Children with complex medical needs represent more than half of all hospitalized children and 82% of hospital days. A new medical group aims to change how their care is delivered.
A new medical group has taken an innovative approach to care redesign to serve Medicaid-eligible children with medical complexity and special healthcare needs.
Children with medical complexity make up less than 1% of children in the United States, but they represent 56% of hospitalized pediatric patients and 82% of hospital days in children's hospitals. Children with medical complexity represent just 5% to 6% of children covered under Medicaid, but they account for approximately one third of Medicaid expenditures on pediatric patients.
Imagine Pediatrics launched nearly a year ago with a virtual-first care model that provides care and support services to Medicaid-eligible children with medical complexity and special healthcare needs on a 24/7 basis. The medical group, which features a pediatrician-led multidisciplinary approach, does not replace a pediatric patient's primary care providers or specialists, but is geared to filling care gaps with a high level of access.
"We work in collaboration with their existing doctors and medical homes, so we are not replicating or duplicating care," says Patricia Hayes, MD, chief clinical officer of Imagine Pediatrics. "We bring an extra layer of support for these children.”
"Mostly, we are reinforcing the care plans and meeting these families where they are in their homes virtually," she says. "We address care gaps when a primary care team and specialists are not available. We find this is exceptionally helpful during off-work hours, weekends, and holidays, when these children and their families do not have any access to care."
In addition to its virtual-first care model, Imagine Pediatrics can dispatch paramedics with pediatrics training to the homes of patients. These paramedics offer a range of services, including IV antibiotics, IV fluids, testing for common illnesses, lab draws, and helping with hospital transitions of care.
The medical group is serving 20,000 patients in Florida and Texas, and has full-risk, value-based contracts with three health plans: UnitedHealthcare Community Plan of Texas, UnitedHealthcare Community Plan of Florida, and Superior HealthPlan, which is based in Florida.
"We are unique because we provide 24/7, integrated care delivered to Medicaid-eligible children with medical complexity and special healthcare needs," Hayes says. "Although they are a small percentage of the pediatric patient population, they account for an outsized share of healthcare spending. We are providing them with unprecedented access, when they have historically had limited access to primary care or specialty care."
These patients are frequent healthcare users, often requiring multiple hospitalizations or trips to the emergency room or urgent care clinic. As a result, their care is often fragmented and uncoordinated, leading to care gaps and unnecessary expenses.
Imagine Pediatrics aims to improve that care platform, coordinating care and reducing stress on hospitals and PCPs.
"We have the time, capacity, and access to provide these children with proactive care to keep them from having to have heavy emergency care utilization, which drives a higher cost of care and contributes to taxing an already taxed pediatric care system," Hayes says.
Imagine Pediatrics provides virtual care through multiple channels, including an app and telemedicine platform. The medical group's care team includes pediatricians, nurses, social workers, therapists, care team assistants, pharmacists, and dietitians, along with virtual care support for home health nurses at these children's bedsides, providing an extra layer of support for consultation services.
Providing care coordination
In working with health plans and their networks, the medical group's leadership team says they can work faster than primary and specialty care teams to make sure these families get what they need when they need it. This takes the burden off of PCPs, as well as health system CMOs who are called on to manage care for these patients when they end up in the hospital.
"We do a lot of the legwork and paperwork that it takes to get things done for these families," Hayes says. "We set up appointments for them. We expedite prior authorizations by working closely with their health plans to get them medications, procedures, or equipment."
In many cases, Hayes says, Imagine Pediatrics is in daily contact with patients and their families.
"The idea is to identify gaps and fill them before an emergency situation arises," she says. "We also make sure that everything we do gets communicated back to the primary care teams, so we are all on the same page."
"We do not want to provide care coordination in a bubble and exclude the primary care team," she adds. "We are reinforcing the care plans of the primary care teams and specialists, so these families stay on track and get the support they need. We don't want these families to get into a situation that could have been avoided."
Generating results
Over the past 10 months, the medical group has measured a 15% reduction in inpatient admissions and 20% reduction in total cost of care among engaged pediatric patients.
Patient and family engagement is crucial in reducing inpatient admissions, Hayes says.
"Just in the 11 months that we have been live, we have conducted more than 50,000 care interactions," she says. "That includes virtual visits, in-person visits, and digital messaging through our app. We get ahead of the curve for these families. We are proactive. We are making sure these children stay healthy at home."
Hayes says this strategy helps the medical group reduce total cost of care.
"We try to stay ahead of things, try to prevent unnecessary utilization of emergency care, and try to improve the healthcare experience of these families," she says. "We also try to improve the experience of these patients' primary care team."
With the federal government starting to shape guidance for AI, healthcare organizations are forging ahead with the technology.
Artificial intelligence will take hold in healthcare in 2024, a pair of chief medical officers say.
President Joe Biden recently made an executive order on AI to promote the safe, secure, and trustworthy use of the technology. While the executive order did not provide details on healthcare guidelines for AI, healthcare executives expressed cautious optimism about the government's approach to the technology.
Looking ahead to 2024, healthcare is going to continue to see clinicians embrace and get more comfortable with AI to ease workflows, boost the flow of patient and provider data, and improve quality of care and outcomes, says Peggy Duggan, MD, executive vice president, chief physician executive, and chief medical officer of Tampa General Hospital.
"The important steel thread here is the 'why,' which for our physicians and team members at Tampa General Hospital is the delivery of the highest quality care possible," she says.
