A top CommonSpirit Health executive weighs in on likely trends for this year.
In 2023, there are four primary predictions for clinical care, a CommonSpirit Health executive says.
Ankita Sagar, MD, MPH, is system vice president for clinical standards and variation reduction at the Chicago-based health system. Prior to joining CommonSpirit in November 2021, she was an attending physician at Northwell Health, where she held two leadership positions: director of ambulatory quality for medicine service line and director of the COVID Ambulatory Resource Support program.
HealthLeaders recently talked with Sagar about her healthcare predictions for 2023. The following transcript of her comments has been edited for brevity and clarity.
1. Annual wellness visits
''One of the top predictions for 2023 is getting back to annual wellness visits and getting patients into the doctor's office again. We need to make sure that we are talking about routine vaccines, cancer screening, [and] managing chronic conditions such as heart disease, diabetes, and kidney disease because there has been a lot of prevention missed over the past few years due to the coronavirus pandemic. There are also patients who move from state to state, and they need to establish connections with new providers. It is important to get people in to prevent disease and keep chronic conditions from getting worse.''
2. Behavioral health
''Heightened efforts to address behavioral health concerns is another prediction for 2023. Statistics show that depression, anxiety, insomnia, and substance use dependence have worsened over the past few years. Part of the issue now is that we are having to manage people who have gone longer without care for behavioral health conditions, and we are trying to bring them back into the fold. We need to make sure we have made the right diagnosis and are doing the right treatment. We also need to focus on surveillance to make sure patients are doing well after treatment has started.
''There is a significant need to address behavioral health disorders—specifically depression, anxiety, and insomnia. First, we need to remove barriers from care such as having physicians and advanced practice practitioners provide care at the top of their license. Primary care physicians and advanced practice practitioners need to be able to manage mild to moderate illnesses, with coaching from behavioral health teams. That way, the behavioral health teams can manage the more severe conditions. We also need to improve insurance coverage of behavioral health conditions, which is currently a barrier to care. It is difficult for some people to access behavioral health care if their insurance does not pay for it.''
3. Health equity
''Healthcare providers are going to be doing more to address equity in 2023. We need to make sure we are addressing disparities that have been in the healthcare system for years. We need to come at equity in a more meaningful, patient-centered, and community-centered way.
''At CommonSpirit, we have had a long journey on equity. We have a mission-driven approach to make sure we are addressing the needs of vulnerable populations. We are making sure that equity is part and parcel of everything we do on a daily basis.
''For 2023, one of the main areas for equity concerns is going to be around preventive care. If no-cost preventive care under the Affordable Care Act ends, it is going to make it more challenging for us to ensure that our vulnerable populations and people of color are given the appropriate care, especially when it comes to cancer screenings, vaccines, and chronic disease prevention. So, conditions such as obesity, diabetes, high blood pressure, heart disease, and kidney disease are going to be key considerations for equity concerns.
''The concern is that if the Affordable Care Act requirement for no-cost preventive care goes away, there will not be a guaranteed way for health insurers to cover preventive health services for patients. There could be high cost-sharing, which will create more disparities for patients who are at the lower end of affordability for healthcare.''
4. Healthcare worker burnout
"In 2023, there will be a renewed emphasis on caring for our physicians, advanced practice practitioners, and other healthcare workers. We need the care providers to be well in order to take care of patients. CommonSpirit is working diligently on multiple fronts to ensure that the well-being of our physicians and advanced practice practitioners is top of mind. We recently signed on with the Dr. Lorna Breen Heroes' Foundation and the National Physician Suicide Awareness Day to be a supportive organization and bring to light that our physicians and advanced practice practitioners are cared for in a supportive manner.
''We want to make sure that our physicians and advanced practice practitioners have access to healthcare—whether it is physical, emotional, or mental health—and can cope with stress and moral injury in a comprehensive and supportive manner.
.''Prior to the pandemic, when healthcare leaders talked about burnout, we talked about physicians, advanced practice practitioners, and clinical teams including nurses being resilient. It was an individualized approach to burnout. What we have all learned nationally is that burnout is not an individual problem—you need systematic change, particularly in the culture. At CommonSpirit, we are involving the physicians and the advanced practice practitioners to help us make cultural change happen. You cannot wave a magic wand and make burnout disappear—it is a journey that requires continuous improvement over time.''
The federal agency is creating 200 new residency slots every year over a five-year period.
