The essential elements of providing primary care to patients via telemedicine include an affordable financial model and exceptional patient experience.
A San Francisco–based telehealth provider is on a mission to transform primary care services for patients and their physicians.
The coronavirus disease 2019 (COVID-19) pandemic has accelerated adoption of telehealth services at health systems, hospitals, and physician practices. Many payers, including the Centers for Medicare & Medicaid Services, have expanded coverage of telemedicine.
PlushCare has been providing primary care telehealth services to patients since its founding five years ago.
"Our median patient age is 40 years old. We are at parity with what a typical primary care provider can do. We deal with urgent care visits, preventative care, and we also take care of patients with chronic conditions such as high blood pressure, asthma, depression, anxiety, and high cholesterol. We have treated more than 3,500 unique diagnoses," says Ryan McQuaid, co-founder and CEO of PlushCare.
PlushCare, which has a nationwide patient population of more than 200,000, employs more than 100 physicians. The COVID-19 pandemic has boosted demand for PlushCare's services, with a 400% increase in telehealth visit volume, McQuaid says.
The business model at PlushCare features five elements.
1. Financing mechanism
The financial model at PlushCare includes a monthly patient membership fee set at $14.99. "The membership fee is for all of the benefits that our patients are getting that are not billable through insurance. When you compare Plushcare to people paying $10,000 a year for a concierge doctor, it is extremely reasonable," McQuaid says.
In addition, there are payment mechanisms for virtual visits, he says. "Patients can pay cash or use their flexible spending account or health savings account. We also are contracted with most of the major health plans. For patients with health insurance, they pay the primary care copay that they would typically pay for a bricks-and-mortar primary care practice visit."
2. Patient experience
An exceptional patient experience is a foundational aspect of PlushCare, McQuaid says. "We have seen that providing what we consider a 'wow' patient experience is incredibly valuable for people getting excited and telling their friends and family members about us. Our net promoter score has consistently been at 90, and the average primary care physician office across the United States is about 3, which is according to the Advisory Board. Our focus on the patient experience is huge."
PlushCare offers patients 24/7 access to a physician.
"From a patient perspective, the way we work is you can go on our website or download our app, then book a video visit with your physician. Patients select a dedicated primary care provider with whom they have an ongoing relationship. Our clinicians do not work 24 hours a day, seven days a week; so if a patient has an urgent need on the weekend and their primary care physician typically works Monday through Friday, the patient can see one of his or her colleagues to get immediate help," he says.
PlushCare employs more than 40 care coordinators to help patients with a range of issues, McQuaid says. "Patients can use in-app messaging to talk with their care coordinators. So, if a patient's prescription did not show up at a pharmacy, or if a patient needs help finding a specialist who is in-network and highly rated, our care coordinators can help patients figure that out. It is a concierge-like service."
There are also registered nurses available to help patients, he says. "If patients have a question that does not necessarily need contact with their dedicated primary care providers, they can contact a registered nurse who can respond to any questions."
From a technology perspective, PlushCare has a world-class patient app, McQuaid says. "When you think of healthcare, technology, and apps, you often do not think of great consumer experiences. We hired some of the best product folks, designers, and engineers who came from consumer-focused companies such as Amazon. They focused on building an amazing consumer experience."
3. Physician experience
A crucial element of providing a good patient experience is promoting a positive physician experience, he says. "We feel it is important for physicians to feel happy and not to be burdened by bureaucracy or imputing information into an electronic health record. We use technology to make functioning as a physician seamless."
PlushCare developed a physician-friendly electronic health record, McQuaid says. "We built our own electronic health record because a virtual primary care EHR did not exist when we founded PlushCare. Similar to the consumer side, we got amazing designers, engineers, and product specialists who had built fantastic consumer experiences to build our electronic health record, which our physicians love."
For example, PlushCare's EHR is designed specifically for primary care, so it is not bloated to support many specialties. The EHR also is configured to decrease paperwork for physicians, with forms and coding completed behind the scenes by a tech-enabled administrative team.
In addition to building an innovative EHR for physicians, PlushCare's billing processes reduce the administrative burden on clinicians, he says. "We have removed physicians from the billing process as much as we possibly can. The goal is to remove everything that is distracting our physicians from building a relationship with their patients and taking care of their patients."
PlushCare's company culture includes making sure physicians feel they are part of a community, McQuaid says. "When you talk with our doctors, one thing they love is the community we have established—they are able to share information absolutely seamlessly. It may not be what you would think because everybody is working virtually, but our management team has done an awesome job at creating a community for our physicians."
4. Top-notch physicians
Employing high-quality physicians has been one of the keys to success at PlushCare, he says. "All of our physicians are recruited from the Top 50 medical institutions in the country and, on average, they have 15 years of experience."
Building a team of excellent physicians has appealed to patients, McQuaid says. "When you think of professional services—whether you want a lawyer, or a physician, or a management consultant, or an investment banker—everybody wants the best. By having high-quality doctors, we instill trust in patients that they are going to get an amazing doctor at PlushCare."