Clinical documentation is an example of a key area for AI adoption, Duggan says. There is a lot of work physicians do that is not value added but is required to advance care, so incorporating AI into documentation continues to offer an opportunity to free up clinicians to spend more time with patients and directly provide care, she says.
Managing data is another area where AI can boost healthcare, Duggan says. "It's critical that provider-level data flows freely, as well as patient and system-wide data, so AI will be able to help us identify more opportunities to improve patient care," she says.
In 2024, AI will be used more frequently to guide clinical decision-making, Duggan says.
"At Tampa General Hospital, we are already piloting data-driven technology that supports the proper choice of antibiotics and pathways that prompt when antibiotics can be decelerated," she says. "These are great tools to support our teams while ensuring that a large volume of data—especially at a large academic health system treating some of the most complex conditions—doesn't overshadow a salient data point, which could drive not only safer care but also the delivery of the right care at the right time."
AI is likely to make major advancements in healthcare next year, says Ghazala Sharieff, MD, MBA, corporate senior vice president and chief medical and operations officer for acute care at Scripps Health.
"We recently had a retreat with a two-hour session on AI. The radiologists are asking to use AI more as they are doing their diagnostic readings. Telemedicine made a big splash during the coronavirus pandemic, and AI is the next big thing for healthcare," she says.
"The trend in decreased Medicare reimbursement is not sustainable," chief medical officer says.
A 3.4% conversion factor reduction in Medicare's 2024 Physician Fee Schedule final rule will make a bad situation worse for healthcare providers, says Catherine "Mindy" Chua, DO, chief medical officer of Davis Health System.
The conversion factor is the number of dollars assigned to a relative value unit (RVU), which is a key element of physician payment by the Centers for Medicare & Medicaid Services. The new Physician Fee Schedule final rule will cut the conversion factor from $33.89 in calendar year 2023 to $32.74 in calendar year 2024.
The biggest financial impact of the conversion factor cut will be on health systems and hospitals, Chua says. "About three-quarters of physicians are currently employed by hospital systems. So, for most physicians who are employed at hospital systems, the conversion factor reduction is not going to affect them in their pocket. What it is going to affect mainly is hospital systems and health system-owned physician practices. It will also affect physicians in private practice and physicians at physician-owned practices."
Health systems and hospitals are taking a hit financially, but they are unlikely to pass along the conversion factor cut to their employed physicians' compensation, she says. "The trend in decreased Medicare reimbursement is not sustainable, particularly for hospitals that employ most of their medical staff. The physician fees are going to the hospitals to maintain the physicians they employ. We are not going to be decreasing what physicians are paid because Medicare is cutting our reimbursement—you are not going to keep physicians if you do that."
The conversion factor cut will pose a financial hardship for many hospitals, Chua says. "Hospitals are having to pay more for supplies and staffing. Many hospitals have negative margins, and the cost of operations continues to go up. Then you decrease one of the main sources of income for hospitals—physician billing—and it is not sustainable."
Hospitals may have to cut services in response to reduced Medicare reimbursement, particularly in rural areas such as those served by Davis Health System, she says. Rural community hospitals must provide certain services to serve their patients such as emergency care and general surgery. However, there are services such as oncology, pulmonology, and orthopedics that are not necessary to operate a rural health system, Chua says.
"The unessential specialties are important for our communities, so patients do not have to travel long distances for care. But for health systems like ours, if Medicare continues to make cuts, we are not going to be able to keep these service lines going," she says.
Targeting Medicare reimbursement reform
It is technically impossible for hospitals to maintain a negative margin and the conversion factor cut comes at a bad time, Chua says. "There have been a significant number of hospitals in small communities that have shut down over the past three years because of financial distress. The reduction in the Physician Fee Schedule conversion factor is only going to make the situation worse."
The American Medical Association has made reforming Medicare payments for physicians a top priority. According to the AMA, Medicare's physician payments have decreased 26% since 2001, when adjusting for inflation.
The AMA is on the right track, but Medicare reform needs to be broader than just addressing physician payments, Chua says. "We need to look at Medicare payment reform overall, and the Physician Fee Schedule is just a piece of that reform. We need to be pushing Medicare toward more value-based contracting, so hospitals can maintain their main priority, which is to take care of the sickest of the sick."
Value-based payments are superior to fee-for-service reimbursement, which still dominates Medicare, she says. "Fee-for-service incentivizes us to not provide quality care. It is a broken system. We must make some hard decisions and make some major changes in Medicare reimbursement. From all accounts, it seems that value-based payments are the way that health systems are going to improve quality and reduce costs."
Value-based payments incentivize health systems to move outside of the four walls of the hospital and help their communities to get healthier, which reduces dollars spent on healthcare, Chua says. "Value-based payments also give providers more time to address social determinants of health. They give us more opportunities and resources to engage patients," she says.
The West Coast health system has launched six initiatives to improve clinical care and boost its operating margin.
The chief medical and operations officer for acute care at Scripps Health has developed six facets of operational excellence that she calls the 6 "Rs."
With slim operating margins, hospitals must optimize operational capabilities to remain financially viable. Recent data from Kaufman Hall shows that hospital operating margins are slim but positive: The median year-to-date operating margin index increased from 0.9% in July to 1.1% in August.