On Monday, the Centers for Medicare & Medicaid Services (CMS) awarded the first 200 of 1,000 Medicare-funded physician residencies to bolster the physician workforce and add physicians at hospitals serving underserved communities.
The new residencies are designed to improve health equity and access to care. The emphasis of the new residencies is on primary care and behavioral health, with 125 of the residencies for primary care and 20 of the residencies for psychiatry.
The residencies target critical needs, CMS Administrator Chiquita Brooks-LaSure said in a prepared statement. "These graduate medical education residency slot awards will help address access to care challenges and workforce shortages in the highest need areas. The majority of the positions are for primary care and mental health specialists, who are the foundation of our healthcare system. I encourage potential applicants to apply to our next application period, which opens in just a few weeks."
The next application period closes on March 31.
The Fiscal Year 2022 Inpatient Prospective Payment System final rule created 1,000 new Medicare-funded physician residency slots to qualifying hospitals authorized by the Consolidated Appropriations Act of 2021. There will be 200 slots phased in per year over five years.
For the new residencies, CMS prioritized hospitals with training programs in geographic areas with greatest need for additional clinicians, as determined by Health Professional Shortage Areas. The new residencies were awarded to 100 teaching hospitals across 30 states, the District of Columbia, and Puerto Rico. They will be effective July 1, 2023.
The new residencies will enhance the physician workforce and boost health equity, Meena Seshamani, MD, PhD, CMS deputy administrator and director for the Center for Medicare, said in a prepared statement. "Prioritizing these awards to areas that need the most support will bolster the workforce while also arming new providers with a unique understanding of the specific needs of these communities. This is critical in advancing our goals of providing high-quality care to all people."
Based on occupation among healthcare workers, nurses have the highest level of unionization (17.5%).
The level of unionization of healthcare workers has not changed significantly over the past decade, with unionized workers gaining higher weekly earnings and better noncash benefits, a recent study found.
Unionization efforts across industries have accelerated in recent years, with the National Labor Relations Board reporting a 57% increase in union election petitions in the first half of 2022. Workers pursue unionization primarily to seek better pay, better noncash benefits, and safer work conditions.
The recent study, which was published in the Journal of the American Medical Association, is based on data collected from more than 14,000 healthcare workers from 2009 to 2021. The data was collected from the U.S. Census Bureau-sponsored Current Population Survey and Annual Social and Economic Supplement.
The study included data collected from 6,350 technicians and support staff, 4,931 nurses, 1,072 physicians and dentists, 981 advanced practitioners, and 964 therapists.
The study features several key data points:
13.2% of healthcare workers reported union membership or coverage, with no significant change in unionization level from 2009 to 2021
Compared to nonunionized healthcare workers, unionization was associated with higher weekly earnings ($1,165 versus $1,042), higher likelihood of having a pension or other retirement benefits (57.9% versus 43.4%), and having full premium-covered health insurance (22.2% versus 16.5%)
Compared to White healthcare workers, Asian, Black, and Hispanic healthcare workers were more likely to be unionized
Healthcare workers living in metropolitan areas were more likely to be unionized
Compared to nonunionized healthcare workers, unionized workers reported more weekly work hours (37.4 versus 36.3)
Older healthcare workers were significantly more likely to be unionized than younger healthcare workers: 15 to 29 years old (8.6%), 30 to 44 years old (14.0%), 45 to 59 years old (15.2%), and 60 years old and older (14.5%)
Nurses reported the highest level of unionization (17.5%)
Physicians and dentists (9.8%) and technicians and support staff (9.9%) reported the lowest level of unionization
"From 2009 through 2021, labor unionization among U.S. healthcare workers remained low. Reported union membership or coverage was significantly associated with higher weekly earnings and better noncash benefits but greater number of weekly work hours," the study's co-authors wrote.
Cannabis use may worsen pain and nausea after a procedure and increase the need to prescribe opioids for pain, an anesthesia and pain medicine group says.
Patients getting procedures that require anesthesia should be asked about cannabis use, according to new guidelines from the American Society of Regional Anesthesia and Pain Medicine (ASRA Pain Medicine).
Cannabis use has increased over the past 20 years. Cannabis is second only to alcohol in the use of psychotropic substances, with about 10% of Americans using cannabis monthly, according to the U.S. Substance Abuse and Mental Health Services Administration.
The new guidelines were published by the journal Regional Anesthesia & Pain Medicine. "Surgical patients using cannabinoids are at potential increased risk for negative perioperative outcomes," the guidelines say. For patients undergoing surgery, cannabis use may worsen pain and nausea after a procedure and increase the need to prescribe opioids for pain management, according to a prepared statement from ASRA Pain Medicine.
