Effective approaches to emergency preparedness during a pandemic include proactive resource management and involving stakeholders in planning efforts.
The coronavirus disease 2019 (COVID-19) pandemic has exposed emergency preparedness weaknesses in the U.S. healthcare system.
In the early stage of the COVID-19 pandemic, hospitals in New York City struggled mightily to cope with an epic surge of coronavirus patients. Across the country, the pandemic has strained supply chains for critically important materials and equipment such as personal protective equipment (PPE) and ventilators.
There were three primary reasons why health systems and hospitals were ill-prepared for the COVID-19 pandemic, according to Brian Armstrong, RN, MBA, BSN, a healthcare consultant at Philips Healthcare Transformation Services, a business division of Amsterdam, The Netherlands–based Royal Philips Electronics. He has extensive experience in emergency preparedness, including serving as director of emergency services at Prime Healthcare in Atlanta.
1. Dusty emergency management plans
Once emergency management plans are developed and agreed upon, they are frequently stored away and rarely revisited, Armstrong says.
"Instead, these plans should be more frequently practiced and become flexible, living documents that align with evolving operations. Due to the fast pace and busy nature of health systems and hospitals, often plans are reviewed once a year when the healthcare organization runs a drill to meet regulatory requirements. Unfortunately, this lack of ongoing review and reassessment meant that when COVID-19 began to sweep the globe, many health systems did not have adequate plans in place for defining roles or adjusting supply chains."
2. False sense of confidence based on experiences with earlier outbreaks
Before COVID-19, contagion response was not a high priority at health systems and hospitals, he says.
"Prior to COVID-19, there was not much emphasis placed on contagion response. Pandemics are very rare, and we have no recent experience with an overwhelming outbreak of this fashion. While the H1N1, Ebola, and SARS viruses were expected to have a dramatic effect on public health and the healthcare system, the actual effects were less severe than anticipated, which may have lulled organizations into a false sense of security."
3. Regional variation in emergency preparedness
Hospitals and health systems conduct annual vulnerability threat assessments that create a regionally specific priority matrix on what to focus on related to disasters and major threats. These vulnerability threat assessments are not well-suited to national calamities such as the COVID-19 pandemic, Armstrong says.
"This can be quite different depending on location. A hospital in Florida will have hurricanes rate much more highly than a hospital in Ohio, which might see tornados high on the list. A global pandemic was not high on any hospital's threat assessment."
Preparing for future pandemics
Pandemics are not a matter of "if" but "when," he says. "With this reality in mind, it is not too soon for health systems and hospitals to examine what policies and procedures failed them during this COVID-19 event."
There are four main ways health systems and hospitals can be better prepared for future outbreaks, Armstrong says.
1. Proactive resource management
Many health systems and hospitals function with "just-in-time" supply chains. Healthcare organizations should take time to identify and activate supply streams, review stockpile levels, and rotate supplies to avoid expiring items, he says.
2. PPE management
Health systems and hospitals need better command and control for PPE. These organizations spend a lot of time on training about how to use PPE, then must retool when new PPE is substituted, Armstrong says.
Health systems and hospitals should look closely at longer term and renewable PPE such as powered air-purifying respirators and N95 respirator masks as well as methods to extend the life of PPE. One suggestion is to develop a system to forecast PPE usage based on burn rates. This system should be reviewed daily or weekly depending on the usage tempo, he says.
3. Involving stakeholders in planning
It is crucial to involve all departments and decision-makers in emergency preparedness planning and recovery efforts. Involving frontline clinicians in planning improves understanding of their experience during an emergency, helps with engagement and adoption of new processes, and gives medical professionals a vested interest in emergency preparedness rather than just telling them what to do, Armstrong says.
4. Boosting technology infrastructure
Health systems and hospitals should be working now to improve technology infrastructure such as establishing robust telemedicine and remote work capabilities. These investments ensure business and operational continuity during a crisis, he says.
Pandemic lessons learned
From an emergency preparedness perspective, there have been several lessons learned from the COVID-19 pandemic, Armstrong says.
"COVID-19 has taught us that there is no one-size-fits-all emergency management plan—each needs to be customized and adjusted frequently. Rather than having a plan just to check a regulatory box, make emergency management an integrated part of operational strategy and incident command systems a part of everyday work."
The COVID-19 pandemic has demonstrated the importance of vigilance, he says. "Health systems and hospitals need to consider that novel infectious diseases have been relatively common over the past decade, and the ongoing risk of resurgence and the chance of new pathogens requires healthcare leaders to take a new approach to maintaining essential capabilities to respond to an initial outbreak or event."
Vigilance requires ongoing emergency preparedness, Armstrong says. "When previous infections have run their course, the command center has closed, equipment has been put away, and plans have gone back on the shelf. While it may not be necessary to maintain incident command readiness at all times, some aspects of command systems and monitoring need to remain a constant part of daily operations to help ensure infection outbreaks are a staple consideration in daily huddles and reports."
To avoid emergency preparedness pitfalls during future infectious disease outbreaks, health systems and hospitals should avoid a lack of reflection, he says.
"After a crisis, people get complacent, memories fade, and processes slide back into pre-crisis operational structures. It is important that no time is wasted to examine what did not work and put plans in place to mitigate root issues the next time. While an after-action report is important, organizations also need to do mid-action reports and address hard-hit areas to improve response for a potential second wave or future pandemic."
Emergency departments have developed strategies to handle coronavirus patient surges such as addressing limited space in their facilities.
Emergency department management and clinical care practices to cope with coronavirus disease 2019 (COVID-19) patient surges have evolved since the pandemic began, according to a recent journal article.