5. Physician-patient relationship
PlushCare has focused on building relationships between patients and their primary care physicians, he says. "To optimize the physician-patient relationship in telehealth, it really is a longitudinal primary care experience, in which the patient sees the same physician over time and builds a relationship with the physician on an ongoing basis."
Since the first phase of the coronavirus pandemic in the United States erupted in March, HealthLeaders has published more than 70 clinical care stories on the outbreak.
The coronavirus disease 2019 (COVID-19) pandemic has been the most momentous clinical care story of the year.
Here are the Top 10 HealthLeaders clinical care COVID-19 stories so far in 2020:
1. Healthcare worker mental health: During the COVID-19 pandemic, the mental health needs of healthcare workers should not be overlooked, a disaster response expert says.
2. Home-based medical care: The coronavirus pandemic has increased demand for home-based medical care, according to the chief medical officer of Landmark Health.
3.Infection prevention: After months of grappling with the novel coronavirus, infection preventionists have developed several best practices for tackling the germ, the president-elect of the Association for Professionals in Infection Control and Epidemiology says.
4.Respiratory therapists: With respiratory distress common among seriously ill coronavirus patients, respiratory therapists are at the tip of the spear on the pandemic frontline.
5. Preparing for a surge: WakeMed Health & Hospitals was spared a dramatic impact in the first wave of the coronavirus pandemic and is ready if a second wave hits.
6. Managing a surge: It was a nightmare scenario. Emergency rooms were overwhelmed with coronavirus patients—sick patients walking through the door and dozens of seriously ill boarded patients awaiting inpatient beds. In some metropolis hospitals, demand for ICU beds exceeded supply.
7. Alternative to ventilator care: Nasal high flow therapy is a less invasive alternative to ventilator care for many seriously ill coronavirus patients, UnityPoint Health experts say.
8. Care rationing: In addition to ventilators, there are four primary care rationing scenarios during the coronavirus pandemic, a bioethicist says.
9. Life support: After all other conventional treatments have failed, extracorporeal membrane oxygenation (ECMO) life support can be a coronavirus patient's last hope for recovery.
10. Rural hospitals: In response to the coronavirus pandemic, an Indiana-based rural hospital succeeded in boosting staff, increasing bed space, and securing essential equipment such as ventilators.
The Personal Health Inventory self-assessment has been adapted from a self-assessment tool that clinicians use to help patients with chronic illness.
Clinicians and other healthcare workers can complete a two-minute self-assessment to gauge their wellbeing and help prevent burnout.
Research published in September 2018 indicated that nearly half of physicians nationwide were experiencing burnout symptoms, and a study published in October 2018 found burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction. Burnout has also been linked to negative financial effects at physician practices and other healthcare organizations.
"Number One, you need to pay attention to yourself. If you are wounded, it is very difficult to help patients or your fellow staff members," says Wayne Jonas, MD, a family physician and executive director of the Samueli Foundation's Samueli Integrative Health Programs. The foundation is based in Corona del Mar, California.
The Personal Health Inventory self-assessment for healthcare workers has been adapted from what clinicians are trained to do with patients who have chronic disease to have the patients focus on their self-care and lifestyle for the management of their chronic illnesses.
"These assessments of patients are done about every three to six months, depending on the intensity of chronic disease. For clinicians, retaking the self-assessment in three months is a good idea," Jonas says.
The Personal Health Inventory self-assessment has four domains, with a set of simple questions in each domain that can be answered quickly.
1. External environment: The questions assess wellbeing-related factors in the workplace and the home.
2. Behavior and lifestyle: The questions include assessments of sleep and food intake.
3. Social and emotional: The questions focus on whether you are connecting with others and your level of social support.
4. Spiritual and mental: The questions help examine whether you are doing things that are meaningful for you and provide insight about whether you are doing things that are important in life such as developing abilities and talents.
Utilizing the self-assessment
"What you do is rate where you are in each of these four domains from one to five—you put a number down. You rate where you would like to build your self-care—where you want to see enhancements. If you have a very low score—three or below—that is a need area and where you should focus, especially if you have readiness to change. Then you reassess after three months and find out how the change is occurring," Jonas says.
The self-assessment tool is not a burnout assessment, he says. "What this self-assessment does is give clinicians a score on where they can take action in their lives. So, this is a self-care action assessment. It helps clinicians narrow down and isolate their core needs."
Once clinicians and other healthcare workers have done the self-assessment, they can look at the domain scores and pick one or two things at most, then set smart goals for specific improvements, Jonas says.
"We are trying to avoid burnout by doing this self-assessment—this is preemptive and about resilience. Resilience is not the entire solution for burnout—there need to be changes in the organizational environment, too. But resilience correlates quite well with risk for burnout. This self-assessment is a way to address burnout and to do a preemptive strike on burnout, especially in these very stressful times."
Coronavirus patients who are placed on ventilators need help from speech language pathologists such as restoring the ability to swallow.