Ghazala Sharieff, MD, MBA, corporate senior vice president and chief medical and operations officer for acute care at the San Diego-based health system, has taken a multi-pronged approach to promulgating these guidelines. They have been included in marketing updates, shared with about 300 supervisors and managers who serve on the health system's inpatient management team, parceled out to the health system's physician operations executive team and physician leadership academy, and embraced by the organization's board of directors.
"It has taken on a life of its own," she says.
The six Rs are as follows.
1. Retaining staff
Like many health systems across the country, Scripps has been grappling with workforce shortages, and staff retention has become a high priority for the organization, Sharieff says.
While a primary effort has been keeping pace with market-based compensation for healthcare workers, she says, workplace culture is equally important. Scripps has "Sprint Teams" that tackle challenges and initiatives through engagement with frontline care teams. Supervisors, managers, and chief operating executives are charged with maintaining a culture of openness and communication, and C-suite executives routinely round in the health system's five hospitals to promote visibility and engage healthcare workers.
"Retention is not just about money,” Sharieff says. “It's about making sure the staff feels they are part of the solution to our challenges.”
2. Reducing length of stay
Managing hospital length of stay is important for throughput and revenue purposes, Sharieff says. In one instance, a behavioral health patient has been an inpatient at one of its hospitals for more than 900 days because the health system has not been able to find another facility. As a result, that hospital bed has been tied up for nearly three years, limiting revenue that could have been generated from other patients using the room.
"We have been tying up a bed because there are no resources to turn to in the region or the state," Sharieff says.
To address that kind of problem, Scripps has launched several initiatives to reduce length of stay. The health system is partnering with skilled nursing facilities to move patients out of the hospitals when appropriate.
Scripps has a hospital initiative called 10-12-2. Physician orders should be written by 10 a.m. If appropriate, a patient should be home by 12 p.m. And the patient's room should be cleaned and ready to go by 2 p.m. If a patient needs an X-ray or tests, the hospital tries to expedite the imaging or testing so the work is done on that day prior discharge rather than making the patient come back the next day.
Scripps is also working with county officials to increase the number of behavioral health beds in the region, Sharieff says.
"Increasing behavioral health beds is not going to be a quick process because we have a lot of patients in-house that we cannot discharge because there is no one to take them," she says. "That is a national issue that we are dealing with."
3. Reducing costs and increasing revenue
There are simple ways to reduce costs, Sharieff says. For example, the health system was able to cut rental and maintenance costs by cutting down on the number of printers on campus.
The health system has also adopted cashless registers in its cafes, which has saved thousands of dollars, and is relying on frontline staff to find other cost savings.
"That is why we have the 6Rs, so staff can understand our focus and where we need to go," Sharieff says. "Otherwise, they would not have a good idea of our strategy. When I round at our hospitals, I see the 6Rs on bulletin boards, with action plans on what they can do to reduce costs and increase revenue. For example, some units have cut down on printing documents that are not necessary."
Scripps has launched several initiatives to increase revenue. For example, the health system, which is comprised of north and south regions, formed the North Region Surgery Optimization Team five months ago. This team has looked at several factors, including the best locations for surgeries, blocking surgeon time, rearranging surgeries so they are more efficient and back-to-back, and increasing the efficiency of operating room robots. As a result, the health system performed 5,000 more surgeries over the past five months compared to the same period last year.
"This not only generates more revenue but also improves patient experience," Sharieff says, adding that more efficient and timely surgeries benefit patients.
Other initiatives to increase revenue include boosting hospital throughput, pushing growth in profitable service areas that communities, strengthening partnerships in payer contracting, and advocating for an increase in Medi-Cal reimbursement, which has not increased in 10 years.
4. Repatriation
Scripps has focused on keeping patients in network, Sharieff says. During the pandemic, the health system did not have enough hospital beds to serve patients, and it lost about 20% of its patients. Since then, she says, Scripps has made substantial progress in repatriation.
"No. 1, these are our patients, and we want them back," she says. "No. 2, it is a matter of revenue. If we have patients who are our covered lives, we get charged more if they seek care out of network. We put a Sprint Team together around repatriation, and in 2023 less than 1% of our patients have been seeking care out of network."
5. Raising money through philanthropy
To support the health system's operations, Scripps has stepped up efforts to raise money through philanthropy, Sharieff says. The health system receives philanthropic support mainly from individuals, who are often grateful patients, and from foundations, and it raises an average of $40 million annually through philanthropy.
"Scripps was founded on philanthropy nearly 100 years ago, and it continues to be an important source of financial support, particularly during these challenging economic times," she says.
6. Reassessing and reimagining
The newest of the 6Rs is reassessing and reimagining, which was adopted late this past summer. These efforts are in their infancy, but Sharieff offers a couple of examples.
One idea is reassessing the value and timeliness of meetings. A one-hour meeting with 20 people that is not necessary takes away 20 hours of staff time that could be used doing other things such as rounding or having time to strategize.
Another example focuses on reimagining certain processes or tasks. Sharieff has looked at the assignments she gives to members of her team. For example, one staff member has been chairing the Pharmacy and Therapeutics Committee for 10 years. Sharieff wants to groom the next layer of leaders, so she is going to find a new person to chair this committee, which will allow someone else the chance to learn and the incumbent will have a chance to have more time to do other things.
"That is a simple example of reimagining and thinking about succession planning," she says.
Generating positive results
Pursuing the 6Rs has improved operations and bolstered the bottom line at Scripps, Sharieff says.
