Techniques to retain millennials include dress code changes and providing opportunities for career advancement.
Having trouble with turnover in your millennial healthcare workforce?
Since more than a third of the U.S. labor force are millennials, according to the Pew Research Center, you want to ensure you have strategies in place to understand the needs of the millennial workforce and how to retain them.
It matters to keep millennials happy in the workplace. That's why one Indianapolis-based health system has made millennials the focus of its workforce strategy.
AtIU Health, about 59% of its new hires are millennials, says Amanda Bates, vice president of human resources. "We employ a lot of millennials, and strategically as we look at growth and future hires, they will become more and more of our new hires."
"Forty-one percent of our workforce is millennials. Fifty-one percent of our nurses are millennials, and 31% of our physicians are millennials. So, a lot of our key jobs that touch our patients are millennials, and they will continue to grow in terms of the numbers employed. Strategically, we need to accommodate these folks."
IU Health has implemented four strategies to accommodate and retain millennial healthcare workers at their organization.
1. Adopt a new dress code
IU Health, with 16 hospitals across Indiana, has relaxed its dress code to allow all staff members to have tattoos and piercings, which are defining characteristics of many members of this generation. The change took some courage and it came with a measure of controversy, Bates says.
"The one thing we did that was the big difference maker was go to our patient advisory councils. We went to our patients and asked, 'What's important to you?' We found that what patients really cared about was the quality of their care and the compassion of their caregivers. They cared less about what their caregivers looked like."
Bates and other health system leaders addressed opposition to the new dress code by demonstrating the necessity for change.
"When we rolled it out, there was overwhelming acceptance, but there was a small group of people who were sending me letters about selling out to tattoos and piercings. My response was that we had not sold out at all—this is reality. Millennials present differently than the baby boomers presented, and we needed opportunity for that expression," she says.
2. Provide opportunities for career advancement
IU Health has adapted to the desire of millennials for career mobility and advancement, particularly for nurses and medical assistants, Bates says.
"In nursing, we started developing career pathways, which are ways for people to develop knowledge and incremental skills in areas of their preference like research, leadership, clinical care, safety, or informatics. We give people in clinical areas many options in terms of their development and pathways to gain knowledge or certifications."
Prior to establishing career pathways and ladders for medical assistants, they had the highest job turnover of any other clinical role at IU Health, she says.
"We did focus groups with our medical assistants, and we found out that they wanted career development and career progression. It was a very flat job that did not pay a lot. So, we talked with them about the skills that would be of most benefit, then we developed opportunities for people to become trained and certified in those skills. Now, we have 65% of our medical assistants who have received promotions on our career ladder, which comes with pay increases and increased responsibility. Our turnover is down to the 10th percentile."
IU Health also has established career pathways and ladders in other areas of the organization, including human resources, finance, and information technology.
3. Reform hiring and training practices
The health system has made the hiring process more appealing to millennials, Bates says.
"Until 18 months ago, you had to apply the old-fashioned way—getting on a computer and filling out an application that took 30 minutes, then taking a test to measure job aptitude. You can still apply that way, but 65% of our applications now are made on a mobile app—it takes just a few minutes. We significantly reduced the number of questions that we asked, and we have doubled the number of applications that we get."
Texting is the next frontier of IU Health's hiring efforts, she says. The health system is adopting a texting application that helps communicate with applicants with a text rather than a phone call.
IU Health is starting to conduct screening interviews via text. The health system has built a library of standard questions that recruiters ask of each candidate, which they can auto-populate into the chat trail for quick conversations to learn about factors such as candidate qualifications and shift availability. A transcript of the conversation can be shared internally to help avoid duplicate questions being asked when the hiring leader conducts interviews.
Millennials tend to be more job ready than earlier generations of healthcare workers, so the health system has streamlined orientation processes, she says.