Speech language pathologists are providing essential rehabilitation services to patients recovering from serious cases of coronavirus disease 2019 (COVID-19).
Many seriously ill COVID-19 patients are placed on ventilators due to acute respiratory distress syndrome. Speech language pathologists provide rehabilitation services for damage caused by mechanical ventilation, which includes injury to vocal cords from breathing tubes and deconditioning of the muscles needed for swallowing.
"Those patients who end up in the ICU either have a tracheostomy, or they have a tube that is pushed down through their vocal cords to have an airway to help them breathe. Then they are placed on a ventilator to help save their lives. They are on a machine that is helping them breathe, potentially for weeks. They are bedridden and they have a tube down their throat, so they lose their ability to eat and swallow," says Rinki Desai, MS, a speech language pathologist and adult outpatient lead at the University of Mississippi Medical Center's Voice and Swallowing Center in Jackson, Mississippi.
Rehabilitating patients' ability to swallow is a primary service provided by speech language pathologists, she says. "About 90% of what we do in the field of medical speech language pathology is treating swallowing disorders. For example, patients who experience a stroke can have trouble with swallowing, breathing, speech-language communication, and cognition. So, on a given day in a hospital ward or ICU, that is the kind of care that we provide."
COVID-19 patients who are placed on a ventilators need speech language pathologists to regain key functions, Desai says.
"These patients are not swallowing. They are not able to communicate verbally, and they have a significant impact on their voice. If a patient goes anywhere beyond two days on a ventilator, there can be significant injuries. For COVID-19 patients, the most immediate impairment that speech language pathologists treat in the ICU is helping patients communicate while they are on a ventilator using a white board or gestures. Once patients are off the ventilator, we help them breathe, swallow, and use their voice again."
There are three main categories of rehabilitation services that speech language pathologists provide to COVID-19 patients who require mechanical ventilation, she says.
1. Swallowing: "We start patients with swallowing ice chips, then gradually get them to the point where they can eat by mouth. We make sure they are safe, with efficient swallowing. We also help with respiratory-swallowing coordination."
2. Communication: "If patients have trouble communicating, we will provide specific therapies to get their communication back. Typically, they lose their voice because of the damage to their vocal cords. In those cases, we have very specific voice therapy techniques and exercises to help patients get their voice back as soon as possible."
3. Cognition: "If patients have trouble with memory, orientation, loss of consciousness, or delirium, our goal is to help patients regain function. We help them process and follow commands. We help them to get back to being as independent as possible with activities of daily living before they leave the hospital."
Pandemic challenge
In the early phase of the coronavirus pandemic, shortages of personal protective equipment (PPE) posed a significant challenge for speech language pathologists and their seriously ill COVID-19 patients, Desai says.
"We did not have enough personal protective equipment, so we had to limit the number of people going into patient rooms. We had to make a decision—who are the most essential people who need to go into the patient rooms? It was the pulmonologists, the ICU physicians, and the ICU nurses. So, we were dealing with rehab professionals not being able to see patients quite a bit—sometimes until they were COVID-19 negative."
Delaying the rehabilitation services that speech language pathologists provide to COVID-19 patients increased length of stay in ICUs, she says. "For every day a patient is in an ICU, the patient is bedridden and deconditioning, and it takes about a week to recover function."
Fortunately, University of Mississippi Medical Center was able to secure adequate supplies of PPE, Desai says.
"Now that we have enough PPE—we have our N95 masks, face shields, and other equipment—speech language pathologists are going in right away even if the patient has tested positive for COVID-19. We start therapy as soon as we can because we want to minimize deconditioning and weakness. We want patients to start eating and using their voice muscles as soon as possible."
New research indicates that sterilized and expired N95 respirator masks offer effective protection against coronavirus infection for healthcare workers.
N95 respirator masks as many as 11 years past their expiration date and used N95 respirator masks treated with ethylene oxide or vaporized hydrogen peroxide maintain their filtration efficiency, new research shows.
Limited supply of personal protective equipment was one of the most daunting challenges for U.S. healthcare organizations in the early phase of the coronavirus pandemic. Shortages of N95 respirator masks, which filter at least 95% of 0.3-μm particles and are the gold standard for protection against airborne pathogens, were particularly vexing for healthcare workers and their employers.
The new research, which was published by JAMA Internal Medicine, tested the fitted filtration efficiency (FFE) of 29 fitted facemasks. The fitted facemasks included N95 respirator masks, surgical masks with ties, and procedure masks with ear loops.
The FFE tests were conducted from April to June in a custom-built exposure chamber at the U.S. Environmental Protection Agency Human Studies Facility in Chapel Hill, North Carolina. The testing followed the Occupational Safety and Health Administration's Modified Ambient Aerosol CNC Quantitative Fit Testing Protocol For Filtering Facepiece. Three sterilization methods were tested on used N95 respirator masks: ethylene oxide, steam, and vaporized hydrogen peroxide.