"Before surgery, anesthesiologists should ask patients if they use cannabis—whether medicinally or recreationally—and be prepared to possibly change the anesthesia plan or delay the procedure in certain situations," Samer Narouze, MD, PhD, senior author of the guidelines and ASRA Pain Medicine president, said in the prepared statement. "They also need to counsel patients about the possible risks and effects of cannabis. For example, even though some people use cannabis therapeutically to help relieve pain, studies have shown regular users may have more pain and nausea after surgery, not less, and may need more medications, including opioids, to manage the discomfort. We hope the guidelines will serve as roadmap to help better care for patients who use cannabis and need surgery."
The guidelines were crafted by ASRA Pain Medicine's Perioperative Use of Cannabis and Cannabinoids Guidelines Committee. The panel featured 13 experts, including anesthesiologists, chronic pain physicians and a patient advocate.
The panel fielded nine questions and made 21 recommendations. The recommendations were graded on a scale established by the United States Preventive Services Task Force (USPSTF). The USPSTF assigns letter grades to recommendations: A, B, C, D, and I. An A grade is given to recommendations with the highest level of evidence. An I grade is given to recommendations with insufficient evidence.
The panel assigned an A grade to four recommendations:
Screen all patients for cannabis use before surgery
Postpone elective surgery for patients who have an altered mental status or impaired decision-making ability at the time of surgery
Counsel heavy users about the potentially negative effects of cannabis use on postoperative pain control
Counsel pregnant patients on the risks of cannabis use to the unborn child
The panel assigned a B grade to two recommendations:
Counsel patients about the potential risks of cannabinoid use before, during, and after surgery
Discourage cannabis use during pregnancy and immediately following childbirth
"The medical, social, and political landscape of cannabis is fluid, changing on an almost daily basis. Cannabinoid use in the perioperative setting has significant potential negative medical implications," the guidelines say.
A new personal protective equipment manufacturing company is set to open in Cincinnati next year.
Bon Secours Mercy Health has established a strategic relationship with a locally based manufacturer of personal protective equipment (PPE).
Securing supplies of PPE was one of the most challenging healthcare supply chain challenges of the coronavirus pandemic. In the United States, reliance on foreign suppliers of PPE such as China-based manufacturers led to shortages.
Cincinnati-based Bon Secours Mercy Health has forged a strategic relationship with Emerge Manufacturing, which is building a 50,000-square-foot facility in the Roselawn-Bond Hill neighborhood of Cincinnati. Emerge was founded by Cynthia Booth, a Cincinnati business leader and entrepreneur.
"We are excited to work with someone like Cynthia who has advanced thinking. She is all about the community. She is all about how we can bring to life not only local jobs but also a solution for a global supply challenge," Daniel Hurry, MBA, chief supply chain officer at Bon Secours Mercy Health and president of Advantus Health Partners, told HealthLeaders.
Advantus is a subsidiary of Bon Secours Mercy Health that specializes in supply chain functions. "We put up our own supply chain organization so we could do things more strategically, effectively, and efficiently rather than relying on third party resources that might be in a traditional group purchasing organization model," Hurry says.
Emerge plans to manufacture face masks, surgical masks, N95 masks, clinical gowns, and other PPE. Construction of the company's manufacturing plant is slated to begin in the first quarter of 2023, with an expected opening in early 2024.
Bon Secours Mercy Health has invested in Emerge, Hurry says. "We made a meaningful and significant investment. All the way from the start, we were talking about how to support Cynthia in making sure that we have resiliency in how we supply while supporting local communities. While there is a monetary investment, there is also strategic investment in helping to support and develop the relationship."
He declined to specify the amount of the financial investment.
The strategic relationship is focused on gauging the PPE market, Hurry says. "It is important that we are keeping an eye on the challenges that are in the market. We are looking at raw material factors. We are looking at logistics challenges. We are looking at what may need to be addressed in the future rather than what may have been a pinch point historically. It is no secret that masks and gowns were the highlight of the challenge historically. That does not mean that will be in the challenge in two or three years—it may be something else. Strategically, we want to have continuous dialogue and continuous engagement."
Advantages of domestic supplier of PPE
For Bon Secours Mercy Health, there are several advantages to having a strategic relationship with Emerge, he says. "An advantage is the direct connection on the full manufacturing process. It creates jobs locally. It creates jobs domestically. It keeps us aligned with what the market can bear in this particular product mix."