"We have had 5,100 more surgeries in five months. The repatriation numbers went from 20% out of network to less than 1%. We have saved millions of dollars with our pharmacy team, supply chain, support services, and consolidation of vendors. We have made progress on retaining staff—we are not paying as much for travelers such as traveling nurses," she says.
A pair of chief physician executives share how their health systems recruit and retain clinicians.
Health systems must adopt a multitude of recruitment and retention strategies for physicians and advanced practice providers (APPs), a pair of top clinical leaders at health systems say.
The physician employment market across the country is tighter than ever, with demand outstripping supply in many specialties. As a result, CMOs are turning to APPs to supplement their physician staff.
Eric Deshaies, MD, MBA, chief physician executive of AdventHealth Medical Group in Orlando, Florida, says AdventHealth's medical group wants to establish a reputation that will support recruitment efforts.
"Career development, mentorship programs, wellness programs, and putting physicians and APPs in the leadership of our medical group all send a strong message externally that this is a medical group that values our physicians and APPs," he says.
Deshaies and Ian Dunn, MD, chief physician executive and chair of neurosurgery at Oklahoma-based OU Health, say their health systems are pursuing nine recruitment and retention strategies for physicians and APPs.
1. Strive to be visible: OU Health takes an approach to recruiting physicians and APPs that is similar to how colleges recruit football players, Dunn says. OU Health makes sure the health system is visible to physician and APP candidates, with multiple physical and virtual touchpoints such as a robust social media presence, he says.
2. Gear workplace conditions for a multigenerational workforce: Health systems should offer workplace conditions that appeal to a range of generations, Deshaies says. For example, younger generations of physicians and APPs are looking for more wellness events, flexibility in schedules, and time off, he says.
3. Be competitive on compensation: To recruit and retain physicians and APPs, health systems must be competitive in compensation in their markets, Dunn says. OU Health is the only academic health system in Oklahoma, which means the health system must have competitive compensation relative to the community health systems in the state, he says. In metropolitan areas with several academic health systems, compensation for physicians and APPs tends to be similar at each of the organizations, he says.
Health systems should adjust their compensation for physicians and APPs on a regular basis, Dunn says. OU Health has redesigned physician compensation over the past year, and the health system is doing the same work with APP compensation. OU Health will be refreshing compensation on an annual basis, if not more frequently, he says.
4. Adopt assistive technology: AdventHealth is planning to introduce artificial intelligence technology that will make daily clinical operations more efficient and allow clinicians to be more efficient in clinics or hospitals, Deshaies says. This will help in functions such as dictating notes, ordering medications, and ordering imaging. The health system plans to use AI to make patient visits smoother and faster, while giving physicians and APPs more face time with their patients, he says.
5. Offer leadership opportunities: the AdventHealth Medical Group has changed its governance structure to give physicians and APPs more opportunities to participate in administrative leadership, Deshaies says. The governance restructuring includes the creation of triads featuring physicians, APPs, and business executives across different specialties. The triads not only give clinicians a stronger voice at the leadership table but also promote value, he says. The medical group triads have quality represented by clinicians and cost control represented by the business executives, he says.
6. Make your health system stand out: To recruit and retain physicians and APPs, health systems should try to stand out compared to other organizations, Dunn and Deshaies say. OU Health promotes its academic focus and deep subspecialty expertise, Dunn says.
"Our physicians and APPs embrace our mission," he says. "It distinguishes the clinicians at OU Health—most of them have faculty appointments at the college of medicine or the college of nursing, in the case of some APPs."
The AdventHealth brand, which includes whole-person care, is attractive to many physicians and APPs, Deshaies says.
"This is particularly the case with Millennial and GenZ clinicians, who are looking for a work-life balance and looking for wellness," he says. "That is in alignment with our whole-person care."
7. Ensure that physicians and APPs enjoy their work: Once a health system has recruited a physician or APP, the organization should strive to make sure the clinicians enjoy their work, Dunn says. This factor is not always about metrics, compensation, or titles. Health systems should make sure that a clinician's job is doable with a favorable work-life balance and that clinicians have adequate resources. Examples of resources include medical assistants and patient service representatives as well as clinical support teams for surgeons, he says.
"What a transplant team might need is going to be different from what an oncology team might need," he says. "But we want to understand the resources that our teams need."
8. Promote retention at academic health systems: OU Health promotes retention of physicians and APPs by making sure they benefit from the opportunities of working at an academic health system, Dunn says. Physicians and APPs at the health system have an opportunity to provide advanced care to complex patients. In addition, clinicians can engage in education and research activities, he says.
"Beyond the clinical work, clinicians can grow in other dimensions," he says.
9: Encourage retention of APPs with educational programs: AdventHealth is promoting retention of APPs with a "transition-to-practice" program, Deshaies says. When APPs are recruited, they are paired with a preceptor, and they have training and coursework. The physicians help train the APPs, who have competency exams similar to what they would see in a residency program. The transition-to-practice program helps to reduce the initial stress of coming to a new organization right out of school and boosts retention, he says.
"APPs are not overwhelmed, then looking to leave a couple weeks later," Deshaies says.
Hackensack University Medical Center CMO Lisa Tank says huddles at the hospital promote safety and quality.
Huddles should be held on every floor and in every unit to advance reliability, says Lisa Tank, MD, senior vice president and chief medical officer of Hackensack University Medical Center as well as CMO for the North Region of Hackensack Meridian Health.