The research generated several key findings:
N95 respirator masks as many as 11 years past their expiration date retained FFEs more than 95%
N95 respirator masks treated with ethylene oxide or vaporized hydrogen peroxide retained FFEs more than 95%
Steam sterilization distorted 1860 N95 respirator masks, rendering them unsuitable for reuse
Steam sterilization of 1870+ Aura face masks was effective, with the masks retaining more than 95% FFE after a single sterilization cycle
Chinese-made KN95 respirator masks did not achieve 95% FFE: the Jia Hu Kang KN95 mask with ear loops posted an 85.1% FFE and the Guangdong Fei Fan KN95 posted a 53.2% FFE
N95 respirator masks that were the wrong size for study participants still had substantial protection, with FFE results between 90% and 95%
The mean FFE score for surgical masks with ties was 71.5%
Procedure masks with ear loops had the lowest mean FFE score, at 38.1%
Interpreting the results
New N95 respirator masks are not the only effective face-covering option for clinicians working with coronavirus disease 2019 (COVID-19) patients, the co-authors of the new study wrote.
"This quality-improvement study evaluating 29 face mask alternatives for use by clinicians interacting with patients during the COVID-19 pandemic found that expired N95 respirators and sterilized, used N95 respirators can be used when new N95 respirators are not available. Other alternatives may provide less effective filtration," they wrote.
Sterilization with ethylene oxide (EtO) has one drawback, the co-authors wrote. "A potential disadvantage of EtO sterilization is that the wearer may be exposed to residual EtO within the face mask."
An editorial that accompanied the new study says N95 respirator masks may be preferred in clinical settings with the potential for coronavirus exposure, but they are not necessarily essential.
"Importantly, no documented SARS-CoV-2 outbreaks have been linked to settings in which surgical masks were assiduously used in lieu of N95 masks, which suggests that even if airborne transmission is a considerable contributor to SARS-CoV-2 transmission, surgical masks are likely sufficient to prevent it. Because the infectious dose of virus required to cause clinical infection also remains unknown, it is possible that blocking most, even if not all, viral particles through masks with lower filtration efficiencies of submicron particles is sufficient to prevent disease in the vast majority of cases."
Thomas Ely says doctors of osteopathic medicine are helping to address physician shortages in rural and underserved areas of the country.
The new president of the American Osteopathic Association has prescriptions for U.S. healthcare.
Thomas Ely, DO, assumes his leadership role at the AOA with several momentous challenges facing physicians, including the deadliest pandemic in a century, high burnout rates, and a looming physician shortage.
An Army veteran, Ely served as an aeromedical evacuation pilot early in his military career. He worked for the Army Surgeon General before earning his doctor of osteopathy degree from what is now Kansas City University of Medicine and Biosciences College of Osteopathic Medicine.
He cofounded a private practice in Clarksville, Tennessee, that later helped form a large physician-led multispecialty medical group. He has experience in hospital leadership, including working as chief of medical staff, director of medical affairs, and chief medical officer. When Ely was installed as AOA president last month, he was working as a healthcare consultant.
Ely recently talked with HealthLeaders about the goals of his AOA presidency and the challenges facing U.S. physicians. The following is a lightly edited transcript of that conversation.
HealthLeaders: Besides the coronavirus disease 2019 (COVID-19) pandemic, what are the top priorities of your AOA presidency?
Ely: I have three major goals.
I want to continue the expansion of our osteopathic community. I want to enhance the American Osteopathic Association's and osteopathic medicine's public health mission. And I want to continue to secure the future of our profession.
When I say expansion of the osteopathic community, osteopathic medicine is the fastest growing healthcare profession in the country. We have grown 63% in the past decade, and more than 300% over the past three decades. Despite this growth, many regions of the country are suffering from physician shortages, particularly in rural and underserved areas.
With respect to the public health mission, I would like to focus on vaccination and immunization. Everyone must get the flu vaccine this fall. And we must encourage families to continue the routine care and immunizations that protect them from disease. When there is a vaccine ready for COVID-19, we need everyone to get that, too.
With the potential combination of influenza virus on top of COVID-19, both could kill you. People need to avoid the risk of having that combination.
To secure the future of our profession, I think a lot about our students. One of the great things that has come to fruition is the transition to a single graduate medical education system in this country. Osteopathic physicians and allopathic physicians all now are competing for quality, post-graduate training under a common system.
HL: What are the top challenges facing physicians?
Ely: The first challenge is related to independent physician practices, especially primary care practices because they have experienced devastating economic effects from the pandemic.
The established parameters of physician compensation must be addressed. Physicians should be compensated for their judgment and their outcomes. Payers must recognize that physician practices are different, depending on their specialty, the type of practice, the location of practices, and, most importantly, the makeup of their patients.
The second challenge is personal wellness and self-care. If physicians can schedule patients, they can schedule self-care for themselves and their families. They must take care of themselves if we are going to get through this pandemic.
The third challenge is to make sure that our patients continue to be seen for their chronic medical conditions such as diabetes, heart failure, chronic obstructive pulmonary disease, and renal failure. Most importantly, we need to make sure our patients keep their children current on vaccinations and immunizations.
