4%) was higher than we anticipated. Among those who reported discrimination, 72% experienced it more than once. We know that discrimination has serious downstream impacts on people's health and engagement with the health system, and we see this as an urgent issue," said Paige Nong, BA, a doctoral candidate in the Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, Michigan.
The study highlights the need to address discrimination against black patients, she said. "Because the study is national, we get a picture of the disproportionate impact of interpersonal racism on black people in the U.S. healthcare system. This adds to what we already know about the harms of racism in other domains such as housing, employment, and policing, for example. The discrimination we identify in our study is fundamentally a justice issue, reflecting both historical and contemporary racism."
The study also adds to the foundation of other research that should lead to effective interventions to address discrimination in healthcare settings, Nong said.
"We hope that our findings highlight this critical issue for healthcare systems and focus attention on the harm being done while people are seeking care. Although prior research analyzes interventions and ways to address discrimination more directly, we think that one part of addressing interpersonal discrimination effectively is more precise measurement and evidence-based responses. There is a wealth of important literature on discrimination that should necessarily inform these efforts. We think that our survey questions might be used to better understand the particular experiences of patients in healthcare systems across the country."
RWJBarnabas Health is set to launch the pilot phase of its Health Beyond the Hospital initiative in January.
RWJBarnabas Health (RWJBH) is launching an ambitious initiative that will eventually screen every patient who visits the health system's facilities for social determinants of health (SDOH) that could also serve as a blueprint for other healthcare organizations to follow.
SDOH factors such as food security and housing play a pivotal role in the health of individuals and populations. A landmark 2016 study published by the American Journal of Preventive Medicine found that socioeconomic factors, health behaviors, and the physical environment account for determining more than 80% of health outcomes, with clinical care accounting for only 16% of health outcomes.
In January, West Orange, New Jersey–based RWJBH is set to launch the health system's Health Beyond the Hospital initiative. DeAnna Minus-Vincent, MPA, senior vice president and chief social integration and health equity strategist at RWJBH, says the program will eventually be one of the country's first universal SDOH efforts.
"It is universal because once we get beyond the pilot phase, anyone who comes into an RWJBarnabas facility will be screened for social determinants of health. Some health systems have chosen to limit social determinants of health screening to either the most chronically ill or to those patients with limited income. We have chosen to take a broader view because all patients have social determinants of health and most health outcomes are affected by social determinants," she says.
Through the Health Beyond the Hospital initiative, RWJBH will be screening for several SDOH, including food and nutrition, living conditions, safety at home, isolation and socialization, and substance use.
In the pilot phase, RWJBH is launching Health Beyond the Hospital in a range of clinical settings to test the initiative, "so that we could build out the proper processes for different settings," Minus-Vincent says.
The pilot sites include the following:
An emergency department and inpatient setting in Newark
A clinic and an ICU in New Brunswick
A handful of physician practices across New Jersey
RWJBH Children's Specialized Hospital, which includes several outpatient centers across the state
The pilot phase of the initiative is expected to last about a year, she says.
SDOH assessments and connecting patients to social services
One of the ultimate goals of Health Beyond the Hospital is to make SDOH assessments as routine as assessing patients for height, weight, and blood pressure. Because the initiative is new and the COVID-19 pandemic is surging in New Jersey, RWJBH has contracted with a vendor to help clinicians conduct SDOH assessments, Minus-Vincent says.
"ConsejoSano will do assessments proactively prior to patients coming into a clinical setting. Patients respond to social determinants of health questions so that our clinicians do not have too many questionnaires to do. However, once the assessments become a routine part of our processes, assessments will occur as part of a normal piece of the clinical setting," she says.
Another vendor will play a key role in referring patients for social services, Minus-Vincent says.
"Once a patient identifies that they have a need, we are working with NowPow, which is a technology tool that has already identified services both in the community and within our RWJBarnabas Health network. NowPow will match needs to appropriate services. For example, if a patient does not know how to prepare healthy foods, needs help with nutritional education, cannot afford food and is not already on SNAP, NowPow could refer the patient to a dietitian in-house. NowPow could get the patient set up with cooking classes and could help with phone-based support to get the patent enrolled in SNAP," she says.