Tank has served in several roles at Hackensack University Medical Center over the past two decades. Prior to her current positions, she was chief of the Division of Geriatrics at the hospital. In 2016, she was appointed vice president of medical affairs.
Tank says she faces several primary challenges as CMO of the hospital, including patient safety, clinician well-being, and staffing shortages. The best way to meet these challenges is to be a high-reliability healthcare organization, she says. CMOs have long viewed high reliability such as limiting hospital-acquired infections as a cornerstone of efforts to boost patient safety.
"First and foremost, you must educate every member of the staff about the high-reliability journey, then you must practice high reliability every day," Tank says.
One method for developing high reliability is through daily tiered huddles that involve staff from the frontlines to top executives. Huddles have been in place at the hospital for several years.
"Every floor and every unit have a huddle where the key stakeholders get together," she says. "They talk about the current safety issues, quality issues, and any current challenges that the team is having that impact patient care or team safety. Those huddles percolate throughout the entire day and the executives get involved."
The huddles follow key principles, Tank says. There is a preoccupation with addressing failures, and staff focus on why setbacks occur. Staff members look for opportunities to simplify care and processes. In addition, huddles focus on determining how to integrate clinical care with clinical operations.
For example, if a medication was stored in the wrong place, staff can use a huddle to find out why it was stored in the wrong place and what could be done better, she says.
"With that approach to the challenges, you can not only meet the challenges but also excel in moving forward," Tank says.
Lisa Tank, MD, senior vice president and chief medical officer of Hackensack University Medical Center as well as CMO for the North Region of Hackensack Meridian Health. Photo courtesy of Hackensack Meridian Health.
Leading development of clinical guidelines during the pandemic
Tank also led efforts to develop clinical guidelines during the pandemic. The hospital worked on the clinical guidelines for treating patients by learning from the experiences of clinical care teams with coronavirus in China, Europe, and New York, she says.
Beyond treatments, Tank and the hospital's clinical care teams developed guidelines for communication and caregiver behavior at the bedside.
"The main guidelines we developed were communication guidelines such as how best to communicate a patient's status with their loved ones," she says. "Those were isolating times. There were no visitors allowed. While we were treating the patients, a key component for us was providing empathy and compassion at the bedside, which was as critical as the intravenous medications and high-flow oxygen."
Tank and the clinical staff collaborated on using iPads for care teams to communicate with families and patients to communicate with family members, she says.
"The iPads helped us to communicate with the families about what was going on with their loved ones," Tank says. "It was a multipurpose tool, but the most important piece was allowing patients to communicate with their families."
Promoting value-based care
With the opening of the new tower on the hospital campus, one of the main value-based care initiatives at the hospital has been to create clear best practices, programs, and processes for operating rooms as well as disease-specific clinical pathways, Tank says. The hospital's leadership viewed the opening of the new tower and expansion of services as an opportunity to advance value-based care, she says.
"That has helped us create value and cost-effectiveness. At the same time, it has helped us deliver high-quality care," she says.
Clinical teams should be encouraged to identify opportunities for value-based care, Tank says. For example, in value-based care for orthopedics at the medical center, the frontline teams have come up with clear pathways for using the equipment they need and the kinds of anesthesia they need. They have streamlined the patient's stay in the hospital such as getting physical therapy early in the care process and trying to have patients discharged to home.
Succeeding in care coordination
To boost care coordination, the medical center has tried to create a "hospital without walls," so there is a seamless continuum of care, Tank says. Whether a patient is in the hospital, assisted living, a skilled nursing facility, or at home, the goal is to make sure there is clear communication between the care teams. The Epic electronic medical record helps the care teams communicate. Care coordination often requires a navigator to communicate with the patient and the family as well as the clinical teams to make sure that the patient has access to care. Warm handoffs make sure nothing gets missed.
Care coordination is essential between hospitals and skilled nursing facilities, but the need for care coordination between hospitals and home health service providers is an emerging trend, she says.
"There has been a paradigm shift away from skilled nursing," Tank says. "If we can get the patient home safely and have the right support in the home, that is the goal now."
The health system is building a 200,000-square-foot facility that will integrate behavioral health and physical health for pediatric patients.
New Hyde Park, New York-based Northwell Health is launching a $500 million initiative to boost behavioral health services for pediatric patients.
Behavioral health services for pediatric patients are in a state of crisis. Of the vast numbers of children and adolescents who have behavioral health problems nationwide, only about 20% of them are receiving appropriate care, says Jill Kalman, MD, executive vice president, chief medical officer, and deputy physician-in-chief of Northwell.
The centerpiece of Northwell's $500 million initiative is construction of the Child and Adolescent Mental Health Pavilion, which will be connected to Cohen Children's Medical Center and Zucker Hillside Hospital, Northwell's adult mental health facility in Queens, New York. The new 200,000-square-foot facility will have more than 100 inpatient beds and feature an integrated health services approach to combine behavioral health services with physical health services.
The initiative will be financed with about $350 million from the health system and about $150 million from philanthropic fundraising. The health system is not expecting a financial return on investment, says Charles Schleien, MD, senior vice president of pediatric services at Northwell.
"We are paid poorly for mental health services. This is not being done as a financial investment," he says. "There is no expectation there will be a positive return on investment until the healthcare system is changed to support mental health. This initiative is being done because Northwell feels this is part of its mission in terms of children's health. That is why we are trying to offset some of the cost philanthropically."