Particularly for the most seriously ill COVID-19 patients, emergency departments are an essential healthcare setting during the coronavirus pandemic. Given their key role, EDs need to function efficiently and effectively to save lives.
The recent journal article, which was published in Annals of Emergency Medicine, highlights six lessons learned that can help emergency departments rise to the challenges of addressing COVID-19 patient surges.
"The very novelty of COVID-19, in multiple senses—immunologic novelty for a population lacking herd immunity, clinical novelty in its diversity of presentations, and sociocultural novelty in that it has appeared amid nationwide tumult and institutional distrust—makes it a perfect storm. It has caught much of the United States unprepared. Yet despite the many uncertainties about COVID-19, emergency physicians have gained critical practical knowledge," the journal article's author wrote.
1. Hot zones and cold zones
To deal with a rush of COVID-19 patients, emergency departments should be divided into two areas, according to the journal article. A hot zone should be created for the assessment and treatment of patients who are suspected of having COVID-19 or influenza. A cold zone should be created for other patients.
A contributor to the journal article told HealthLeaders that having hot zones and cold zones in an emergency department generates two primary benefits during a COVID-19 patient surge.
"On the patient side, one of the things that people are most afraid about during the COVID-19 pandemic is being infected. Therefore, having different areas where people with COVID-19 or people with suspicion of COVID-19 are handled creates physical separation and less likelihood that even casual contact could happen. It gives not only a measure of safety but also an enhanced appearance of safety for people coming into an ED," says Donald Yealy, MD, Department of Emergency Medicine chair at the University of Pittsburgh School of Medicine in Pittsburgh.
"On the provider side, having different areas where patients are placed either with or without suspicion of COVID-19 allows for more efficiency in staffing, more consistent care, and more protection of the patients and the providers," he says.
2. Rapid COVID-19 testing
The capability to test patients for COVID-19 in a timely manner is helpful in the ED setting, and it could be essential when the influenza season begins in the fall, the journal article says.
For emergency room clinicians, rapid COVID-19 testing is a desirable tool, Yealy says. "If you could get a test that was quick and retain the accuracy of the more standard viral tests, it would help us identify at the beginning of a hospitalization who has symptomatic and asymptomatic COVID-19."
3. Personal protective equipment
In emergency rooms, having adequate supplies of personal protective equipment (PPE) is crucial during a COVID-19 patient surge, the journal article says. "Ensuring adequate PPE and adapting facilities in ways that conserve this resource by reducing repeated donning and doffing will be essential to safeguard staff before waves of new cases again become overwhelming."
Yealy says four factors determine the availability of PPE: the production of PPE, the distribution of PPE, the intensity of cases, and the use of the equipment. For now, he is cautiously optimistic. "There is enough PPE even if the virus numbers increase. I don't anticipate that there will be widespread shortages again, but there could be individual facilities that could be under duress."
4. Alternatives to mechanical ventilation for COVID-19 patients
Both in terms of available resources and patient outcomes, placing COVID-19 patients on mechanical ventilation is problematic, and alternative treatments should be used when possible, the journal article says.
The approach to mechanical ventilation for seriously ill coronavirus patients has evolved significantly since the beginning of the pandemic, Yealy says.
"Early on, we felt that what was most key was to assist respiration by all means necessary, including endotracheal intubation and mechanical ventilation as early as possible because of the fear of profoundly low oxygen levels. We have now learned that haste to begin standard mechanical ventilation with an endotracheal tube may not serve patients well. Alternatives such as high-flow oxygen, prone positioning without intubation, and using other noninvasive ventilatory techniques can be quite helpful for an extended period," he says.
As is the case with any critical care therapy, expertise is important when proning coronavirus patients in the ED, Yealy says. "Proning is not something you can just learn on the fly. There are lots of things that can go wrong. So, you either have to have proning teams or you have to have within your staff subsets of people who understand how to do proning and are practiced at it."
5. ED space constraints
During a COVID-19 patient surge, EDs need to be creative in managing triage space such as erecting tents and other outdoor facilities, the journal article says.
Using tents to address ED space concerns is a good strategy under the proper circumstances, Yealy says.
"Tents are a reasonable alternative for the patients with the lower level of symptoms and acuity because they help provide care to very large numbers of patients if you have a physically restrained bricks-and-mortar environment. Obviously, outdoor triage and treatment facilities can be shackled by their location and the weather. In the far Northeast, those kinds of facilities would be a very difficult way to provide care in February. In the Southwest, those kinds of facilities could be the perfect way to provide care year-round."
For EDs in many areas of the country, repurposing existing bricks-and-mortar areas for clinical care such as conference rooms is an attractive option for managing limited space, he says.
6. Telemedicine
Utilizing telehealth capabilities can reduce the strain on EDs during a COVID-19 patient surge, the journal article says.
"It can help people with lower-level symptoms get the care and advice they need without having to come to the emergency department," Yealy says.
Combining the World Health Organization's operating room checklist with a preoperative and postoperative checklist benefits patients, research indicates.
Patient safety has been a pressing issue in healthcare since 1999, with the publication of the landmark reportTo Err Is Human: Building a Safer Health System. Despite two decades of attention, estimates of annual patient deaths due to medical errors have risen steadily to as many as 440,000 lives, a figure that was reported in the Journal of Patient Safety in 2013.