Having domestic sources of PPE is crucial for U.S. healthcare providers, Hurry says. "It is critically important to have a resilient portfolio that is not contingent upon a region of the globe. If you have shutdowns in plants overseas and they cannot produce or move product, you run into challenges where it does not matter what your logistics model is—there is nothing to move."
PPE is an essential supply category for healthcare providers, he says. "With PPE, we forget to talk about what it is. Personal protective equipment protects people from disease and the risk that comes with it. With those types of products, resiliency becomes even more important than many other products. When there are elective products, you still need resiliency but the risks at hand are not quite as dramatic if you cannot protect people on an ongoing basis."
With a shortage of nurses, Memorial is relying on traveling nurses, which is placing a financial strain on the health system.
Nursing shortages are having a significant impact on Memorial Healthcare System, according to Marc Napp, MD, MS, executive vice president and chief medical officer of the health system.
Napp has served as Memorial's CMO since March 2021, succeeding Stanley Marks, MD, who retired in late 2020. He previously served as deputy chief medical officer at Mount Sinai Health System in New York. Before working at Mount Sinai, he served in medical leadership roles at Northwell Health in New York.
HealthLeaders recently discussed a range of issues with Napp, including workforce shortages, physician burnout, and clinical care predictions for 2023. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as the CMO of Memorial?
Marc Napp: The biggest challenge is the workforce—primarily nursing. We have had to bring in many nursing travelers from outside the organization, which can dilute the culture. When you bring in people from the outside, it is difficult to inculcate them overnight. There is also concern about the stability of the workforce because people are coming and going.
Another challenge is getting back on our feet after going through the coronavirus pandemic and the financial impact that the pandemic has had on us. With an itinerate workforce and the premium price that it costs, it puts a lot of our capital investments at risk because there is only so much money in the budget. We are spending a premium on our labor. While our hospitals are full and our emergency departments and operating rooms are busy, the cost to deliver care is significant and it is making it difficult to operationalize some of our plans.
HL: How are you rising to these challenges?
Napp: Fortunately, we have a very substantial bank account, so we can weather the storm—at least for the short-term and the medium-term. But we do not want to use our reserves for operations, and the portfolio took a hit when the market took a hit. Right now, we are managing our challenges because we have money in the bank. However, at some point, we are going to have to make some hard decisions. We are working on cost containment. We are cutting back on the premium labor, and we are growing certain programs that we had planned on growing before the pandemic hit.
If you were to look at us from the outside, you would not necessarily notice that there is any issue, unlike some of the other organizations across the country that are reporting massive losses. We are having losses, but they are not massive. So, we can hold our own for now.
Marc Napp, MD, MS, executive vice president and chief medical officer of Memorial Healthcare System. Photo courtesy of Memorial Healthcare System.
HL: What is the status of physician burnout at Memorial?
Napp: I must give the care providers at Memorial some credit. Their fortitude and their resilience have been impressive. We have lost few physicians to retirement or career changes as a result of the pandemic or burnout. There has been an impact on morale and work ethic to a degree as it is affecting every health system, but I have been impressed with the resilience of this group. We are concerned about wellness and burnout. But as far as burnout goes, I am aware of it and we are addressing it, but it has not been demonstrated to be a major concern for us at this point.
HL: How is the health system coping with physician burnout?
Napp: One thing I have noticed about Memorial compared to other organizations is that this is a place where people really love to work. We do a physician engagement survey every two years and we are going to start doing it annually. We are top decile in the country in terms of physician engagement. People like to work here. They are proud of working here. They feel supported, and like the organization cares about them, and that goes a long way in dealing with a lot of the burnout issues that other organizations are seeing.
In general, we have very little physician turnover, which is one measure of burnout. Part of that is the respect that the staff has for physicians and the mutual respect that physicians have for the staff. It is a collegial environment. There is tremendous rapport between the nursing staff and the physician staff. When you go to a small-town community hospital, it feels intimate, warm, and inviting. Despite the fact that we are a six-hospital system, you get the same feeling when you are in our facilities. That goes a long way to addressing the burnout issues that you see at other health systems.
Another thing that is important is there is respect for physician leadership at Memorial. We do a lot to support our medical staff leaders. The medical executive committee at this organization feels like they do something. At every other place I have been, the MEC wonders why it even bothers meeting. At Memorial, the MEC has a significant role to play. The medical staff officers are actively involved in what goes on in the hospitals. I am grateful to them because I have a great set of physician officers.