As is the case with children and adolescents nationwide, there is a crisis in pediatric mental healthcare, Schleien says.
"The numbers of children with behavioral health problems continue to climb dramatically—they have been climbing for years and they accelerated during the coronavirus pandemic. We are overrun with patients in our emergency departments. Schools need help addressing the problem," he says. "It is incumbent on us at Northwell to deal with the issue of behavioral health conditions in children head on as part of our mission to improve health."
Providing integrated care is essential for pediatric patients, Schleien says.
"Many kids with major behavioral health issues are kids that have other chronic, complex disease states," he says. "So, when they are hospitalized, it is frequently true that they need other physicians beyond psychiatric care for treatment of underlying diseases. In addition, many kids with primary mental health issues get sick physically."
The new pavilion reflects the overall approach to behavioral health at Northwell, Kalman says.
"It is part of our strategy for behavioral health in general to improve access, use technology, and improve care in our communities. We want to go upstream—identify behavioral health needs earlier," she says.
Kalman says the primary goals of the new pavilion are to impact serious behavioral health outcomes, including reducing suicide among children and adolescents, which is a leading cause of death in this population.
"We want to impact the most serious outcomes in pediatric behavioral health. Another metric will be reaching our communities and bringing behavioral health services to those who have not had them in the past," she says. "Then, when you look at the most common diagnoses such as depression, anxiety, and substance abuse, we want to improve serious outcomes such as hospitalization. We want to keep children and teenagers in their homes and communities with adequate treatment."
CMO perspective
Integrated health services are part of the clinical care strategy at Northwell, and Kalman says implementing that strategy is an essential part of her responsibilities.
"I am here to align the strategy with the health system and support the clinical leadership to create the vision of integrated health services. Mental health and physical health under one roof is consistent with what we want to do at Northwell in general. We want to put the patient at the center of care and wrap all the services around them," she says.
Kalman is also responsible for filling clinical gaps.
"I make sure we have all the services we need in behavioral health, make sure we are focused on depression and anxiety, make sure we are focusing on substance abuse, and make sure behavioral health is integrated with physical health. In pediatrics, I make sure we are connecting with our schools," she says.
Kalman says she will play a pivotal role in the $500 million initiative.
"I will ensure that the initiative is implemented and that the clinical leaders of pediatrics and behavioral health have the resources they need. I will also promote the vision in outward communications to the communities we serve," she says.
Alan Harmatz, CMO of Medical City Dallas, says patient safety involves assessing how a care process works, determining whether the outcome was anticipated, and identifying improvements.
A strong risk management strategy is what drives chief medical officer Alan Harmatz, MD, of Medical City Dallas. It's a key component of his job for delivering high-quality care for patients.
Harmatz, who was named CMO of Medical City Dallas in August, oversees clinical care at Medical City Dallas, Medical City Children's Hospital, Medical City Women's Hospital Dallas, Medical City Heart Hospital, and Medical City Spine Hospital. The hospitals are part of HCA Healthcare and Medical City Dallas is a flagship hospital, with nearly 900 beds.
Prior to joining Medical City Dallas, Harmatz was CMO of HCA Healthcare's Florida Brandon Hospital.
Harmatz says risk management often involves examining patient safety events after they have occurred. This involves taking what is learned from patient safety events, then putting processes into place to help develop a robust safety program to prevent these events from happening in the future.
Risk management informs patient safety at health systems and hospitals, he says, adding that you must make sure that the processes you have put in place are followed and the clinical staff's focus is where it should be.
"That requires communication, support, education, coaching, and monitoring. Once this process is started, it never stops," Harmatz says.
Patient safety is not only ongoing but also requires a conversation about what care teams are doing, how care processes are going, and what care teams can do better the next time.
"You ask how a care process worked, did it work better, was the outcome what we anticipated, and what do we need to change and improve," he says. "It is a constant cycle."
Alan Harmatz, MD, is chief medical officer of Medical City Dallas. Photo courtesy of HCA Healthcare.
Rising to leadership challenges
Harmatz oversees clinical care at five hospitals that provide a huge range of services, including emergency department care, complex oncology, pediatrics, cardiovascular services, heart transplants, and solid organ transplants. As he acclimates to this CMO role, he says the main challenges are getting to know the facilities, getting to know the people, and understanding the culture.
"First, I must spend time and go to meet people where they are—I must meet the people who make the miracles happen every day," he says. "Second, I must listen—that can be a challenging thing to do but I think it is the most critical thing to do. Third, I must work hard. There's a lot to be done. There is a lot that goes on here every day, and I must commit to it.”
In establishing a working relationship with the medical staff, Harmatz says it is important to recognize they are highly intelligent and engaged professionals who have been at the organization, in many cases for several years.
"I do not lead the medical staff—I collaborate with them," he says.
Listening to the clinical staff will be essential to being a successful CMO, he says.
"Most of the great ideas do not come from me or above—they come from the people who are delivering the care," Harmatz says.
Physician leaders can be a rare commodity, but if CMOs look and listen, they can find them, he says, adding the best physician leaders are not only interested in what they do but also what the entire clinical staff does.
"They are interested in the processes that get us to the point where we can deliver excellent care," Harmatz says.
Promoting infection prevention
Before joining Medical City Dallas, Harmatz led an HCA Healthcare effort to develop a software program that reduces infections in the hospital setting.