The recent research, which was published in JAMA Surgery, examines information collected from more than 9,000 surgical procedures. The research features three key data points:
Joint use of the World Health Organization Surgical Safety Checklist (WHO SCC) and the SURPASS checklist was associated with fewer complications, odds ratio 0.70
Joint use of the checklists was associated with fewer reoperations, odds ratio 0.42
Joint use of the checklists was associated with fewer hospital readmissions, odds ratio 0.32
"Findings from this study demonstrate that adding the preoperative and postoperative SURPASS checklists to the intraoperative WHO SSC may be clinically advantageous. We found that the joint application of the two surgical checklist systems was associated with reduced in-hospital complications, emergency reoperations, and hospital readmissions," the researchers wrote.
The reduction in readmissions was likely due to the SURPASS checklist promoting best practices when patients leave a hospital such as medication management and setting recovery expectations, the researchers wrote.
WHO SCC and SURPASS checkpoints
The SURPASS preoperative and postoperative checklist includes the following steps:
Admission to ward: Ward doctor checks whether imaging is present and lab work has been done; surgeon checks whether informed consent has been registered and the operation side has been marked; anesthesiologist assesses patient's condition and orders blood products; nurse makes sure premedication is administered
Recovery room or ICU: Surgeon provides instructions about drains, diet, and medication; anesthesiologist provides instructions about ventilation and medication
Ward boarding: Surgeon and anesthesiologist specify changes in postoperative instructions
Discharge: Ward doctor conducts follow-up, checks medications, and writes discharge letter
The WHO SCC includes the following steps:
Before induction of anesthesia: Patient should confirm his or her identity, surgical site, and procedure; the surgical site should be marked; the surgical team should know whether the patient has any allergies
Before skin incision: All team members introduce themselves by name and role; essential imaging should be displayed; confirmation of antibiotic prophylaxis within the prior 60 minutes
Before patient leaves the operating room: The OR nurse should verbally confirm the name of the procedure, and the surgeon, anesthesiologist, and OR nurse should identify concerns for the recovery and management of the patient
Combining the SURPASS checklist with the WHO SCC
The lead author of the recent research told HealthLeaders that training medical staff on how to use the SURPASS checklist is a key element of the study.
"The primary elements of the training consisted of written and oral information provided to staff groups from the research/implementation group, with daily follow-ups being made in each department by their own staff. During this effort, exemplifying things having been intercepted by checklist use motivated the staff to use the lists daily," said Anette Storesund, RN, PhD, a consultant in the Department of Research and Development at Haukeland University Hospital in Bergen, Norway.
Combining the surgery checklists has a more significant impact on patient safety and clinical outcomes than adhering to a single checklist, she said. "To get the full benefit from the SURPASS checklist's use, all of the different checklists need to be utilized. We also found stronger effects when all the checklists for all the key healthcare personnel were used, compared to when some of the checklists had been left out."
Financial struggles of physician practices present opportunity to health systems.
The coronavirus disease 2019 (COVID-19) pandemic is impacting the market for health systems and hospitals acquiring physician practices, a recent report says.
The COVID-19 pandemic has had a profound impact on independent physician practices. In the early stage of the pandemic, patient volume at physician practices plummeted, financial losses mounted, and practices boosted telemedicine capabilities to offer services in a safe manner.
The recent report, which was published by New York-based McKinsey & Company, is based on a national survey of general and specialty physicians conducted in 2019 and repeated six weeks into the pandemic.
"New financial pressures resulting from the COVID-19 pandemic may increase physician practice acquisition and consolidation. However, results from McKinsey physician surveys both before and during the COVID-19 pandemic suggest that these partnerships may benefit from an updated approach. … While autonomy has remained a priority for physicians, respondents indicated that they will consider partnerships or joining a health system as a result of financial uncertainty resulting from the COVID-19 pandemic," the report says.
The report includes five key data points about health system and hospital acquisitions of physician practices:
Compared to small independent physician practice clinicians, employed physicians were more likely to cite financial stability as a top factor in their current practice model decision (53% of employed physicians vs. 38% of small independent physician practice clinicians)
About 40% of employed physicians cited personal and practice finances as factors in their decision to become employed
Six weeks into the COVID-19 pandemic, 53% of independent physicians said they were worried that their practice would not survive the pandemic
At large independent physician practices, 58% of survey respondents said they would prefer to remain independent
At small independent physician practices, 71% of survey respondents said they would prefer to remain independent
"In light of these survey findings, health systems and other stakeholders may consider strategies to optimize the mutual benefits of physician practice acquisition," the report says.
Gauging the physician practice acquisition market
The survey data collected during the COVID-19 pandemic indicates a bullish market for physician practice acquisitions by health systems and hospitals, Rupal Malani, MD, MS, MA, a partner at McKinsey & Company, told HealthLeaders.
"In our survey, conducted six weeks into COVID-19, 53% of all independent physician respondents shared that they were worried about their practices surviving, and that roughly 20% to 40% were considering partnering with a larger entity, selling their practice, or becoming employed. This means we have a sizeable number of physicians potentially seeking out new opportunities, and health systems in turn are scrambling to determine how (and if) to acquire this new surge of talent," she said.
However, the appetite for physician practice acquisition is finite, Malani said. "What we also heard in last year's survey is that 26% of physicians who joined a health system or larger entity reported buyer's remorse, indicating that physicians aren't always satisfied with employment. And, anecdotally, we have observed that health systems are also not always achieving their desired outcomes from the employed physician base, whether it is regarding cooperation to reduce supply expense or care coordination to reduce total cost of care."
Based on the survey data, there are significant implications for how health systems and physicians should approach physician practice acquisitions, she said.
"There may be an opportunity for health systems to define and effectively communicate the value proposition to physicians, as well as the expectations of physician employment. Similarly, physicians could benefit from being thoughtful and candid about their expectations of employment and understand what flexibility might exist to meet their needs."