Finally, the opioid crisis has not gone away. We need to continue to provide care and support for patients impacted by this crisis. Many communities in this country are reeling from the double blows of the opioid epidemic and the COVID-19 pandemic. In 2018, there were more than 67,000 people who died from drug overdoses, and in 2019 that number was higher.
Ely: Healthcare professionals are showing significant rates of post-traumatic stress, anxiety, insomnia, and depression, according to new National Institutes of Health research. Not only are our physicians faced with unprecedented levels of death and suffering during this pandemic, many are losing their colleagues and family members. This is truly a devasting time for the entire healthcare community.
There is one thing I tell every graduating medical student that I see and that I tell osteopathic physicians on an ongoing basis: They must take care of themselves. Significant numbers of physicians will—at some time in their practice life and especially during this pandemic—have periods of dysthymia. If that ever occurs, I advise them to reach out to another physician. Don't sit there alone because there is a strong likelihood that any physician they reach out to has encountered the same thing in his or her life, and can give advice on immediate and best steps to take.
Fortunately, there are some good resources available. I would encourage anyone on the frontlines of the pandemic to reach out to the Physician Support Line. It is a free, confidential service that supports the mental health of doctors and medical students.
HL: The Association of American Medical Colleges is predicting there will be a shortage of as many as 139,000 physicians by 2033. How can the physician shortage be addressed?
Ely: When I applied to medical school in 1976, there were only eight osteopathic medical schools. We now have 38 medical schools located on 59 campuses. We are the fastest growing healthcare profession in the country. One out of four medical school students in the United States are in osteopathic medical school.
I am excited about the future growth of osteopathic medicine and how we can help meet the needs of our nation. We are graduating from 7,000 to 8,000 new osteopathic physicians a year. Over the next decade, that is at least 70,000 new physicians. We are projected to rise to as much as 22% of the U.S. physician population by 2030; whereas, right now we are only representing 12% to 13%. That is growth for us.
Our osteopathic medical schools are situated in health deserts—rural health areas and other underserved areas. Almost 60% of osteopathic physicians practice in primary care specialties—family medicine, internal medicine, pediatrics, obstetrics, and gynecology. We tend to go where the need is.
We have medical schools in East Tennessee, Idaho, West Virginia, Alabama, Mississippi, Louisiana, New Mexico, East Texas, and Kentucky. These schools are mainly in rural areas. Our students will do some of their practice training in those areas; and we hope to recruit many of our students from those areas, so they will practice there.
We also have ways of expanding care. The main way is through physician-led, team-based care.
To meet the healthcare needs in our country, we support a team-based approach to medical care, with the physician as the leader of that team. A physician-led, physician-directed model recognizes the growth and expertise of nonphysician clinicians. We totally support their rights to practice within their scope of practice and the scope of practice they are allowed under state statutes, with appropriate physician involvement. Healthcare professionals can work together at the top of their skill sets.
When community-based organizations are already meeting social needs, healthcare organizations should build partnerships rather than building their own programs.
Health systems and hospitals across the country are forming partnerships to help address social determinants of health (SDOH) in the communities they serve.
Social determinants of health such as housing, food security, and transportation can have a pivotal impact on the physical and mental health of patients. By making direct investments in initiatives designed to address SDOHs and working with community partners, healthcare organizations can improve patient health in profound ways beyond the traditional provision of medical services.
For healthcare organizations, there are specific circumstances when forming partnerships is preferred over making direct investments to meet SDOH needs, says Adam Myers, MD, chief of population health and director of Cleveland Clinic Community Care at Cleveland Clinic in Ohio.
"Partnerships are effective anytime when there is work already being started or when work that hasn't been started would best be done collaboratively," he says.
Health systems and hospitals should resist the temptation to create a "de novo project" aimed at any SDOH, Myers says. "Rather than creating our own program, we often need to be learning, listening, and standing beside existing community organizations to determine what we can do to support them and create synergy."
Trust is the indispensable ingredient for a successful SDOH partnership, he says. "It has to be built on trust, and trust is only possible through true listening, seeking to understand each other's felt needs, and partnering in ways that strengthen community-based organizations and help meet community needs."
Humility is also an essential factor when working with community-based organizations (CBOs), says Annette Fetchko, who was the regional director of the Center for Inclusion Health at Pittsburgh-based Allegheny Health Network until recently and currently serves as CEO of the Bethlehem Haven homeless shelter in Pittsburgh. "Health systems have always felt that we have the answer. However, we are learning that we need to understand what is needed from the community's perspective and the CBO's perspective. That has been essential in forging relationships with CBOs."
Barbara Gray, MBA, senior vice president for social determinants of health at AHN's corporate parent, Pittsburgh-based Highmark Health, offers several pieces of advice to healthcare organizations seeking to forge SDOH partnerships.