He was part of a group that looked at how to facilitate discharges from hospitals in a timely and efficient manner. They used an effective discharge tool that was developed by some of HCA Healthcare's software developers and content experts. Harmatz suggested creating a similar tool for preventing infections.
Harmatz was paired by his division chief medical officer with another physician leader who runs HCA Healthcare's innovation center. They were given access to two programmers, and he brought in his infection prevention director, who had three decades of experience.
"Three months later, we had a product that was ready to be used in the division and eventually spread across the enterprise," he says.
At HCA Healthcare, the software program has helped to significantly reduce Clostridioides difficile infections as well as methicillin-resistant Staphylococcus aureus, he says, adding the software program is part of an overall effort to use technology to improve patient outcomes.
Clinical background suited to serving as CMO
Harmatz says his clinical experience as a plastic surgeon was good preparation for becoming a CMO.
Plastic surgeons see a lot of problems, including patients who have had attempts to fix conditions in the past that have not worked out well, he says.
"You see a lot of complex challenges," he says. "Every day, you are confronted by different challenges, and very few of them have cookie-cutter solutions."
CMOs and plastic surgeons have similar thought processes, Harmatz says. A CMO must be able to analyze what the true problem is, come up with the reasons for the problem, then look for ways to mitigate the problem, much like what a plastic surgeon does.
The CMO says clinical integration requires communication, trust, and knowing roles and expectations.
To achieve successful clinical services integration, healthcare leaders can't sit in their offices and wait for things to happen, says Philip Heavner, MD, MBA, chief medical officer of Guthrie Cortland Medical Center.
Heavner became CMO of the medical center in September, having previously served as Guthrie Clinic's system chief of pediatrics. Before joining the five-hospital health system, he was chief of pediatrics at Bassett Healthcare Network.
Heavner recently talked with HealthLeaders about a range of issues critical to the role of the CMO, including ensuring clinician engagement and establishing clinical integration.
Clinical integration success requires communication, trust, and making sure the contributors know their roles and expectations, he says.
"As the CMO of a regional hospital, when you have various clinical services such as the emergency department, inpatient services, surgical services, and a cancer center, you need to make sure that the provision of services is well understood across the organization," he says. "You need to communicate with each other to get things done clearly and safely."
CMOs also need to play an active role in clinical integration.
"You make yourself visible," he says. "You do not sit in your office and wait for things to happen. You reach out to people, and you ask them about what support they need as opposed to being passive. When you ask someone what they need, you need to address it."
When there are inadequate resources to support a clinical integration initiative, healthcare leaders need to be direct and honest, Heavner says.
"You acknowledge that any clinical initiative that makes sense deserves support, but there may be a lack of resources for the initiative," he says. "Our organization has a clear strategic process, where we consider and prioritize the resources that we have. We rely on that expertise to decide how resources are distributed. So, you explain the process for how we make decisions, and you help colleagues understand why we are not able to provide resources based on what our overarching strategy defines for us."
Philip Heavner, MD, MBA, chief medical officer of Guthrie Cortland Medical Center. Photo courtesy of Guthrie Clinic.
Rising to CMO challenges
The biggest challenge for CMOs is balancing the clinical factors that contribute to quality, safety, and patient experience, Heavner says.
"You must manage the expectations of all the stakeholders and be a reliable go-between," he says.
In the current healthcare environment, human resources are a primary consideration for CMOs and other leaders.
The coronavirus pandemic taught healthcare leaders the value of nurses, and their stock has risen as a result, Heavner says. Nurses are in high demand, and there are probably not enough experienced nurses to cover the needs of all the healthcare organizations in the country, he says. To be competitive in recruiting nurses, Guthrie Cortland Medical Center needs to be a place where nurses want to be, he says. "We need to be a destination for their careers."
Beyond nursing, there are human resources challenges in other capacities, Heavner says.
"There are other parts of our team that take care of our hospitals and do the work after hours that most people would not wish to do," he says. "Those folks are in demand, too, and this includes our clinicians—our doctors and advanced practice providers. We are constantly trying to attract and retain the very best clinicians, and that is a challenge right now."
Staff retention is critical for healthcare organizations. "Compensation must be fair," Heavner says.
You must be competitive in your market for clinicians, nurses, and support staff, he says. Healthcare leaders also must be clear about their organization's expectations and standards, he says. They also must make sure staff members feel supported in achieving goals related to patient safety, quality, and patient experience. "It is not just about patient experience—it is about clinician and caregiver experience, too. Those things go hand in hand," Heavner says.
Recruitment starts with a clear vision and a clear message about mission and values, Heavner says.
"It starts at the top with our president and CEO, who is a practicing physician. He talks the talk and walks the walk," he says. "When I sit down with someone who is considering an opportunity here, I tell them that this is a good place to work with a conscience. I tell them we take excellent care of our patients and are involved in our communities. I tell them this is a place where they can build a career."
Effective clinician engagement
Clinician engagement is similar to patient engagement, with a premium on clear communication, transparency, and honesty, Heavner says. But there are other key factors as well to take into consideration.
He says health systems and hospitals need to make sure the electronic medical record is a valuable tool rather than an obstacle to quality care. They need to make sure clinicians have time to continue their medical education, he says. And clinicians need to know that their voices are heard. "When a clinician speaks up and says they need assistance with an issue, it should be addressed," he says.