Long-term impact of pandemic on physician practice acquisitions
As health systems and hospitals ponder rebuilding their enterprises after the COVID-19 pandemic crisis passes, now is a good time for them to consider what they really want out of the physician practices they are acquiring, Malani said.
"It's a true moment of reflection for health systems to consider their own value proposition, but they shouldn't reflect too long. There are other entities out there looking to acquire these practices, and health systems have to be prepared to act with alacrity."
In this decision-making process, local market concerns are crucial for health systems, hospitals, and physician practices, she said.
"Our survey is a great way to get an aggregate voice of physicians, but the ultimate decision for the acquisition of a practice will depend on myriad local market factors and the health system's approach to individual physician needs. That is where communication is paramount, and the more upfront each side can be about their own goals and expectations, the better chance all parties have for success."
A respiratory therapist who traveled to New York City during The Big Apple's coronavirus patient surge shares her story.
With respiratory distress common among seriously ill coronavirus patients, respiratory therapists are at the tip of the spear on the pandemic frontline.
Respiratory therapists have been in short supply during the coronavirus disease 2019 (COVID-19) pandemic. A study published in 2015 identified the supply of ventilators and the staff to manage them as a weak point in the U.S. healthcare sector's capability to function effectively during a public health crisis.
Julie Sullivan, who has worked as a respiratory therapist for the past 16 years, answered the call when hospitals were overrun by COVID-19 patients in New York City. She took a leave of absence from her Texas hospital and traveled to Brooklyn, New York, to work at NYU Langone Hospital during the height of New York City's COVID-19 patient surge in the spring. She is currently working at Prince William Medical Center in Manassas, Virginia. She also is a spokesperson for the Allergy and Asthma Network.
"When I was in New York at NYU Langone in Brooklyn, all I had was ventilated patients. It was pretty much an all-COVID hospital when I was there," Sullivan says.
During a COVID-19 patient surge, respiratory therapists are assigned to work with patients in respiratory distress, she says. "They are usually desaturating, so their oxygen level is low. You want the oxygen level for a normal, healthy person to be as close to 100% as possible. If a patient has an underlying disease such as chronic obstructive pulmonary disease or asthma, it might be OK for the oxygen level to be in the low 90s. I often get a call for a COVID-19 patient with an oxygen level in the 70s."
There are three primary kinds of care that respiratory therapists provide to seriously ill COVID-19 patients, Sullivan says.
1. Heated high-flow nasal cannula therapy allows respiratory therapists to provide patients with 100% oxygen at a rate of at least 40 liters per minute. In contrast, a regular nasal cannula provides patients with about six liters of 100% oxygen per minute.
2. A CPAP orBiPap machine is used for COVID-19 patients who do not respond well to heated high-flow nasal cannula therapy. The machine uses pressure to push oxygen into the lungs.
3. Intubation and mechanical ventilation is the last resort for respiratory therapists to oxygenate COVID-19 patients when other methods fail. "For ventilated patients, we maintain their airway, we draw arterial blood gases because that gives you a better picture of what their arterial blood gas levels are, and we try to maximize the ventilator settings to improve oxygenation. We also have done things like continuous nebulizers and vasodilators."
At NYU Langone, ventilators were often unsuccessful in saving patients, she says. "I know of only two patients who got intubated and got off the ventilator. A lot of times, I felt that no matter what we did, nothing helped the patients. When they got so sick, even intubating them just prolonged the inevitable."
Dealing with respiratory therapist shortages during a patient surge
Under ideal circumstances, respiratory therapists work with a handful of ventilated patients during a shift. At NYU Langone, Sullivan worked with as many as 18 ventilated patients at a time.
Pairing respiratory therapists with critical care nurses was the primary strategy to maximize the efforts of respiratory therapists at NYU Langone, she says. "We typically worked side-by-side with the nurses because we went into the patient rooms and tried to tag-team the patients together."
The nurses performed routine tasks that the respiratory therapists would normally have done themselves, Sullivan says. "We trained the nurses to be a little more self-sufficient and not call respiratory therapists for simple tasks such as switching a nasal cannula or doing a couple of puffs with an inhaler for a COVID-19 patient with COPD. These are not critical emergent issues that could take a respiratory therapist away from the beside where we need to be. You can use nurses to do some of the basic things that busy respiratory therapists may not be able to get to."
NYU Langone also used hygienists to clean respiratory therapy equipment because the respiratory therapists did not have the time to process equipment, she says.
Working in a 'warzone'
At NYU Langone, the hardest part of working during the COVID-19 patient surge was the sheer volume of seriously ill patients, Sullivan says.
"We called one of the COVID-19 units the seventh circle of hell because it was not negative pressure. So, you would have two COVID-19 patients in a room, and it literally looked like a warzone. I still have flashbacks about how many sick people were in the same rooms and how overwhelming that was. I can't tell you how many times we went into a room and a patient would be expired and still be on the ventilator with IVs going."
Under these kinds of circumstances, medical staff need to brace for the worst, she says. "You need to know that the situation is intense and unlike anything you have ever seen before. In a typical week, you might have one or two code blues when a patient goes into cardiac arrest, and you might think that is a lot. At NYU Langone, there was a time when we counted 26 code blues in an eight-hour period. That is an insane number of codes in a short amount of time."
To cope emotionally and physically with a COVID-19 patient surge, healthcare workers must draw on every strength in their being, Sullivan says.