"A couple of years ago, we reduced the amount of time new hires spend in orientation before they join their units. For our nurses, we used to have service requirements before we would move them into operating rooms or ICUs, but we discontinued that. We can move millennials into jobs that require fast-pace and critical thinking."
With the proclivities of millennials in mind, IU Health also has been innovating in how the organization trains employees in ways that are novel, fun, and social, Bates says.
"We recently rolled out an escape room program for new nursing hires. They are broken into groups and have an hour to solve safety and quality puzzles. You need to try to beat the time of the other cohort teams in your training group."
4. Enhance tuition reimbursement for continuing education
IU Health also is using tuition reimbursement to cater to millennials as an opportunity for career advancement, she says.
"We have improved tuition reimbursement. We stopped making it a requirement for nurses to have a bachelor's degree and offered a generous tuition reimbursement. We doubled the number of academic programs that we would pay for. In one year, we tripled the number of people in our tuition reimbursement program."
Researchers find that market concentration has a negative impact on all 10 of the patient satisfaction measures in Hospital Compare.
Market concentration including vertical integration between hospitals and physicians has a negative impact on patient satisfaction, recent research indicates.
With the changing economics of the healthcare sector, vertical integration between hospitals and physicians as well as hospital mergers have become increasingly common. For example, the number of hospital-employed physicians increased about 63% from 2012 to 2016.
Market concentration is reducing competition with predictable results, the lead author of the recent research published in Medical Care Research and Review told HealthLeaders last week.
"From a data standpoint, market concentration is a proxy for competition within the market, where higher market concentration corresponds with
lower competition. With lower competition, we suspect that there is simply less incentive for providers to keep patients content," said Marah Short, associate director of the Center for Health and Biosciences at the Baker Institute for Public Policy, Rice University, Houston.
The researchers examined 29 quality measures in the Hospital Compare database at the Centers for Medicare & Medicaid Services from 2008 to 2015. While vertical integration was linked to a minor impact on some quality measures, market concentration in general was "strongly associated" with reductions in all 10 patient satisfaction metrics such as measures for doctors communicating well and patients receiving help as soon as they want it.
"Given the nature of some satisfaction measures, such as explaining medications and communicating well with patients, overall clinical quality could suffer if patients do not properly understand care recommendations during their hospital stay or post-discharge," Short and her coauthor wrote.
The researchers acknowledge that patient satisfaction may not always be associated with clinical quality; however, they contend that patient perception is an important metric because more and more patients are using online physician reviews to pick healthcare providers.
"In one U.S. study, 59% of survey respondents stated that physician ratings are 'somewhat' or 'very important' in their choice of physician, and consumers aged 18 to 24 years are more likely to use online health information and physician ratings for provider selection than the general population. As this young cohort becomes a larger consumer of healthcare, we expect this increase to continue," they wrote.
Regulatory review is needed to maintain patient satisfaction levels after healthcare deals that impact market concentration, the researchers wrote. "Regulators should continue to focus scrutiny on proposed hospital mergers, take steps to maintain competition, and reduce counterproductive barriers to entry."
The difficulties of achieving appropriate administration of antibiotics in intensive care units include early treatment of patients due to severity and acuity of illness.
Appropriate prescribing of antibiotics by healthcare providers is essential to help avoid the development of antibiotic-resistant infections, which the Centers for Disease Control and Prevention calls one of the most severe public health problems in the country. About 23,000 Americans die annually from an antibiotic-resistant infection, the CDC says.
Research co-author Richard Wunderink, MD, FCCP, of Northwestern University Feinberg School of Medicine in Chicago, told HealthLeaders that there are three primary unique aspects of antibiotics stewardship in the ICU.
Severity and acuity of illness requires early administration of antibiotics
Diagnostic uncertainty in a patient who presents with multiple potential sites of infection prompts multiple potential antibiotic treatment regimens
There is a tendency for patients with risk factors for multidrug-resistant, extensively drug-resistant, and pan-drug-resistant infections to require transfer to the ICU
As a result of these challenges, ICU clinicians often deal with the negative impact of excess antibiotic therapy, Wunderink and his co-authors wrote in the journal CHEST.