HL: Do you have predictions for clinical care in 2023?
Napp: We are going to see a rapid return to the way we used to do business before the pandemic. We are going to see some decline of telehealth, although there will be places where telehealth continues to make sense.
There will also be some significant innovation because we learned that we could innovate during the pandemic—we had to solve problems on the fly and remote patient monitoring is an example of that innovation.
We are going to see more of the same issues that plagued us before the pandemic in terms of difficulty discharging patients because of lack of placement opportunities in the community, complexity of the payment system, and issues of people not being able to access care. We haven't fixed many of the issues that existed before the pandemic—they just became less important in the scheme of things over the past two-and-a-half years. So, these issues are all going to resurface, and I am concerned about people feeling frustrated by these issues because we had some workarounds during the pandemic that made life easier that are not going to be there in the future.
HL: What are your primary challenges now that the crisis phase of the pandemic has passed?
Napp: What has happened in our area is clinical, but it is also operational and business-related. The certificate-of-need mandates were lifted in Florida, and we are a safety net health system surrounded by for-profit and aggressive not-for-profit health systems that are not safety nets. So, we take care of everybody whether they have an ability to pay or not. We have programs in place specifically for people who do not have insurance. We are taking care of those people, but that comes off our operations budget.
What is happening with the lifting of the certificate-of-need requirements is more competition, which is generally a good thing because it drives better performance, but it is not fair when the playing field is not level. I am concerned about skimming of patients—other health systems are getting the well-paying patients and we are being left holding the bag for the uninsured or poorly insured patients.
HL: How would you describe your leadership style?
Napp: I am collaborative. I feel strongly that I need to promote people to be experts in their areas and to recognize their expertise. So, I don't tend to be dictatorial or directive. That can lead to slower decision-making, but I do find that in the long run it has been the most successful way for me to lead. I am most comfortable in that mode.
The only time I lead in a different way is when we have a crisis situation such as an emergency management role. In that case, I become more directive. But even then, there is always going to be a cabinet of people I listen to. I am fortunate—I have some great leaders that I work with who have tremendous expertise, and I rely on them for counsel and to figure out what is best for the organization.
Learn about healthcare worker burnout research and methods for addressing burnout at your organization.
With the coronavirus pandemic in its third year, healthcare worker burnout was a top concern in 2022. The following seven HealthLeaders stories provided insight and solutions for healthcare worker burnout.
This article appeared in the November/December 2022 edition of HealthLeaders magazine. Health systems and hospitals realize a return on investment when investing in the wellness of the clinical workforce. Learn about how to address burnout among physicians and nurses.
The physician burnout level and other measures of physician distress increased dramatically during the pandemic, a research article found. In survey data, mean emotional exhaustion scores among physicians increased 38.6% from 2020 to 2021.
Nearly 32% of nurses planned to retire or leave the field altogether, while 40% planned to pursue a nursing role elsewhere, a study found. Nearly half of nurses surveyed said they planned to change jobs because of burnout and a high-stress environment.
In survey data, emotional exhaustion among physicians decreased from 31.8% in 2019 to 28.3% in 2020, then increased to 37.8% in the second year of the pandemic. Emotional exhaustion among nurses increased from 40.6% in 2019 to 46.5% in 2020 and 49.2% in the second year of the pandemic.
The American Nurses Association partnered with SE Healthcare to create the Burnout Prevention Enrichment Center. The web-based platform offered 24/7 access to a collection of tools and audio and video educational content to help prevent career burnout.
Survey data showed that 45% of clinicians reported burnout in 2019, with the burnout rate rising to 60% in late 2021. Higher rates of burnout were reported in chaotic workplaces (odds ratio 1.51) and settings with low work control (odds ratio 2.10).
At Bon Secours Mercy Health, a peer support program is a key component of the health system's healthcare worker well-being efforts. Bon Secours Mercy Health's peer support program started with physicians in May 2020 and has grown to serve all healthcare workers.
Sepsis can develop as the result of any kind of infection, including influenza.
Influenza patients are at risk of developing sepsis, according to the Sepsis Alliance.
Sepsis is the body's extreme reaction to an infection, and it can lead to tissue damage, organ failure, and death, according to the Centers for Diseases Control and Prevention. CDC annual statistics on sepsis are eye-popping: about 1.7 million American adults develop sepsis, at least 350,000 American adults with sepsis die during their hospitalization or are discharged to hospice, and 1 of 3 people who die in a hospital had sepsis during their hospitalization.
