The Center for Women's Health Equity has received a $750,000 grant from New York State.
Westchester Medical Center Health Network (WMCHealth) has launched the Center for Women's Health Equity to address maternal morbidity and mortality across New York State's Hudson Valley.
In several reports, the United States has the highest maternal mortality rate compared to other developed countries—a report from The Commonwealth Fund found the United States had the worst maternal mortality rate compared to 10 other developed countries. U.S. maternal mortality is particularly problematic for Black women. In 2021, the maternal mortality rate for Black women was 69.9 deaths per 100,000 live births, which was 2.6 times the rate for White women, according to the Centers for Disease Control and Prevention's National Center for Health Statistics.
The Center for Women's Health Equity is designed to address a pressing need, says Sean Tedjarati, MD, MPH, MBA, director of obstetrics and gynecology at Westchester Medical Center.
"Despite the advances we have made, we now have the highest maternal morbidity and mortality in the United States in 65 years. Clearly, that by itself denotes the reason why we should have this kind of center that is going to bridge the gaps. We have made great discoveries and great advances, but we are not getting them to the right people who need care. The United States spends 20% of its gross domestic product on healthcare, and we should not have the type of maternal morbidity and mortality that we have, especially in underserved communities and among women of color," he says.
The primary goals of the Center for Women's Health Equity are to marshal resources in the health system and develop community partnerships, Tedjarati says.
"The goal is to bring all the talent and resources that we have under one roof and in an integrated manner. We want to improve communication and coordination. We want to bridge gaps and make sure patients have access to care. We also want to develop community resources and partnerships in order for both the health system and the communities it serves to have the same vision of making sure that the type of care that needs to get to the population gets there. The center brings everything together. It is like air traffic control. You may have great pilots coming into an airport, but without interconnectedness and communication, all you would have is crashes, which is what we are having in our maternal morbidity and mortality in the United States," he says.
The Center for Women's Health Equity will have operations at Westchester Medical Center in Westchester County and HealthAlliance Hospital in Ulster County. The program, which was formally launched yesterday, was established with the help of a $750,000 grant from New York State.
Tedjarati says the center will be built on five pillars: clinical integration, education, research, advocacy, and technology. "Those pillars will allow us to put a pebble in the foundation of building something that will ultimately reduce the burdens of our patients. We are not going to change all of society, but we can change our sphere of influence," he says.
The center will help lead efforts to address mothers' determinants of health, Tedjarati says. "The way we address determinants of health is through our community partnerships and our advocacy within the state. We want to talk about some of the economic issues that women may be having. We want to address issues such as transportation, which is an issue that allows women to have access to healthcare. We want to advocate for longer Medicaid coverage of postpartum care."
The center will be staffed with existing healthcare workers at the health system and dedicated employees, he says.
"The first thing we have done is started a collaboration between our maternal-fetal medicine specialists and our cardiologists. We are bringing them under the same roof so they can see patients together in an integrated model. Similar to what we do in cancer, when we bring different specialties under one roof, patients get better care. We will have a dedicated staff as well. We have already hired a program coordinator who is going to be involved in seeing that this program gets off the ground. We will have staff that will be working with the maternal-fetal medicine department because a lot of the work on maternal morbidity and mortality will be coming from that department. We are in the process of hiring dedicated therapists and social workers. As we build out our capacity, the staff will grow."
Primary care clinician productivity also leads other specialties, survey finds.
Primary care clinician compensation increased 6.1% from 2021 to 2022, compared to a 1.5% increase for medical specialties and 1.6% increase for surgical specialties, according to a new AMGAsurvey.
The 36th edition of the AMGA's Medical Group Compensation and Productivity Survey features data collected from 446 medical groups that employ more than 193,000 clinicians.
In addition to leading other specialties in compensation growth, the survey found primary care had more significant growth in work relative value units (wRVUs) than other specialties. Primary care physician wRVUs increased 4.0%, compared to a 1.7% increase for medical specialties and a 1.4% increase for surgical specialties.
In part, the trends are related to changes made by the Centers for Medicare & Medicaid Services (CMS) as well as wRVU changes, AMGA Consulting Director Elizabeth Siemsen said in a prepared statement.