"Many ICUs become sinks for multi-drug resistant pathogens, accumulating patients with treatment failure due to antibiotic resistance. Prolonged duration of mechanical ventilation also predisposes to recurrent ventilator-associated pneumonias (VAPs), with each pathogen more resistant than the previous."
The research team found there are three main barriers to good antibiotics stewardship in the ICU: diagnostic uncertainty, fear of not adequately covering the causative pathogen, and underestimation of antibiotics toxicity. Wunderink said there are approaches to overcome these barriers.
Developing new rapid diagnostic tests as opposed to culture-based techniques—the greatest needs are for direct-from-blood samples and accurate samples from respiratory secretions
Promoting better clinical research with more accurate tests to determine the true incidence of "missed" pathogens
Raising awareness about antibiotic toxicity and the difficulty of separating drug toxicity from the underlying infection; for example, both often can cause fever
Antibiotic stewardship program
Implementing a formal antibiotic stewardship program is essential in the ICU setting, the researchers wrote.
"Judicious use of antibiotics in the ICU is essential to control development of resistant organisms and the benefits of implementing an ASP in the intensive care unit are well-documented. Studies have shown that ASPs reduce rates of antibiotic resistance, duration of ventilation, days of antibiotic use, and healthcare costs in critically ill patients."
An ASP in the ICU setting should have seven elements, according to the researchers.
Leadership: An infectious disease pharmacist and infectious physician should responsible for administering the ASP along with the ICU leadership.
Audit and feedback: Antibiotics administration should be reviewed and revised in response to changing circumstances such as new diagnostic results. Revised courses of treatment include de-escalation of medication.
Antibiotic time out: This physician-trainee approach reviews antibiotic indications on a bi-weekly basis and includes monthly trainee instruction.
Rapid diagnostics: The ICU should be equipped with a viral multiplex polymerase chain reaction platform, rapid PCR for methicillin-resistant Staphylococcus aureus, and serial procalcitonin.
Clinical pathways: These guidelines require physicians to document signs and symptoms, then provide antibiotics recommendations. Some pathways stratify patients based on risk factors for multi-drug resistance, which can determine the length of antibiotics treatment.
Computerized decision support: Electronic analysis of antibiograms and patient data generate antibiotics recommendations. Computerized decision support can provide an individualized approach to antibiotic decision-making for each patient.
Infection control: ICU staff should take preventative measures such as hand washing.
New research contradicts the perception that better sepsis care alone can reduce mortality.
Most sepsis-associated deaths are linked to other underlying causes and are not preventable with better sepsis care alone, research published today indicates.
On an annual basis, sepsis affects about 1.7 million American adults and the infection is linked to more than 250,000 deaths.
The research published today in the Journal of the American Medical Association focused on sepsis-associated deaths at six academic medical centers and community hospitals, where sepsis was the most common immediate cause of death.
"However, most underlying causes of death were related to severe chronic comorbidities and most sepsis-associated deaths were unlikely to be preventable through better hospital-based care. Further innovations in the prevention and care of underlying conditions may be necessary before a major reduction in sepsis-associated deaths can be achieved," the researchers wrote.
The researchers reviewed the case histories of more than 500 randomly selected patients who either died in the hospital or were discharged to hospice care. The case history reviews generated several key findings.
300 of the patients were afflicted with sepsis and the infection was the immediate cause of death in 198 of those patients, or 34.9% of the total study cohort
The second most common immediate cause of death was cancer, which claimed 92 patients, or 16.2% of the total study cohort
The third most common immediate cause of death was heart failure, which claimed 39 patients, or 6.9%
For the 300 patients with sepsis, the top underlying causes of death were solid cancer (63 patients), chronic heart disease (46 patients), hematologic cancer (31 patients), dementia (29 patients), and chronic lung disease (27 patients)
Suboptimal care such as delayed administration of antibiotics was found in 22.7% of the 300 sepsis cases, but only 12% of sepsis-associated deaths were deemed potentially preventable
Gauging the preventability of sepsis-associated deaths
These findings call into question prior views of sepsis care, the researchers wrote.