There are two primary connections between sepsis and influenza, says Jim O'Brien, MD, MS, vice president of operations for population health at OhioHealth and a member of the Sepsis Alliance Board of Directors.
"First of all, sepsis can be caused by any sort of infection, including influenza. Sepsis can be viewed as an inappropriate response to an infection. So, viral infections can lead to sepsis as much as bacterial infections, fungal infections, or even parasitic infections. There also is a secondary connection that occurs. It is relatively common for people who get severely ill with influenza to also be at higher risk of developing a secondary infection with a bacteria—in particular, bacterial pneumonia. So, patients may end up with influenza and particularly influenza pneumonia, then subsequently develop a bacterial infection that can lead to sepsis," he says.
Sepsis is the cause of death for many influenza patients, O'Brien says. "Annually, there about 200,000 hospitalizations that are associated with influenza, and there are around 40,000 deaths. If you look within those deaths, there is a significant number of patients who end up dying of sepsis, either associated with the influenza or a bacterial infection."
It can be difficult to diagnose sepsis in influenza patients, he says.
"The good news with influenza is we have good diagnostics for determining whether someone has influenza. The challenge that we have is isolating the people who feel terrible with influenza versus someone who subsequently develops organ failure and sepsis, where they are at higher risk of dying. It gets tough when people ask, 'When should I know to go see a doctor?' We talk about having an elevated temperature due to sepsis, but influenza can result in a temperature of 103 in adults. A high temperature does not necessarily mean you are developing sepsis. Generally, we talk about if patients are feeling the worst they have ever felt; but for young and healthy people, those symptoms can be driven by influenza."
Changes of cognitive status in influenza patients can indicate the development of sepsis, O'Brien says. "One of the big triggers in influenza patients that indicates the development of sepsis is if someone's brain is not working the way it should be working. You may not be able to wake the patient. They may be confused. Those are real warning signs of someone who has developed complications beyond just feeling terrible with influenza, and they should seek help."
There also are risk factors for sepsis in influenza patients, he says.
"Extremes of age are a risk factor—children under 5 and adults over 65. Those extremes are at much higher risk for influenza complications, including sepsis. The farther you get to the age extremes, the higher the risk of sepsis. So, children less than 2 are at greater risk than children less than 5, and adults over 80 are at greater risk than adults over 65. Pregnant women with influenza are at risk of developing sepsis—there are certain races and ethnicities of pregnant women who are at higher risk of developing sepsis. It appears that Native Americans and Alaskan Natives are at higher risk of complications from influenza such as sepsis compared to White populations. Influenza patients with chronic medical conditions such as diseases that affect the immune system are at higher risk for sepsis. People who live in long-term nursing facilities or skilled nursing facilities are other people that we worry about."
The best way to prevent sepsis in the context of influenza is to get a flu shot, O'Brien says. "Flu shots are not perfect, but they are the best form of protection against severe disease from influenza, including sepsis. If you look at patients who progress enough that they need to be on a ventilator, people who did not get vaccinated are six times more likely to be on a ventilator from influenza than those people who got vaccinated. So, flu shots are the first line of defense."
Taking measures that prevent the spread of infection are also important to avoid sepsis developing from influenza, he says. "Washing hands frequently is helpful. Covering our mouths when we sneeze or cough is helpful. If we are sick, not being around other people is helpful. Those measures work."
The Sepsis Alliance offers resources on influenza and sepsis, including a sepsis and fluwebpage that features infographics and information guides as well as a free webinar for healthcare professionals.
AdventHealth's Neil Finkler predicts healthcare workforce shortages will spur adoption of technology such as artificial intelligence and machine learning.
The shift of medical services from the hospital setting to the ambulatory setting and the home will accelerate in 2023, the chief clinical officer of AdventHealth's Central Florida Division predicts.
Neil Finkler, MD, became AdventHealth's chief clinical officer for the six-county region in 2021. In 1992, he joined AdventHealth Orlando, where he founded the gynecologic oncology program and fellowship program. Before taking on his current role, he was senior vice president and chief medical officer for AdventHealth Orlando's acute care services.
HealthLeaders recently talked with Finkler about a range of issues, including clinical care predictions for 2023, the challenges he faces as a chief clinical officer, physician burnout, and workforce shortages. The transcript of that conversation below has been edited for brevity and clarity.
HealthLeaders: What predictions do you have for clinical care in 2023?
Neil Finkler: We will continue to see an out-migration of hospital-based procedures that are transitioning to outpatient settings, specifically ambulatory surgery centers.