When NowPow makes a referral, the primary stakeholders are notified, which helps to ensure patients get connected with services, Minus-Vincent says. "The patient knows the organization providing the service, the organization providing the services knows there has been a referral, and the referral goes into the patient's electronic medical record. So, everybody knows that the patient has selected a particular organization for services."
If a patient does not connect with a social service, there will be follow-up contact via text, email, or phone calls within a week, she says. "The patient will get a text, email, or phone call noting that they have not received nutritional counseling or another service, and they will be asked questions about whether they need help, such as transportation."
Monitoring the impact
RWJBH will be following several metrics to gauge the impact that Health Beyond the Hospital has on patients and other stakeholders. Minus-Vincent says those metrics include the following:
Comparing health outcomes data prior to a patient receiving social services to health outcomes data after social services have been received
Tracking whether providers and other crucial healthcare workers are being educated about SDOH
Examining health outcomes of patients by types of providers
Conducting financial modeling for the initiative
Monitoring changes in healthcare spend at the patient level
Tracking whether patients believe they have fewer SDOH after receiving services
Following whether unnecessary emergency department visits are reduced
"There is a laundry list of metrics that we will be looking at to see how we are changing knowledge base, behaviors, and health outcomes," she says.
Laying a foundation for Health Beyond the Hospital
There will be two primary educational efforts for the RWJBH healthcare workforce, Minus-Vincent says.
"First, there is a mandatory session for all of our RWJBarnabas Health employees that will educate them about some of the technology tools and available resources. Second, we have developed a program with Rutgers University that is a five-part, guided, virtual series for physicians and intake workers and everyone in between that touches on equity, racism, bias, culturally competent care, and social determinants of health such as food and nutrition, housing, substance use, and violence."
Education for RWJBH healthcare workers is an essential component of the initiative, she says. "The education is important because we have a great deal of diversity in New Jersey. We have pockets of great wealth and pockets of poverty. Some of our physicians believe few of their patients have social determinants of health, so they are hesitant to do SDOH work."
When it is fully implemented, Health Beyond the Hospital will have a broad scope, Minus-Vincent says.
"We have created an end-to-end program that includes the relevant stakeholders, with the patient as our true North Star. We also know that if we do not build a program that is easy for our providers to use, it will not get used. And we have thought about how we create a comprehensive program that brings in our government and nonprofit partners. We want to reengineer how the health and social service sectors work together."
As has been the case in 2020, the COVID-19 pandemic will dominate the clinical care field in 2021, three experts say.
A trio of clinical care experts have shared their 2021 clinical care predictions with HealthLeaders.
As is likely expected by most healthcare observers, the coronavirus pandemic looms large in the predictions for the coming year. But the grim COVID-19 outcomes of 2020 should ease in 2021, the experts say.
1. Coronavirus vaccine and the course of the pandemic
With two COVID-19 vaccines already granted emergency use authorization in the United States and more vaccines on the horizon, the vaccination of Americans will have a major impact on clinical care in 2021, says Shafeeq Ahmed, MD, MBA, interim president of Howard County General Hospital—A Member of Johns Hopkins Medicine.
"Vaccination is going to help us in healthcare. We are going to have fewer healthcare workers out sick because of COVID-19. That is going to be important from a staffing perspective," he says.
Despite the rollout of vaccines, Ahmed predicts coronavirus will affect patient care significantly into the summer of 2021.
"In 2021, we are still going to be social distancing, wearing masks, and taking other precautions. From an outpatient perspective, there is still going to be prepping and managing of patients with the precautions that we currently are taking. On the inpatient side, we are still going to be dealing with coronavirus patients, which challenges us on many levels including not being able to have visitors. After the summer, we will still have COVID-19 patients, but we are not going to have overwhelming surges."