"It's will power, and you dig deep. My grandmother was an Army nurse, and my grandfather was a surgeon during World War II, and I just thought this was my chance to help out my fellow man. I committed myself to doing the best that I could do. I committed myself to working hard from the moment I walked through the hospital door to the moment when I would leave."
Facing death on an epic scale was a daunting challenge, she says. "The most heartbreaking thing for me—and it still gets to me—was all of the people who were dying horrible deaths. And they were dying alone with strangers. There were not enough iPads to call family members. We did not have the passwords on patients' smartphones. But we did Facetime with family members when we had time."
For Sullivan, small acts of kindness helped her deal with the darkest times. "I would do little things to make myself feel better, like cleaning a patient's face. If they had tears, I would wipe them off. I would sing to my patients when I went into their rooms. I hoped that it helped them—I hope that it showed that people cared about them."
The pandemic has highlighted problems that have plagued U.S. healthcare for decades.
The coronavirus disease 2019 (COVID-19) pandemic has four monumental implications for U.S. healthcare, a recent journal article says.
The COVID-19 pandemic poses the greatest public health threat in the United States since the Spanish flu outbreak a century ago. As of Aug. 4, more than 4.8 million Americans had been infected with the novel coronavirus and 159,000 had died, according to worldometer.
The recent journal article, which was published by the New England Journal of Medicine, says the COVID-19 pandemic has laid bare fundamental weaknesses in U.S. healthcare.
"The novel coronavirus pandemic has spawned four intertwined healthcare crises that reveal and compound deep underlying problems in the healthcare system of the United States. In so doing, however, the pandemic points the way toward reforms that could improve our ability not only to cope with likely future epidemics but also to serve the basic healthcare needs of Americans," the journal article co-authors wrote.
1. Health insurance crisis
The economic calamity associated with the COVID-19 pandemic has dealt a devasting blow to employer-sponsored insurance.
More than 20 million Americans have lost their jobs since the COVID-19 pandemic upended society in March. The spike in unemployment is likely to prompt millions of Americans to lose their employer-sponsored insurance. A recent Commonwealth Fund survey found that 40% of respondents or their partner who were laid off or furloughed had employer-sponsored insurance.
The pandemic-induced healthcare coverage mess is an opportunity to build on the coverage gains achieved through the 2010 Patient Protection and Affordable Care Act, the journal article co-authors wrote. "Proponents of expanded coverage have multiple policy options to choose from, ranging from a government-financed single-payer system such as Medicare for All to reforms that build on current law."
2. Healthcare provider financial crisis
The COVID-19 pandemic has wreaked calamitous financial losses at hospitals and physician practices. "Office-based practices had reductions of 60% in visit volumes in the first months of the crisis, and, by their own estimates, hospitals will lose an estimated $323.1 billion in 2020," the journal article co-authors wrote.
There are two primary solutions for the healthcare provider financial crisis, they wrote.
Shifting away from the fee-for-service model of healthcare payment to a capitation model. "One advantage of full or partial capitation and prospective budgeting is that they offer hospitals and health professionals a predictable stream of revenue that is unlinked from the volume of services provided. Capitation would have protected many providers against the sharp short-term losses they are sustaining as a result of COVID-19," the journal article co-authors wrote.
Boosting resources for services that have not been well-financed under the fee-for-service model such as primary care, behavioral health, and rural healthcare.
3. Healthcare disparity crisis
The coronavirus pandemic has exposed racial and ethnic disparities in U.S. healthcare, the journal article co-authors wrote. "Black persons constitute 13% of the U.S. population but account for 20% of COVID-19 cases and more than 22% of COVID-19 deaths, as of July 22, 2020. Hispanic persons, at 18% of the population, account for almost 33% of new cases nationwide."
There are five primary ways healthcare disparities can be address, they wrote.
Broad societal action could be taken to improve the social determinants of health problems that beset communities of color such as substandard education and food insecurity.
Establishing universal healthcare coverage would improve access to care for racial and ethnic groups, which would help reduce the incidence of chronic conditions in these populations.
Boosting resources for safety-net hospitals and small community healthcare facilities also would improve access to healthcare services.
Anti-bias training could be mandatory in the education and licensing of healthcare workers.
Medicare and Medicaid payments could be tied to quality of care metrics for healthcare services provided to communities of color.
4. Public health crisis
Compared to other countries, the United States has been the hardest hit during the COVID-19 pandemic, uncovering weaknesses in the American public health system.
"Put simply, that system failed to quickly identify and control the spread of the novel coronavirus. The United States did not make testing widely available early in the pandemic, was late to impose physical-distancing guidelines, and has still not implemented either as widely as needed. National guidance on managing the pandemic has been inconsistent and delayed. Many states have now abandoned stringent physical-distancing guidelines without careful attention to public health measures needed to prevent resurgence," the journal article co-authors wrote.
There are five primary actions to improve the public health system, they wrote.
The country needs to strengthen its ability to implement collective public health measures such as bolstering state and local public health authorities.
During a public health emergency, federal authorities should have the ability to spend taxpayer dollars without congressional approval.
During a pandemic, the federal government should be able to mandate state efforts to control the spread of infection.
During a pandemic, the federal government should be able to manage the distribution of vaccines and antimicrobial agents.
During a public health emergency, the federal government should be able to compel states to allow clinicians to provide interstate telehealth services.
Research indicates homebound seniors and non-homebound seniors with complex medical conditions benefit from home-based medical care.
For older patients, there are opportunities to expand home-based medical care, which can lower cost of care and improve clinical outcomes, a new research article says.
In particular, there is untapped potential to provide home-based medical care to homebound seniors. According to estimates, there are about two million homebound seniors in the United States and about five million seniors who can only leave home with assistance or significant difficulty.