The hospital at home models will continue to grow nationwide next year. Health systems are looking at how they can care for chronic conditions in the home. They are also looking at identifying the triggers when a patient is in trouble at home, and they are looking at how they get the appropriate care at home. If you think about populations at risk, where we as healthcare providers will be at full risk, we need to put the appropriate patient in the appropriate setting at the appropriate time. The least costly setting remains taking care of the patient at home. Many health systems have been dabbling with hospital at home, and we will see more innovative and creative models as we move forward.
Another thing we are going to see, and we are beginning to see it in the post-pandemic world, is that the nontraditional healthcare players including retailers such as Walmart and the Amazons of the world are going to start expanding beyond what they have done in healthcare so far. We are going to see them do blood tests, vaccinations, and other medical services that have traditionally been delivered in the hospital setting.
In our market, Walmart has been opening health clinics. They have behavioral health. They are adding ophthalmologic services, and they are putting services in one easy place for the consumer and making it an affordable option.
We are also going to see a continued look at how we leverage technology to automate tasks to alleviate our workforce restraints. This includes artificial intelligence, machine learning, and remote monitoring. For example, we can use this technology to determine who is at risk for a readmission after a coronary bypass.
We can use artificial intelligence and machine learning to help us identify whom we need to put resources around once they get discharged, so that their readmission rates are lower and their utilization rates in the emergency department are lower, which will give us more inpatient capacity.
Neil Finkler, MD, chief clinical officer of AdventHealth's Central Florida Division. Photo courtesy of AdventHealth.
HL: What are the primary challenges of serving as the chief clinical officer of the Central Florida Division of AdventHealth?
Finkler: Before the pandemic, we were clearly on a pathway of top performance and performance improvement from a quality standpoint. Our organization defines clinical excellence as being a Centers for Medicare & Medicaid Services 5-star and Leapfrog A. We had achieved those goals in the early days of the pandemic, but we have slipped, particularly in the CMS star rating—we were a 5 star and now we are a 4 star.
This slippage has clearly been created by the pandemic, with things like workforce shortages, burnout, some financial instability, and supply chain constraints. All of this has shifted our focus and made it harder to keep up with the processes that we know are needed to maintain top quality and safety. One of the things we are doing as we emerge from the pandemic is putting our efforts back on those processes that we know work so we can get back to a CMS 5-star rating. The particular areas that we struggle with are hospital-acquired infections as well as readmissions.
Another challenge that we have is the workforce. As we look forward into the future, we know that our population here is growing and we know that the population in Central Florida is aging. In addition, chronic diseases such as diabetes, chronic obstructive pulmonary disease, and cardiovascular disease continue to increase. This increase in demand for healthcare services while we experience workforce shortages is going to challenge us.
Another challenge is the value transformation, where we are looking to improve the value proposition for both patients and payers. The question is, how do we improve quality while decreasing cost? Both the payers and the patients continue to expect reductions in waste and for us to cut the costs of healthcare.
HL: What is the status of physician burnout at AdventHealth?
Finkler: It clearly exists. Our workforce, not just physicians but also our nursing workforce and other members of the clinical workforce, has not yet fully recovered from the impact of the pandemic. Burnout remains prevalent, in many cases unrecognized. Even though COVID-19 admissions have decreased, the hospitals are still full and the clinical demand on our physicians continues at an all-time high. All of this contributes to physician burnout and dissatisfaction.
What are we doing to address burnout? The number one factor is to recognize it—to openly admit that it does exist and to advance a culture where it is OK for a physician to admit that they are experiencing burnout, talk about it, and ask for help. We have robust physician support services. We have a robust physician wellness program. We have a physician lead of physician wellness. All of these programs deal with physician burnout. We believe that openly attacking the issue and providing the physicians with tools is important.
The culture work is crucial. We need a culture of respect. We need to determine what a culture of professionalism looks like within a healthcare environment. We need to determine what teamwork looks like. When I was trained, we were not trained in teams, and the reality is that we now know that teams are an effective way of dealing with things including burnout.
HL: What are your primary clinical challenges now that the crisis phase of the pandemic has passed?
Finkler: We need to refocus on hospital-acquired infections such as central line–associated bloodstream infections and catheter-associated urinary tract infections. There are factors that have increased these infections during the pandemic such as new healthcare workers who do not understand the importance of the processes that were in place to keep these infections under control. As we enter a post-pandemic world, we are reteaching and restressing the importance of the processes that got us to low hospital-acquired infection rates.