"Take the time to invest in the relationship. Understand each other's goals and objectives. Articulate the guiding principles under which you are going to operate as a partnership. Be flexible. Recognize what each other brings to the table. And be open to learn from each other and transform—not only the program but also the way you see your role in serving your population," Gray says.
Food security partnerships
The opening of two Healthy Food Centers on AHN hospital campuses is a prime example of effective SDOH partnerships, Fetchko says.
The first step was identifying the need and recognizing the benefits of establishing partnerships, she says. "When we began to screen at the system level for food insecurity and evaluated the data, we clearly recognized that there was a significant social gap in access to nutritious food. As a health system, we also recognized that we were not the experts in identifying access to nutritious food and distribution of those foods. Organizations in our communities were far better experts."
AHN opened the health system's first Healthy Food Center in April 2018 at the West Penn Hospital campus in Bloomfield, Pennsylvania. The second Healthy Food Center opened in January at Allegheny General Hospital in the North Side neighborhood of Pittsburgh.
Each Healthy Food Center is managed by a registered dietician and stocked with nutritious dried, refrigerated, and frozen foods. AHN clinicians can make patient referrals to the Healthy Food Centers through the health system's electronic medical record, Epic. CBOs can make referrals to the Healthy Food Centers via a scanned document or fax.
Making referrals through Epic helps ensure that referred patients don't fall through the cracks, Fetchko says. "If a referred individual has not engaged with the Healthy Food Center, we have a process where we will do outreach to that individual. We ask whether they plan on making an appointment, whether they understand the concepts of the Healthy Food Center, and whether they need transportation assistance because we set up a partnership with a local nonprofit organization to provide transportation."
As of mid-April, there had been 2,200 referrals to the Healthy Food Centers, providing meals to more than 6,700 people, she says.
The cost of operating one of the Healthy Food Centers, which is funded by AHN, ranges from $175,000 to $200,000 annually inclusive of personnel costs. However, community partnerships play a pivotal role at the facilities, Fetchko says. "As we identified the needs of community residents, we worked with CBOs such as Greater Pittsburgh Community Food Bank and 412 Food Rescue to determine how to source, distribute, and provide access to nutritious food. We leveraged the expertise of each organization."
The food bank helped AHN convene several CBOs to learn about the community's food needs as well as about food distribution and sourcing, Fetchko says. And 412 Food Rescue, which is a nonprofit organization that sources food that would otherwise be thrown away, makes a "very large donation" to the Healthy Food Centers, she says.
Other significant CBO partnerships for the Healthy Food Centers include the Bloomfield Development Corporation, which hosts a farmers' market, and The Food Trust based in Philadelphia.
The Food Trust provides "food bucks" to the Healthy Food Centers that can be redeemed at participating corner stores, supermarkets, farmers' markets, and Green Grocers for fresh produce, says Senior Healthy Food Center Manager Colleen Ereditario, MPH, RD. "Since July 2018, $15,000 worth of coupons have been redeemed from our Healthy Food Center clients alone. The clients report that, as a result, they have increased fruit and vegetable intakes and access that they would not have had otherwise."
Early longitudinal data shows the Healthy Food Centers are having a positive impact on clinical metrics, Fetchko says. "Because the first Healthy Food Center has been open for more than 18 months, we can look to see whether we have had a positive impact on hemoglobin A1c, cholesterol, and high blood pressure. As part of the longitudinal study for A1c, we have seen a 20% reduction in A1c over a six-month period and sustained that over a nine-month period."
Although no single organization can meet the emergency food needs resulting from the COVID-19 pandemic, the Healthy Food Centers have risen to the challenge, Fetchko says. "The Healthy Food Centers have continued to maintain daily access to nutritious food sources by implementing a modified process whereby individuals can receive bags of nutritious food at the centers that are packaged and distributed by center staff. Included in these bags are recipes to support meal preparation as well as nutrition information."
The Healthy Food Centers have also added community-based services during the pandemic, she says. "Our team has implemented a process to distribute emergency food boxes via the centers as well as home delivery for those who are quarantined or self-isolating due to health risks associated with the pandemic. These individuals are not able to access the broader drive-up food distribution, so the Healthy Food Centers' ability to try to serve these individuals is critical."
Nurse practitioners report several impacts on their profession during the pandemic, including the easing of practice restrictions in some states and furloughs.
A new survey shows the coronavirus pandemic has had a profound impact on nurse practitioners.
Nurse practitioners have been providing care to all coronavirus disease 2019 (COVID-19) patients from testing and triage, to emergency medicine, to inpatient medical wards, and ICUs. To address coronavirus patient surges, many states have loosened restrictions to practice for nurse practitioners.
The new survey, which was conducted online from July 28 to August 9 by the American Association of Nurse Practitioners (AANP), features data collected from 4,000 nurse practitioner respondents. This is the second survey AANP has conducted during the coronavirus pandemic.
The new survey includes several key data points.
Treatment capacity: 82% of nurse practitioners said their facility was better prepared to address the novel coronavirus compared to the beginning of the pandemic. About one-third of survey respondents said their facility was prepared for a COVID-19 patient surge, challenges related to delayed or deferred care, and the upcoming flu season.