"The high burden of sepsis and the perception that most sepsis-associated deaths are preventable with better care has catalyzed numerous sepsis performance improvement initiatives in hospitals around the world. The extent to which sepsis-associated deaths in adults might be preventable, however, is unknown."
Sepsis-associated mortality may not be as preventable as previously considered, they wrote.
"Sepsis disproportionately affects patients who are elderly, have severe comorbidities, and have impaired functional status. Some of these patients may receive optimal, guideline-compliant care yet still die due to overwhelming sepsis or from their underlying disease."
The researchers acknowledge that their conclusions are at odds with earlier studies that have shown positive outcomes from efforts to improve sepsis care.
"Our findings are notable in light of many sepsis quality improvement initiatives that reported substantial decreases in mortality rates after implementation of sepsis care improvement initiatives. These studies imply that many sepsis-associated deaths are preventable," the researchers wrote.
They say there are two possible explanations for the discrepancy.
The hospitals in the JAMA study had already improved sepsis care, impacting the preventability of sepsis-associated deaths.
Sepsis-care improvement initiatives have over-estimated their impact on mortality. A common element of these improvement initiatives is better recognition of sepsis, which leads to identification of more subtle cases of the infection and the impression of lower mortality rates.
To decrease sepsis-associated deaths, hospitals may have to expand the scope of care for patients afflicted with the infection, the researchers wrote.
"Our findings do not diminish the importance of trying to prevent as many sepsis-associated deaths as possible, but rather underscore that most fatalities occur in medically complex patients with severe comorbid conditions."
ProMedica's initiative is designed to help the country rise to the challenge of the exploding senior population.
Toledo-based ProMedica launched an aging institute earlier this month.
The Centers for Disease Control and Prevention (CDC) has forecast meteoric growth in the country's senior population, which is expected to also drastically increase the number of Americans afflicted with chronic diseases. In 2015, 45 million adults were 65 or older, and that figure is anticipated to reach about 80 million by 2050, according to the CDC.
"We are going to have an explosion of people who are going to be in their 70s and 80s, and our national workforce is going to have a lot fewer young people compared to seniors," says Steve Cavanaugh, MBA, president of the HCR ManorCare division of ProMedica and a member of the leadership team at the new ProMedica Healthy Aging Institute.
The aging institute will be working in three core areas.
Innovation and research: Identifying and developing new health and wellness models for the senior population
Education and training: Preparing the next generation of administrators and clinicians to support all aspects of senior health and well-being such as continuing education for professionals in the senior care field
Advocacy: Driving industry reform and supporting efforts to redesign healthcare for seniors
The long-term goal of the aging institute is to serve as a catalyst for change at a national level, Cavanaugh says.
"If you think about the current state of healthy aging and healthcare in general, despite all the work we have done the country's health system remains siloed. We still have a system that is anchored in fee-for-service, and we still have a model that is focused on the clinical aspects of care that ignores things like social determinants of health."
Innovation and research
The aging institute is being designed to generate evidence-based approaches addressing the challenges associated with the country's increasing senior population, Cavanaugh says.
"On the innovation and research side of the institute, we see opportunities to try some things with our own health system and provide some academic rigor on whether initiatives work and whether they can be applied across the country."
Education and training
The aging institute is not expected to provide training. Instead, the institute is expected to partner with other institutions to develop curricula to train the next generation of clinicians and healthcare professionals who work with elderly patients, he says.
"We are going to need a healthcare workforce that is more and more well versed in caring for seniors."