Patrick Godbey, MD, president of the College of American Pathologists, and laboratory director at Southeast Georgia Regional Medical Center in Brunswick, Georgia, is more optimistic about the course of the pandemic.
"I expect the number of cases to go down in the spring. As the weather gets warmer, people will be able to spend more time outside and spend less time indoors close together. The major holiday season will be over. And more people will have been vaccinated. So, for a combination of reasons, by March or April our coronavirus infections should see a significant decrease," Godbey says.
2. Return of the patient
Both Ahmed and Godbey predict deferred care linked to the pandemic will decrease significantly in 2021.
"What has been shown is that patients are still interested in coming in for routine care as opposed to delaying care for a long time. They will want to get back to seeing their doctors. So, we should see an uptick in growth in care that is not related to COVID-19. With the vaccine out, people are not going to be as afraid to seek care. They are going to feel more comfortable with healthcare organizations and they are going to come back," Ahmed says.
"We have had patients who have broken their hips and have waited much longer than they should to receive medical care because they were afraid of COVID-19. Or care has been delayed at healthcare organizations because of the need to take care of COVID-19 patients. I predict that we will be able to deliver care and patients will seek care in a more expedient fashion as we get a better handle on COVID-19," Godbey says.
3. Coronavirus testing
Demand for coronavirus testing will remain high in 2021, but the healthcare system should come closer to meeting the need in the first half of the year, Godbey predicts.
"What we would like to have happen is to have more polymerase chain reaction tests available, so that we can have everybody who needs to be tested receive tests. We are not there yet. We need to be able to provide accurate testing to every patient who needs it. The demand will continue, and we need to address that need. We have been told that in the first quarter of 2021, we will see an increase in the availability of reagents. If that is the case, we will come closer to meeting the need," he says.
4. Telehealth sustainability
After explosive growth in the early phase of the pandemic, telemedicine will continue to play a major role in clinical care next year, Ahmed predicts.
"Healthcare organizations will continue to use telemedicine as an option for care to manage patients. Telemedicine is just another version of social distancing, so it is going to be with us for the foreseeable future. People are recognizing that there is a value to not having patients come in for office visits. Patients can get their health condition management from the comfort of their own homes. It is going to be very tough for patients to want to give that up," he says.
Brian Johnson, MD, the chief medical officer at West Penn Hospital in Pittsburgh, Pennsylvania, is bullish on telemedicine in 2021.
"Telehealth has certainly ramped up. It is here to stay—the question is to what degree. If we go back to March and April of this year, telehealth was being used a lot. Then it tailed off, but it has gone back up again. Telehealth will find a sweet spot in 2021," he says.
Telemedicine will help drive the consolidation of physician practices next year, Johnson says. "We will be able to use telehealth to consolidate outpatient practices and reduce overhead, particularly in primary care. We can have less overhead but bring better care to patients by adding telehealth services to the book of services that practitioners provide."
5. Behavioral health bubble
Demand for behavioral health services will explode in 2021, Johnson predicts. "Given the stressors around the coronavirus—not just the disease process itself but also the relationship challenges, economic challenges, and healthcare challenges for the general public and healthcare workers—I foresee much more of a need for behavioral health services."
6. Addressing health equity
After decades of lurking in the healthcare background, health equity will emerge as a high-priority issue in 2021, Johnson says. "COVID-19 has brought health equity to the forefront."
Large healthcare organizations will lead the charge on addressing health equity next year, he says. "With engagement from large healthcare institutions, we can make progress on health equity. We are not going to make headway through government. We are not going to make headway through little pockets of small physician practices or small healthcare organizations. It is going to require large healthcare entities such as mine at Allegheny Health Network."
The larger healthcare entities need to make a commitment to address health equity, Johnson says. "That is where we are going to have an impact—2021 is the year when we are going to begin to see health equity rise to the forefront. We may not be able to create an impact where we see changes in mortality or changes in health outcomes, but we will make the first step to ensuring that more people have appropriate access to the care and health education that they have not had in the past."