Testing: Three-quarters of nurse practitioners reported that lack of timely coronavirus testing is the most daunting barrier to providing effective COVID-19 care. Limitations on testing due to eligibility criteria have improved since the first AANP survey in the spring. In the first survey, 69% of nurse practitioners reported limited testing due to eligibility criteria. In the new survey, 46% reported limited testing due to eligibility criteria.
Safety impact: In the first AANP survey, 2% of nurse practitioners reported being infected by the coronavirus, and that figure has nearly tripled to more than 5% in the new survey. In the first survey, a quarter of survey respondents cited insufficient personal protective equipment (PPE) as a major pandemic concern, with 79% reporting they had been forced to reuse PPE. In the new survey, 18% of nurse practitioners said they had insufficient PPE.
Workforce impact: Since the beginning of the pandemic, nearly 17% of nurse practitioners report being furloughed; but most have gotten their jobs back, with 4% remaining furloughed at the end of July. Nurse practitioners have also experienced layoffs or termination, with 3% remaining laid off or unemployed after termination at the end of July. In the new survey, about 40% report income decreases, compared to 36% in the first survey.
Practice restrictions eased: In the new survey, more than half of nurse practitioners reported that temporary suspension of state supervisory or collaborative practice pacts was beneficial.
Telehealth: The two surveys reflect the expansion of telehealth services during the pandemic. In the first survey, more than half of respondents reported their practice was shifting patient care to telemedicine. In the new survey, 63% of nurse practitioners reported their practices were transitioning patients to telehealth services.
Interpreting the data
While coronavirus testing has improved since the beginning of the pandemic, testing issues remain to be resolved, Sophia Thomas, DNP, APRN, president of the AANP told HealthLeaders. "More than half of NPs say there is adequate access to testing in their community. But there are many NPs who report access to testing is limited, especially for patients who need to meet eligibility criteria."
Delayed test results is a major concern, she said. "Three-quarters of NPs are reporting delays in getting test results, which is probably the most significant thing in controlling the spread of coronavirus other than wearing masks. Getting adequate test results back in a timely manner is key in preventing the spread of COVID-19. Especially for asymptomatic carriers, once they get a positive result it reaffirms to them that they need to wear a mask to prevent the spread to others and they need to socially isolate."
In several states, the temporary lifting of practice restrictions on nurse practitioners during the pandemic has been a welcomed change, Thomas said. "Five states—Wisconsin, New York, New Jersey, Kentucky, and Louisiana—have temporarily lifted all practice agreement restrictions on nurse practitioners. The actions taken by these governors are models for the nation, allowing their states to surge the number of frontline providers, treat patients with underlying health conditions, and meet vital primary care needs."
More states should ease practice restrictions on nurse practitioners, she said. "About 89% of nurse practitioners are educated in primary care roles, which is important to providing care and access to care for patients. We are calling on the remaining governors to waive the restrictive barriers that undermine access to care and limit scope of practice. We need to modernize all of these outdated barriers. Twenty-two states and the District of Columbia currently have full practice authority for nurse practitioners."
The new survey's finding that 18% of nurse practitioners lack adequate PPE is troubling, Thomas said. "It is always a concern when any provider is without the recommended PPE."
However, the availability of PPE has improved significantly since the beginning of the pandemic, she said. "The supply of PPE is much improved."
The employment market for nurse practitioners, which took a hit in the early phase of the pandemic, is relatively strong, Thomas said. "While nearly 17% of nurse practitioners have had a furlough, the majority of them have returned to work. As primary care reopens and practices are better prepared for the pandemic, we expect furloughs will end and nurse practitioners will go back to work."
The expansion of telehealth services during the pandemic is likely to continue, and telemedicine has become a crucial element of the nurse practitioner skillset, she said.
"Telehealth is now an essential skill for nearly everybody in healthcare. Nurse practitioners have a strong presence in this space, and the pandemic has exposed more nurse practitioners and patients to this form of care. … In our survey, 63% of nurse practitioners are continuing to transition patients from in-person visits to telehealth visits, and I am encouraged by this tremendous demand. This is an opportunity to improve access to care."
An outdoor coronavirus screening station can be configured and equipped to eliminate direct contact between patients and healthcare workers.
A walk-through novel coronavirus screening station that isolates patients from healthcare workers decreases personal protective equipment utilization and quickens patient processing, a new Annals of Emergency Medicineletter to the editor says.
Personal protective equipment (PPE) has been in limited supply since the coronavirus disease 2019 (COVID-19) pandemic hit the United States early this year. For health systems and hospitals facing surges of COVID-19 patients, emergency departments have been strained in providing triage.
Compared to an outdoor COVID-19 screening station where healthcare workers come into direct contact with suspected coronavirus patients, an outdoor COVID-19 screening station that isolates healthcare workers from patients generates significant benefits, the letter to the editor says.