Administrative leaders will be another focal point of the aging institute's education and training efforts, Cavanaugh says.
"We are going to need leaders who know how to manage in the senior care space. Now, the leadership in healthcare is heavily weighted toward the hospital setting. As we shift away from hospitals to postacute care, we are going to need leadership that is more familiar with that setting of care."
Healthy aging advocacy
Entering the political arena is a necessary step toward improving care for seniors, he says.
"You can come up with the best public policy options available, but if you don't implement them through the regulatory and reimbursement systems in the political process you are not going to get the change that the country needs. We have a role to provide information and work with other parties to arm them with arguments for particular policy options that we view as beneficial for the country."
Seeking to end the practice of denying Medicare coverage for skilled nursing facility costs after an observation-status stay at a hospital is an example of the aging institute's advocacy role, Cavanaugh says.
"That might be a narrow issue where we can raise our hand with others in the near-term and say, 'It's not right. It's not good policy.'"
Jerry Penso shares insights from visiting more than 65 AMGA member organizations since October 2017.
You could say that Jerry Penso, MD, MBA, likes to travel. With purpose.
The former family physician at Sharp Healthcare in San Diego became president and CEO of AMGA in 2017, and he made a commitment to the organization that racked up thousands of frequent flyer miles.
"When I took the role, I promised the board of directors that I would visit 40 medical groups in 40 weeks. It started in October 2017 and ended in June 2018," Penso says.
After making that promise as part of his hiring process, Penso visited more than 65 AMGA members.
He joined Alexandria, Virginia–based AMGA seven years ago as the organization's first chief medical and quality officer. Prior to working for AMGA, Penso was continuum of care medical director for Sharp Rees-Stealy Medical Group in San Diego.
AMGA—formerly the American Medical Group Association—has more than 400 medical group and health system members. More than 175,000 physicians practice at AMGA members.
HealthLeaders recently spoke with Penso to discuss his 9-month cross-country journey to visit physician practices and medical groups, and he reveals the three primary issues on physicians' minds. Following is a lightly edited transcript of that conversation.
HealthLeaders: Were there commonalities between healthcare organizations?
Penso: There were three issues that came up repeatedly at every medical group or health system that I visited.
1. Pressure on margin: Most of them are seeing or projecting flattening revenues, but expenses continue to rise based on a bunch of reasons from labor, to pharmaceuticals, to information technology. They are focused on the margin issue and are trying to figure out how to manage expenses.
2. Challenges in the move to value: Many see value as the future, and they understand that is the direction they need to go. However, there are challenges—struggles with the payers, care redesign, and grappling with some of the payment models.
3. Physician leadership and physician burnout: Senior leaders are finding they need a new kind of physician leader to help with the challenges they face—integration with other practices, the move to value, engagement of physicians in working with patients in new ways, and practice redesign. These responsibilities are contributing to burnout—more and more burdens are being place on physicians.
HL: Gauge the level of optimism you encountered during these visits.
Penso: It was one of the surprising things that I found—the medical group and health system leaders I met were surprisingly optimistic. They realize there are challenges with the payment models, redesigning care, and physician engagement, but these leaders are committed to their communities.
Our medical groups and health systems are often the largest employers in their areas. So, they are embedded in their communities. That commitment gives them a mission to improve the healthcare they provide for their friends, families, and others who live among them.
HL: What were the qualities of the top performers?
Penso: There were two keys to top performers.
1. They had an organized system of care. They had infrastructure to deliver care in a systematic, coordinated, consistent, and reliable way, and a common electronic health record across their system. They also had good analytics to understand their population, and a care coordination strategy. They also had strong physician leadership to manage the group.
2. Top-performing medical groups had a culture of learning and collaboration. They are always working to improve care and outcomes, and they measure it. All of the components collaborate—the hospital, nurses, physician staff, and IT professionals all work together.
HL: How is the physician shortage impacting AMGA members?