Guthrie Cortland Medical Center has several clinician engagement strategies, Heavner says.
The medical center conducts safety huddles every day, which promotes clinician engagement. The hospital also conducts multidisciplinary rounds every day, where the clinical care teams review every inpatient, their care plan, and what can be done better. In addition, there are regular medical staff meetings. "I meet with the leadership of the medical staff and departments on a regular basis. We talk about how we are taking care of our staff. If you make engagement a priority and talk about it consistently, you can establish momentum," he says.
Health systems are devoting resources to develop physicians as administrative leaders.
Health systems must be committed to developing physicians to serve in administrative leadership roles, the chief medical officers of AdventHealth and RWJBarnabas Health say.
Physicians bring a clinical perspective to administrative roles at health systems and hospitals. Once physicians take on administrative roles, they can help other administrators balance factors that drive clinical care with business priorities such as finance and operations.
"We have a strong belief that physician leadership matters, and we have a strong commitment to physician leadership all the way up to the senior roles at the health system," says Brent Box, MD, senior vice president and CMO of AdventHealth.
Physicians play leadership roles at all levels of the Altamonte Springs, Florida-based health system, he says. "It starts at the top with the chief clinical officer of the health system, who is a physician, Dr. David Moorhead," Box says. In addition, the health system's chief quality and safety officer is a physician, as is the leader of AdventHealth's hospital medicine and clinical documentation program. Several hospital CEOs are physicians, and physicians lead medical groups, service lines, and institutes, he says.
AdventHealth's market leaders make selections of physician leaders such as chief medical officers and work collaboratively with the medical staff and medical executive committees to select physician leaders at the service line level and department levels of the health system's acute care facilities, Box says.
AdventHealth looks for physician leaders who have credibility, he says. Physician leaders should possess clinical excellence, they should be respected by their peers, and they should demonstrate leadership potential at medical staff committees, the market level, or the regional level, Box says. "In addition to credibility, healthcare is team based, so we look for physicians who are oriented toward team leadership," he says.
Physician leaders are pivotal players at RWJBarnabas Health, says Andy Anderson, MD, MBA, CMO and chief quality officer of the West Orange, New Jersey-based health system. "It is important for physicians at the front lines to know there is physician leadership at the table making key decisions for hospitals, service lines, and the health system," he says.
Physicians are involved at almost every level of management at RWJBarnabas, Anderson says. They are involved at the unit level in partnership with nursing leaders. They are involved in hospital administration, including CMOs working with hospital administrators. They are involved at the health system level such as physician leaders who manage medical affairs initiatives and service line leaders.
At RWJBarnabas, physicians are generally selected for administrative roles in a process that takes time, he says. "Typically, a physician would get involved at their local level in areas including committee work or health system quality initiatives. Over time, they take on more administrative responsibilities. Ultimately, physicians become available to serve in leadership roles such as chief of a service line or CMO of a hospital."
Encouraging physician leaders
It can be a challenge to attract physicians to serve in administrative leadership roles, Box says. "We recognize the importance of physician leadership and cultivate it through several programs at the system level and the market level to generate interest in the administrative side of the health system."
Physician leaders are attracted to administrative leadership roles by having the opportunity to change healthcare in a positive way, Anderson says. "Part of that is having role models—having other physician leaders as mentors and people who have been on an administrative leadership trajectory. That helps spark interest and helps nurture physician leaders so they can take on leadership roles at the site level, the hospital level, or the health system level."
Devoting resources to physician leadership
The AdventHealth Leadership Institute, which was established several years ago, is engaged in physician leadership training, Box says. "The leaders of the AdventHealth Leadership Institute are constantly thinking about what it means to be a learning organization. The clinical team partners with our leadership institute to sponsor physician leadership training."
The health system has two other physician leadership programs, he says. In the Physician Team Leadership program, the health system sponsors a six- to seven-month leadership program specifically for physicians. The physicians are nominated for the program by their market leaders. There are 50 clinician leaders in each training cohort. In early 2024, the health will graduate its fifth cohort out of the program. The health system also has the AdventHealth Hospital Medicine Leadership Fellowship. In this program, hospital medicine leaders are trained in a partnership between the clinical team and the leadership institute. About 125 physicians have gone through this program.
RWJBarnabas has dedicated sessions with outside speakers to get physicians motivated and excited about playing leadership roles, Anderson says. The health system has also sent physicians to formal training and national meetings, where they can network and have curriculum around leadership. In addition, the health system encourages mentorship for physician leaders, he says.
RWJBarnabas has developed a manual as a resource for physician leaders, Anderson says.
Effective leadership is a fundamental driver of change and reinforces culture, the manual says. "An effective physician leader should be a role model, teacher, and coach for physician colleagues and for all members of the healthcare team. Leaders should not work in a vacuum, but rather must seek out the input of stakeholders to develop and implement the strategies, goals, and tactics to achieve exceptional outcomes for patients," the manual says.
Physician leadership training has a return on investment, Box says. "At the corporate level, we have invested the money and resources required to pay for our leadership programs because of the recognition of the value of leadership."
Lisa Tank, MD, senior vice president and chief medical officer of Hackensack University Medical Center as well as CMO for the North Region of Hackensack Meridian Health. Photo courtesy of Hackensack Meridian Health.
Alan Harmatz, MD, is chief medical officer of Medical City Dallas. Photo courtesy of HCA Healthcare.