Another area of focus is length of stay. We have watched our length of stay creep up. There are several reasons this has happened, and as we are pressured from both a workforce and capacity standpoint, we are going to have to put a heavy focus on length of stay. Within our institution, we have stood up a "mission control" that meets several times weekly to look at length of stay. There are lengths of stays that we will have trouble controlling—some of the outlier lengths of stays that may be due to unavailability of skilled nursing facility beds or long-term assisted care facility beds. You cannot solve those issues overnight.
There are things we can do to lower length of stay. We can expedite the discharge process. We can do what needs to be done during a hospitalization, then schedule other things that would be nice to have but not necessary to have as an outpatient service.
HL: What kind of workforce shortages are you experiencing at AdventHealth?
Finkler: We have workforce shortages not only in the nursing area but also in other disciplines, including pharmacy, radiology, laboratory technicians, and certified registered nurse anesthetists. It is important for everybody to recognize that the shortages do not stop in the nonphysician side—we are seeing physician shortages in several specialties.
HL: What are the primary efforts you have in place to address workforce shortages?
Finkler: The first thing we have done as an organization is taken a step back and said, "We understand that the pay must be competitive." In the pre-pandemic era, we would do market surveys every year or every other year. Now, we need to conduct market surveys more frequently. What was competitive a week ago may not be competitive four weeks from now. We are making sure that we are paying at the top of the market.
However, it is not just pay that is contributing to workforce shortages. It is also about benefits.
I am proud of our nursing innovation and workforce strategies that have helped stem the tide. We have gone from 3% turnover per month down to 1% per month. Things like working in a team model have helped.
We also are working on virtual nursing models. We recognize that we have a paucity of experienced nurses. Many of our nurses are young—many are graduate nurses. They do not have an enormous amount of experience, and they do not have a seasoned nurse to turn to on the floor. So, we have been working with experienced nurses in a virtual nurse model where they can cover several units in a hospital. They help the nurses on the floor with problems and questions, and they can do work such as discharges.
We have told our nurses if they want to go back to school to continue their education, we will pay for it, and they will be debt free. We also have been providing nurses more flexibility in scheduling. So, we are taking a proactive approach to the nursing shortage.
Inadequate access to mental health care is straining emergency departments, researcher says.
For pediatric patients with mental health conditions, prolonged lengths of stay in emergency departments increased significantly during the coronavirus pandemic, according to a new research article.
The pandemic has had a negative impact on the mental health of children due to factors such as caregiving disruptions and social isolation. Last month, the American College of Emergency Physicians and 34 other healthcare organizations raised alarm over the boarding of patients in emergency departments for days or weeks, including pediatric patients with mental health conditions.
The new study, which was published by the Journal of the American College of Emergency Physicians Open, is based on data collected from January 2020 to December 2021 at 107 emergency departments in 29 states. The study features several key data points:
At emergency departments, pediatric mental health visits with a length of stay greater than 12 hours accounted for 20.9% of all pediatric mental health visits
At emergency departments, pediatric mental health visits with a length of stay greater than 24 hours accounted for 7.3% of all pediatric mental health visits
At emergency departments, pediatric non-mental health visits with a length of stay greater than 12 hours accounted for 1.8% of all pediatric visits
At emergency departments, pediatric non-mental health visits with a length of stay greater than 24 hours accounted for 0.2% of all pediatric visits
The monthly counts of pediatric emergency department visits for mental health conditions peaked at 2,455 in September 2021
The monthly counts of pediatric mental health visits with a length of stay greater than 6 hours peaked at 975 in November 2021
At emergency departments, the most common diagnoses for pediatric mental health visits with a length of stay greater than 24 hours were suicide, self-injury, and depressive disorders
The data show aspects of the pandemic's negative impact on healthcare, the study's co-authors wrote. "In this sample of 107 EDs in 29 states, visit counts with prolonged LOS >24 hours more than doubled in some months since the arrival of COVID-19. These findings are indicative of an increasingly strained emergency and mental health system."
In a prepared statement, the lead author of the study said the data reflect a lack of access to mental health care in many communities.
"A cycle of compounding system failures is hindering care for many of our most vulnerable patients. Insufficient access to mental health care stands out among the factors that contribute to prolonged stays in the nation's emergency departments—there are too few options outside of emergency care for patients in many communities," said Alexander Janke, MD, MHS, national clinical scholar at the VA Ann Arbor Healthcare System and University of Michigan Institute for Healthcare Policy and Innovation.