Home-based medical care, which includes services such as primary care and medical interventions, is more intense than standard home health services such as physical and occupational therapy.
Home-based primary care has been associated with decreased hospitalizations and emergency room visits. A home-based primary care program for high-risk seniors launched by the Center for Medicare and Medicaid Innovation—Independence at Home Demonstration—lowered cost of care significantly. "In its first two years, Independence at Home saved an average of $2,700 per beneficiary per year over expected patient costs," the new research article's co-authors wrote.
The research article, which was published today by Health Affairs, is based on survey data collected from more than 7,500 community-dwelling, fee-for-service Medicare beneficiaries. The study features several key data points.
Almost 5% of the Medicare beneficiaries had received home-based medical care during the study period from 2011 to 2017
Among the Medicare beneficiaries who received home-based medical care services, 75% were homebound
Compared to homebound Medicare beneficiaries who did not receive home-based medical care services, those homebound beneficiaries who did receive this kind of care were more likely to live in a metropolitan area or assisted living facility
Compared to non-homebound Medicare beneficiaries who did not receive home-based medical care, non-homebound beneficiaries who did receive this kind of care had more chronic illnesses, more functional impairment, and higher healthcare utilization
Compared to non-homebound Medicare beneficiaries who did not receive home-based medical care, non-homebound beneficiaries who did receive this kind of care were more socially disadvantaged
For healthcare providers, there is a golden opportunity to provide home-based medical care to homebound seniors and medically complex non-homebound seniors, the research article's co-authors wrote. "The significant unmet needs of this high-need, high-cost population and the known health and cost benefits of home-based medical care should spur stakeholders to expand the availability of this care."
Fee-for-service model ill-suited to home-based medical care
Fee-for-service payment models are a primary barrier to expansion of home-based medical care, according to the research article.
"Our finding of higher rates of home-based medical care among those living in assisted living facilities and in metropolitan areas likely reflects the fact that favorable factors related to geography and the built environment create operational efficiencies and opportunities to improve the financial sustainability of home-based medical care practices," the research article's co-authors wrote.
Value-based payment models are a better fit with home-based medical care, the lead author of the research article told HealthLeaders.
"Even in the absence of broader payment reform, many home-based medical care practices are pursuing value-based contracts with insurers that provide per member per month reimbursements to care for high-risk patients," said Jennifer Reckrey, MD, an associate professor at the Icahn School of Medicine at Mount Sinai in New York City.
There are strategies that home-based medical care providers can pursue to make fee-for-service payment models financially sustainable, she said. "Examples include forgoing physical office space and relying on advanced practice nurses or physician assistants to provide the majority of patient care."
Helping underserved patients
The finding that non-homebound seniors who received home-based medical care tend to be socially disadvantaged is highly significant, Reckrey said.
"Because home-based medical care provides highly personalized team-based care in the home, it is uniquely able to care for high-risk patients who are not currently well-served by the healthcare system. While the homebound as a group have difficulty accessing care, among the non-homebound social factors like poverty, lack of access to transportation, and racial and ethnic discrimination are also potentially powerful barriers to accessing needed care. Home-based medical care may be an important way for these individuals to build trust with an engaged care team and receive needed care."
Innovation initiatives during the coronavirus disease 2019 (COVID-19) pandemic were the primary focus of this month's HealthLeaders Innovation Exchange.
For health systems, hospitals, and physician practices, innovation has been critically important during the COVID-19 pandemic. For example, healthcare providers have dramatically ramped up their telehealth capabilities to continue to serve patients in a safe and effective manner.
Asaf Bitton, MD, executive director of Ariadne Labs in Boston and a practicing primary care physician at Brigham and Women's Hospital in Boston, discussed how Ariadne Labs has been promoting end-of-life conversations during the pandemic.
"A distressingly low number of patients discuss their preferences and goals with their clinicians at the end of life. We also know that, unfortunately, many clinicians do not feel comfortable having conversations about aligned care at the end of life," he said.
During the coronavirus pandemic, Ariadne Labs has adapted an existing program that provides training for clinicians to hold meaningful conversations with patients about end-of-life-related topics. The program's serious illness conversation model has seven components:
1. Setting up the conversation, including introducing the purpose of the conversation and asking permission to discuss end-of-life care
2. Assessing a patient's understanding and preferences
3. Sharing prognosis, including allowing silence and exploration of emotions
4. Exploring key topics, including goals, sources of strength, and tradeoffs
5. Closing the conversation, including a summarization, making a recommendation, and affirming commitment
6. Documenting the conversation
7. Communicating conversation to key clinicians
A randomized controlled trial published last year on the impact of the conversation program generated impressive results:
90% of clinicians found the conversation effective and efficient
87% of patients found the conversation worthwhile
Incidence of moderate-to-severe anxiety and depression among patients was reduced 50%
"Very few things—including antidepressants and anxiolytics—reduce depression and anxiety at the end of life," Bitton said during the HealthLeaders Innovation Web Exchange.
To rise to the end-of-life conversation challenge during the COVID-19 pandemic, Ariadne Labs has been able to disseminate feasible and acceptable end-of-life conversation tools with the Centers for Disease Control and Prevention, he said.
"We built open access guides for training ambulatory care clinicians on having conversations with patients who have serious illness before they have COVID-19, so the patients can start articulating their goals, wishes, hopes, and fears. We also have guides for inpatient clinicians, long-term care clinicians, as well as patients and their families."