Average daily consumption of N95 respirator masks decreased 87%
Average daily consumption of isolation gowns decreased 93%
Processing time to screen patients decreased 83%
An outdoor COVID-19 screening station that isolates healthcare workers from patients has several key elements, the letter to the editor says.
Separate passageways for patients and healthcare workers
A quarantine triage area, a patient tele-consulting room, a chest X-ray booth, and consultation cubicles for nasal sampling
All assessments are conducted with healthcare workers behind acrylic windows, so there is no need for the workers to don PPE
Healthcare workers communicate with patients through an audio system
The chest X-ray booth is configured so technicians can position the digital cassette and portable X-ray unit without coming into direct contact with patients, avoiding the donning of PPE
Nasal swabs and blood samples are collected at windows equipped with glove ports
Specimen tubes and vials in collection bags are passed from patients to healthcare workers through a sealed port
Patients are screened sequentially, which lowers congestion of patients and speeds the screening process
Injuries to the head and neck in absence of injury to other parts of the body can be suspicious injury patterns in older adults.
Elder abuse is difficult to identify, but recent research shows injury patterns that are indicative of elder abuse rather than unintentional injury.
Elder abuse from violence is difficult to detect because seniors have thin skin and take medications such as blood thinners that lead to easy bruising, and they can have osteopenia or osteoporosis that increase the risk of broken bones. Elder abuse has serious health consequences, including depression, anxiety, post-traumatic stress disorder, and significant trauma injuries. And it is not well recognized in the clinical setting.
The lead author of the recent research, which was published in Annals of Emergency Medicine, told HealthLeaders that clinicians play a unique and vital role in the detection of elder abuse.
"Elder abuse is dramatically underrecognized and underreported. One of the reasons for that is many older adults do not come into contact with other folks. In fact, contact with a medical professional might be the only time that an older adult leaves their home. As a result, physicians—particularly emergency room clinicians—have an opportunity and responsibility to identify elder abuse, neglect, and exploitation," said Tony Rosen, MD, MPH, and assistant professor of emergency medicine in the Department of Emergency Medicine at Weill Cornell Medicine and New York Presbyterian Hospital in New York.
The research is based on medical, police, and legal records collected from 78 successfully prosecuted elder abuse cases with physical injury from 2001 to 2014. There was a control group of 78 patients who suffered injuries in unintentional falls.
The study features several key data points.
Compared to older adults who experienced unintentional falls, elder abuse victims were more likely to have bruising, 78% vs. 54%
Compared to older adults with unintentional falls, abuse victims were more likely to have injuries on the maxillofacial, dental, and neck area, 67% versus 28%
Compared to older adults with unintentional falls, elder abuse victimes were more likely to have maxillofacial, dental, or neck injuries in the absence of upper and lower extremity injuries, 50% vs. 8%
Compared to older adults with unintentional falls, seniors who were victims of physical abuse were more likely to have injuries to the left cheek or zygoma (22% vs. 3%), neck (15% vs. 0%), or ear (6% vs. 0%)
The head and face are a primary target for elder abuse perpetrators, Rosen said. "When you are angry at someone, you lunge for things that are exposed and things that are symbolic of the person you are angry at. Ultimately, the face is an attractive target to an assailant. According to the literature on younger age groups, the face is a common place to be injured in an assault."
Injuries to the face in the absence of injuries to other parts of the body should raise suspicion of elder abuse, he said. "If someone is prone to bruising, they should be covered with bruises in an accidental fall. So, the presence of bruising in the face combined with the absence of bruising in places where people get bruised more often—like the shins or the knees—is more concerning."
Neck injuries are particularly suspicious, Rosen said. "We found injuries to the neck were most consistent with elder abuse. When you fall, the neck is protected by the face and the shoulders. So, it is hard to injure your neck in a fall, unless you fall against the edge of a table or refrigerator. As a result, we think injuries to the neck are particularly concerning."
The study's data indicate exploration of elder abuse is appropriate for a small but significant percentage of fall patients, he said. "We recognize that no matter how good of a job we do identifying elder abuse, falls and other unintentional injuries are still going to be more common. So, the first thing we can do with these findings is to keep in mind that every single fall is not necessarily a fall. There ought to be characteristics about the injury pattern that ought to make us question whether injuries really occurred from a fall."
Addressing suspicion of elder abuse
In most states, clinicians are mandatory reporters of elder abuse, and most cases are reported to adult protective services.
When elder abuse is suspected, the first step for clinicians is to interview the patient with no home caregivers or family members present, Rosen says. "The second thing is you want to make sure that you conduct interviews in a supportive and nonjudgmental manner while ensuring privacy. You need to build a therapeutic alliance with the patient and the family."
Patients should be treated sensitively because they are potentially trauma survivors, he says. "Providing trauma-informed care is important for these patients and their families. Trauma-informed care includes being sensitive to the profound impact of traumatic and stressful life experiences on a patient's physical and mental health. Previous and even remote traumatic experiences can cause depression, anxiety, or post-traumatic stress disorder."