Penso: I heard about physician shortage at many of the places I visited, but particularly in the rural areas of the country. Their challenge is to attract and retain physicians—especially primary care physicians.
Most practices are facing a demographic issue. Many physicians are older and nearing retirement. Figuring out a strategy to replace those physicians is on the minds of many of my health system and physician practice leaders across the country.
In response, they are figuring out how to deliver care differently, which will probably require more of a team-based approach. They want to make their practices more efficient and use their physicians exactly as they are needed, then use other providers such as advanced practice practitioners to provide care for patients. They are also utilizing technology such as telemedicine, so you may not need as many face-to-face visits with a physician.
HL: How do your members view the healthcare policies of the Trump administration?
Penso: In late 2017 and early 2018, there was a lot of uncertainty about the Trump administration—the direction they were going with healthcare. The unsuccessful effort to repeal the Affordable Care Act was on everybody's mind. AMGA members wanted some help understanding the direction of the administration. The previous administration had been very assertive in moving toward value, and they wanted to know whether the current administration was going to follow those policies.
We have seen a lot of movement in this administration toward value, so we are very encouraged. There is also a strong push toward regulatory relief. So, we think the direction under Alex Azar and Seema Verma appears to be favorable to moving toward value-based models.
Physician says hospitals are too tolerant of assaultive behavior by patients and their loved ones.
Amy Costigan, MD, wants to be able to practice emergency medicine without being punched in the face.
Healthcare staff carry a heavy workplace violence burden, with about 74% of workplace assaults occurring in the healthcare setting. Workplace violence is prevalent in the emergency department—78% of emergency physicians have reported being targets of workplace violence in the prior 12 months.
Costigan wrote about her workplace violence experience in Annals of Emergency Medicine. She had lost a young woman in cardiac arrest, then went to a family room to inform the woman's mother.
When she entered the room, the ER physician had a choice—sit in a chair near the door or sit on the couch next to the young woman's mother. Costigan picked the couch.
After she shared the bad news, the enraged mom punched her in the face.
"I do things a little differently now when giving bad news. I never go alone," Costigan wrote in the journal. "Sometimes I have security stand around the corner. The door always stays open. I know my exits. I always choose the seat by the door."
Extended impact of workplace violence
Costigan, a member of the Department of Emergency Medicine at the University of Massachusetts Medical School in Worcester, shared her views about workplace violence with HealthLeaders last week.
In the healthcare setting, workplace violence erects barriers between physicians and patients in two ways, she said.
"First, we can never provide good patient care when workers are scared for their safety. It creates distraction, mistrust, apathy, poor care, and disengagement with patients. You don't want your doctor or your nurse to be afraid to sit with you, hold your hand, or sit there and cry with you. Unfortunately, workplace violence is slowly stripping our ability to be physically and emotionally present with patients.
"Second, an unsafe environment for staff is an unsafe environment for patients. In the emergency department, patients are witnessing violence. It is traumatizing and scary for those patients. They are also at risk."
Costigan said being the target of workplace violence has compromised her ability to be compassionate with her patients and their loved ones.
"We are taught in medical school to sit with the patient when giving bad news. You are supposed to put a hand on their shoulder. You are supposed to be close emotionally and physically. Most of the time now, I try to figure out the best place to sit for my safety. I still try to be close and emotional, but I never go alone and sometimes I have security outside the room. That's not the way I want it to be."
'We are tolerating it'
In healthcare, the widespread practice of abstaining from pressing charges in cases of workplace violence is making the problem worse, Costigan said.
"Workplace violence is persisting and increasing because we are tolerating it. It's never OK to assault another person, not when you're drunk, not when you're sick, not when you're having a bad day—it's just never OK. To my knowledge, violence is not tolerated in any other profession."
The emotionally challenging environment in healthcare settings does not excuse assaultive behavior or justify exposing healthcare workers to violence, she said.