2. Standardized care
Toledo, Ohio-based ProMedica was able to standardize coronavirus care across the health system's broad collection of metropolitan hospitals, community hospitals, and critical access hospitals, Chief Medical Information Officer Brian Miller, MD, said during the web exchange.
"To scale up standardization, we created a virtual clinical command center. On a 24/7 basis, we had critical care doctors who were connected to the COVID-19 ICUs across our health system to provide consultation for all the clinicians in all those different settings. We also got our clinicians to buy into that process," he said.
The virtual clinical command center helped ProMedica to rapidly achieve a high level of standardized coronavirus care, Miller said. "That care was not necessarily different than the care at most health systems, but we scaled it up as quickly as the evidence would show. We were proning as fast as anyone else. We were doing immunoglobulins as fast as anyone else."
The care standardization effort helped reduce COVID-19 patient mortality, he said. "As a result of our interventions, we had a very low mortality rate in our ICUs compared to the national rate. Our rate for intubated patients was about 20%, which is a very good number when you look at national benchmarks."
3. Innovation vs. transformation
In the healthcare sector, transformation is a preferable term compared to innovation, said Sameer Badlani, MD, chief information officer at Minneapolis, Minnesota-based Fairview Health Services. "I would love to replace the word innovation with the word transformation. Over the past six months, we have transformed ourselves with what already existed. We focused on the gap, evaluated the tools we had, and got it done. This was more transformation than innovation—we just did our jobs."
High degrees of focus and collaboration are essential to achieve transformation, he said.
"What COVID-19 has shown us is that if we all have focus, together we can move mountains. For example, our legacy infrastructure could barely enable remote workers above 2,000, and on a snow day we would see the system get stretched. We scaled up to 29,000 remote workers in less than three weeks. This was mission critical in our collective response to keeping our workforce safe as COVID-19 spread quickly in our communities. Everyone focused and collaborated."
Particularly for patients who are older and frail, home-based medical care is a viable alternative to urgent care centers and emergency rooms.
The coronavirus pandemic has increased demand for home-based medical care, according to the chief medical officer of Landmark Health.
During the coronavirus disease 2019 (COVID-19) pandemic, patients have been reluctant to visit healthcare facilities due to concerns over coronavirus infection. In April, a Medical Group Management Association survey found that physician practices had experienced a 60% average decrease in patient volume.
Huntington Beach, California–based Landmark Health specializes in providing home-based medical care such as medical interventions and behavioral healthcare to older patients with multiple chronic conditions. The COVID-19 pandemic has been driving demand for this type of in-home care, says Michael Le, MD, Landmark's chief medical officer.
"There has been a dramatic increase in the interest for our services—about a 33% increase in demand for our type of in-home services since the pandemic began. We think that is only going to grow as the year continues, especially as we get back into the flu season in the fall," he says.
The increased demand for in-home services has boosted Landmark's finances, Le says. "From a financial standpoint, the pandemic has grown revenue. We forecast revenue will increase about 230% for this year."
Landmark focuses on risk-based and value-based contracts, mainly with Medicare Advantage health plans. The organization employs about 450 healthcare professionals such as doctors, nurse practitioners, physician assistants, dietitians, and social workers. Landmark operates in 14 states, including 46 metropolitan service areas.
Landmark's mobile care model
The average age of a Landmark patient is 79, and the average patient has eight chronic conditions, Le says.
"For the frail population, they need someone laying hands on them and looking around at the home environment, especially in this time when family members are afraid of visiting and getting their loved ones sick with the coronavirus. Our patients are even more isolated and lonely than they were before the pandemic, and having someone come to examine them and bring treatment to them helps keep them out of emergency rooms, urgent care centers, or hospitals that are full of COVID-19 patients."
Landmark's mobile geriatric care model has four primary elements, he says.
1. "Complexivist" care features a multidisciplinary team. "Complexivist care includes our doctors, nurse practitioners, physician assistants, psychiatrists, pharmacists, dietitians, and social workers. It is a full care team wrapped around the patient. It takes a village to manage the frailties of these patients," Le says.
Complexivist care is provided 24/7 in the patient's home and caregivers spend a significant amount of time with patients, he says. "As opposed to a 10- or 15-minute office visit, our initial visits are an hour long and our follow-up visits are 50 minutes long."
2. Urgent care services are provided to patients.
"We do not just lay hands on the patient and take vital signs. If we find a health problem, we can make an intervention immediately—we are like a global urgent care or emergency room. We can draw blood and check labs. We can administer medications such as Lasix, IV antibiotics, and steroids to treat and stabilize patients. We can insert catheters, perform suturing, and check X-rays or ultrasound imaging," Le says.
3. Behavioral health services are provided to patients because about 50% of Landmark's patients have behavioral health comorbidities that negatively impact their quality of life and outcomes. "We have our own behavioral health team to help address behavioral health needs and social determinants of health," he says.
4. Palliative care and advanced care planning are provided to patients because they are statistically approaching their last years of life, Le says.
"We train our providers to have end-of-life conversations with patients. As a former hospitalist, I can say there is no worse place to have those kinds of conversations than in an emergency room or an ICU. There is no better place to have those kinds of conversations than in a patient's living room while they are surrounded by their family. That way, the whole family can have discussions about goals and values."
Geared for the pandemic
Landmark's in-home service model is well-suited to rising to coronavirus pandemic challenges, Le says.
"Whether it is a direct impact from the pandemic or an inability to get out and get medications, we have seen worsening behavioral health severity among patients. Our behavioral health team—our psychiatrists, nurse practitioners, and social workers—has seen about a 180% increase in visits during the pandemic."
Landmark caregivers are serving as a "pre-frontline" during the pandemic, he says.