"We work in emotionally charged and high-stress situations, but our protection in the hospital shouldn't be any different than what is afforded to everybody else. We don't tolerate assault in a courtroom, or a library, or a restaurant. The same rules should be applied and enforced everywhere because everybody has a right to feel safe, supported, and protected in their workplace."
There must be some accountability when workplace violence incidents occur, Costigan said. "Healthcare workers need support from the administration, the police, the district attorney, and judges. The only way to stop this violence is to send a clear message that it is not acceptable."
For many cancer patients, the causes of unanticipated hospital stays in the first year after receiving a diagnosis are unrelated to cancer, such as infection.
Many unplanned hospitalizations of cancer patients could be avoided, recent research indicates.
Hospitalization is a leading contributor to cancer-related healthcare spending. Hospitalizations for cancer involve longer length of stay and higher costs than inpatient care for other conditions.
The lead author of the recent research, which was published in Journal of Oncology Practice, told HealthLeaders there are opportunities to avert many unplanned hospitalizations of cancer patients.
"We know that many individuals undergoing treatment for cancer will experience treatment-related symptoms and side effects. Improving symptom management and enhancing access to care such as same-day and after-hours support are promising approaches because they can provide patients with help for distressing symptoms when they need it," said Robin Whitney, PhD, RN.
The researchers found that 35% of cancer patients had an unplanned hospitalization within a year after receiving their diagnosis. Patients who are frail or entering advanced stages of disease could be the most promising focal point in efforts to reduce unplanned hospitalizations, said Whitney, director of research at the Hillblom Center on Aging, and an assistant adjunct professor at UCSF Fresno Medical Education Program in Fresno, California.
"There is evidence that many potentially avoidable hospitalizations in oncology occur among individuals who are already frail, have multiple concurrent health conditions, or who have advanced cancers that are not amenable to treatment. Focusing efforts on individuals who are at high risk of experiencing complications may be the most promising approach. These individuals should receive palliative and supportive care services to address their needs, concurrently with active treatment."
Unplanned hospitalization data
The Whitney team's research, which features data from more than 421,000 patients, generated several key data points for unplanned hospitalizations of cancer patients.
In the year after diagnosis, about 67% of hospitalizations were unplanned
At 32.9%, cancer was the most common diagnosis listed for unplanned hospitalization
Noncancer diagnoses listed for unplanned hospitalizations included infection or fever (15.8%), medical device (6.5%), gastrointestinal (5.8%), cardiovascular (5.8%), and respiratory (4.3%)
Stage of cancer at time of diagnosis was linked to likelihood of unplanned hospitalization, with 21.9% of stage I patients experiencing an unplanned hospitalization compared to 58.3% of stage IV patients
About 67% of unplanned hospitalizations originated in the emergency department
An urgent care strategy can decrease unplanned hospitalizations and emergency room visits, Whitney said.
"Some oncology programs have been able to successfully reduce ER visits and unplanned hospitalizations by improving their ability to address the urgent care needs of their patients. For example, some have implemented workflows for oncology nurses to triage patient symptoms and facilitate same day appointments when needed. Others have had success using navigators who can provide additional support and connect patients and caregivers with community resources."
Large physician bonuses in pay-for-performance reimbursement arrangements are associated with improvement in evidence-based care.
Pay-for-performance arrangements for physicians that feature large bonus payments can have a positive impact on clinical quality, research published today suggests.
As the healthcare sector shifts from volume-based payment models to value-based models, pay-for-performance reimbursement for physicians has become increasingly widespread. The most ambitious pay-for-performance program in the country is the Merit Incentive Payment System enacted under the Medicare Access and CHIP Reauthorization Act of 2015.
Big bonuses are hard for physicians to ignore, the lead author of the research published today in Journal of the American Medical Association told HealthLeaders.
"Increasing bonus sizes brings more attention from clinicians to quality metrics on which they are being measured. More attention may lead to better follow through and achievement of specific quality metrics, especially those that are process oriented. In some cases, the dollars may get invested in infrastructure, processes, or information technology that helps deliver better quality care," said Amol Navathe, MD, PhD, Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
When Navathe and his research team added two behavioral economic factors to their study—increased social pressure and loss aversion—there were no gains in pay-for-performance effectiveness, he said.
"It should be noted however that increasing bonuses has not uniformly led to higher quality of care, which is one reason we tried to bring in behavioral economics to get more 'bang for the buck.' In our study, the behavioral economic designs did not seem to add to the return on investment."
Patients should be the primary concern when structuring bonus payments, Navathe said.
"There are several considerations, but chief among them is aligning the bonuses with what is best for patients. Components of P4P programs like quality metrics and the data underlying them are imperfect, so employers and payers should be mindful that the entire program design should emphasize activities that are good for patients—without putting physicians and patients at odds with good care. This may mean emphasizing areas where we feel more confident about the quality metric, the data underlying it, and the lack of unintended effects."
Gauging impact of bonuses
Navathe's research team examined the proportion of 20 evidence-based quality measures achieved. There were 33 physicians and more than 3,700 patients included in the study's analysis.
Larger bonus size was linked to a greater increase in evidence-based care than a control group. Three individual measures of evidence-based care showed improvement under large bonus size arrangements: blood pressure control, conducting a foot examination with a diabetes diagnosis, and tobacco cessation.
In the study, the mean size of annual bonuses given to physicians was $3,355.
"We found an increase in bonus size was associated with significantly improved quality for patients receiving care for chronic disease relative to a comparison group during a single year," Navathe and his team wrote.
For patients at high risk of postoperative delirium, interventions include medication management and family education.
Preoperative cognitive assessments can identify patients at high risk of postoperative delirium and prompt interventions, recent research shows.
Postoperative delirium (POD) is disturbance of consciousness with impaired attention, and it is the most common surgical complication for older adults. While most deliriums are reversible, they are associated with increased morbidity and mortality, as well as longer length of stay.
The recent research focused on 173 vascular surgery patients who underwent the Montreal Cognitive Assessment (MoCA) before their procedures. After surgery, 11.6% of the patients experienced POD.
"MoCA scores can be used in the preoperative period to identify patients at high risk of POD, which can provide important predictive information to the clinician but also to the patient and family," the researchers wrote.
The research team also identified predictors of POD—some major surgical procedures such as lower limb amputation and open aortic repair, MoCA scores showing moderate to severe cognitive impairment, and previous delirium.
Intervening to limit delirium
The lead author of the research, Rima Styra, MD, MEd, told HealthLeaders there are three primary interventions after a surgical patient has been deemed at high risk for POD.
Medication management: A top priority is discontinuing benzodiazepines and reviewing over-the-counter sleeping drugs. Some patients also have substance abuse issues. If patients can be screened early for delirium risk, care teams can make changes in medications or help with substance abuse.
Anesthesia: Anesthesiologists can make adjustments in care to avoid exacerbating risk factors for POD.
Family education: Many family members are unaware of delirium and need to be educated about the risk. They often don't understand how someone could have surgery and end up confused and paranoid. One-on-one educational conversations with family members are ideal, usually the day when the patient arrives for surgery.
Conducting cognitive assessments
Beyond identifying high-risk patients, there are a pair of significant benefits from administering preoperative cognitive assessments, said Styra, who is affiliated with the Peter Munk Cardiac Center at University Health Network in Toronto, Ontario, Canada, and the Department of Psychiatry at University of Toronto.
"First, you can find out about the patient's cognitive functioning prior to it being affected by surgery—you find out about the overall functioning prior to surgery. It gives a baseline that you want the patient to return to. You also get an opportunity to obtain information from the patient. Many patients have been prescribed medications that they do not take. It's important to know whether they are taking their medications or not."