"We are able to go into homes and treat our patients so they do not have to go into a hospital and be around symptomatic patients who could be spreading the coronavirus. We can alleviate some of the frontline stress in the emergency rooms, so they are not overwhelmed."
Treating frail, elderly patients in their homes limits their exposure to possible infection with coronavirus, Le says.
"Many of our patients have diabetes, heart failure, and cancer, which puts them at higher risk if they contract COVID-19 at a healthcare facility. If they catch coronavirus, these patients will likely have a bad outcome. Our patients have another option to receive care other than just dialing 911 and being transported to an emergency room."
Bright future
Landmark focuses on the sickest and frailest patients now, but healthcare is moving in the direction of the home, he says. "Whether it is for convenience, safety, or good outcomes, more and more healthcare will be shifting toward the home. We believe there is a gap in this area."
As a care delivery method, home-based medical care is likely to follow a similar trajectory as telemedicine, Le says. "Just like telemedicine has surged and will be part of the healthcare landscape for years to come, the shift to more home-based medical care has been accelerated and will continue to grow long after the pandemic."
Healthcare providers who offer a seamless telehealth experience have a competitive advantage.
Patients are embracing telemedicine during the coronavirus disease 2019 (COVID-19) pandemic, according to a new survey report.
With patients fearful of coronavirus infection during in-person visits with clinicians, the COVID-19 pandemic has accelerated adoption of telemedicine capabilities at health systems, hospitals, and physician practices. In 2020, telemedicine is projected to experience 64.3% year-over-year growth, according to Imaging Technology News.
The new telemedicine survey report, which was published by DocASAP, is based on information collected from 1,000 consumers last month. The survey report includes several key data points:
Emergency rooms and urgent care centers (12%) were at the bottom of the list of facilities where consumers felt safe: grocery store, 42%; pharmacy, 37%; hospital, 32%; doctor's office, 26%; work office, 20%; public transportation, 13%
43% of survey respondents said they would not feel safe visiting any healthcare setting until at least the fall
68% of survey respondents had cancelled or postponed an in-person medical visit during the pandemic
50% of survey respondents had scheduled a telehealth visit online
40% of survey respondents have had a telemedicine appointment
91% of survey respondents who have had a telehealth appointment were likely to schedule another telehealth appointment instead of an in-person visit
40% of survey respondents said easy access to quality care would influence their decision to schedule a telehealth visit
45% of survey respondents said whether healthcare providers offered telehealth services would impact their desire to use those healthcare providers
The Top 3 factors that survey respondents said would influence their decision to schedule a telehealth visit were coronavirus safety concerns (47%), whether the telehealth visit was covered by insurance (43%), and the ease of accessing quality care (40%)
Survey respondents said the Top 4 most satisfying elements of their telehealth visits were appointment wait time (38%), pre-appointment communication (33%), the quality of the video or audio technology (33%), and providing health insurance information (31%)
The Top 6 appointment-related activities consumers would prefer to do online were scheduling appointments (45%), checking symptoms before a visit (42%), checking the cost of a visit (32%), completing intake forms (32%), providing insurance information (29%), and receiving directions to prepare for a visit (29%)
More than 90% of survey respondents said they were satisfied with their overall telehealth visit experience
"Consumers today are looking for convenience, transparency, and efficiency in all their transactions, including healthcare. Those providers that offer a seamless telehealth experience from scheduling to follow-up will earn a competitive advantage," the survey report says.
Interpreting the data
DocASAP CEO Puneet Maheshwari, MBA, told HealthLeaders that increased use of telemedicine is part of the new normal and will continue to be popular with patients well into the future.
"Across all demographics, for certain types of visits, we are seeing that patients are finding telemedicine more convenient and efficient than in-person visits. From our survey, we see that an overwhelming majority of respondents (91%) who have had a telehealth appointment said they are more likely to schedule a telehealth appointment instead of an in-person visit in the future. Furthermore, nearly half of all respondents (45%) said if a provider offers telehealth appointments, it would influence their decision to use them," he said.
Healthcare providers, patients, and payers are aligned when it comes to telemedicine, Maheshwari said.
"Providers are now readily adopting telemedicine tools and technologies to accommodate patients in the new normal of healthcare. How thoroughly telemedicine is being adopted by providers—as well as to what degree payers continue to support it—will determine if this trend is sustainable. I am confident, though. It is not often you see patients, providers, and payers advocating for the same thing."
Primary care is a good fit for telemedicine, he said.
"We expect virtual services to play a broader role in primary care, including both preventative care and chronic care management. With tools such as automatic symptom checking and triaging capabilities to virtual care delivery with video, digital solutions will complement in-person visits. Going forward, we believe that close to 50% of primary care visits could be done virtually."
The expansion of telemedicine is part of a paradigm shift in healthcare, Maheshwari said.
"Overall, the care delivery model is going to evolve from a traditional scheduled-based model to an event-based model. Consumers will get care when and how they need it. For example, historically if a patient needed care, he or she would typically schedule an appointment with a long lead time. But, with increased capacity due to the efficiency of telemedicine, providers can handle more patients. Thus, consumers will be proactively redirected to the right provider and setting based on their specific healthcare event."
As the telemedicine landscape evolves, healthcare organizations are likely to view telehealth services as an integral component of care delivery rather than a standalone capability, he said.
"Incorporating telemedicine into health systems' end-to-end care delivery model will drive efficiency and effectiveness. It's not simply about the technology. It's about redefining care delivery, programs, and models to capitalize on this new trend of telemedicine while learning to use technology in a more effective manner to help facilitate better outcomes and experiences."