"We're seeing that the compensation levels for primary care have increased this past year, greater than in other specialty types, which in our opinion, is evidence that the E/M coding changes that CMS put into effect in 2021 are now being reflected in organizations' compensation plans. Survey results indicate that the gains for primary care are evident as the smoke clears from the slow transition to the utilization of new wRVU weights for compensation calculation and the volume swings of the pandemic," she said.
The survey found medical group median net collections outstripped clinician compensation growth. Overall median net collections increased 5.2%. The survey shows revenue gains are not being applied directly to physician compensation, AMGA Consulting President Fred Horton said in a prepared statement.
"Rather, groups are using that revenue to address non-provider expense increases. A lower compensation-to-collections ratio suggests that a higher percentage of revenue is going to cover all the expenses that have seen an increase in the past few years. These include staff expense, supply expense, and the like. Basically, we see that this data reflects that organizations are focusing on the management of the changing financial demands for medical group operations," he said.
NewYork-Presbyterian Queens improved from a 1-star Centers for Medicare & Medicaid Services rank to 5 stars.
To improve the hospital's CMS stars ranking, NewYork-Presbyterian Queens set a clear vision and the goal of wanting to be a regional center of excellence, says Chief Medical Officer Amir Jaffer, MD, MBA.
Jaffer has been CMO of NewYork-Presbyterian Queens since January 2017. He previously served as associate CMO of Rush University Medical Center in Chicago.
HealthLeaders recently talked with Jaffer about a range of issues, including how NewYork-Presbyterian Queens coped with a COVID-19 patient surge in 2020, service line development, and care coordination. The following transcript of that conversation has been lightly edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as CMO of NewYork-Presbyterian Queens?
Amir Jaffer: NewYork-Presbyterian Queens is a 535-bed, Level 1 trauma center and tertiary care teaching hospital, part of the NewYork-Presbyterian Hospital enterprise. We are anchored by two Ivy league medical schools, Columbia University Vagelos College of Physicians and Surgeons and Weill Cornell. NewYork-Presbyterian Queens is a primary affiliate of Weill Cornell Medical College. As the chief medical officer at NewYork-Presbyterian Queens, I view any of the challenges that come our way as opportunities to better serve the Queens community of 2.5 million people. Since I joined NewYork-Presbyterian Queens in January 2017, I have identified three big opportunities.
First, the Queens community is extremely diverse, with approximately 48% of the community born abroad. Queens represents more than 120 countries and more than 35 languages. The diverse community we serve, along with our diverse staff, continues to be our biggest strength. Almost half of our employees reside in Queens. We are working every day to understand the needs of the people in Queens we serve, and we offer robust translation and transcription services to ensure we're able to best communicate with our patients.
Second, we are part of the world-class NewYork-Presbyterian Hospital system and have exceptional physicians from Weill Cornell Medicine. Our model allows us to deliver the best care and continue building new programs that serve the needs of the community, right here in Queens. Most notably, we are proud of the new neuro-ICU opening in July; our comprehensive cardiovascular program, which is ranked 3-three stars—the highest for Society of Thoracic Society rating for coronary artery bypass graft surgery; we are ranked five stars by the Centers of Medicaid & Medicare Services; and we are a top 250-ranked hospital by Healthgrades. None of these outcomes would be possible without NewYork-Presbyterian Queens doctors, nurses, and multidisciplinary teams working together.
Third, our team is flexible. During the COVID-19 pandemic, NewYork-Presbyterian Queens was one of the epicenters, and we were at the front lines in taking care of thousands of patients with COVID. Our camaraderie and teamwork made us resilient, allowing us to serve the community.
HL: New York City was one of the early hotspots in the coronavirus pandemic. How did NewYork-Presbyterian Queens handle high patient volumes during the 2020 surge?
Jaffer: During the 2020 COVID-19 surge, NewYork-Presbyterian Queens was an early hotspot. I personally fell ill with COVID-19 on March 13, 2020, and am so grateful for our incredible leadership team, specifically our chair of surgery, Dr. Pierre Saldinger, and chair of medicine, Dr. Joe Cooke, who stepped in to serve the hospital and greater community in unprecedented times. During those first critical weeks, the leadership team helped to determine how we could create capacity, specifically more ICU beds, and work with the larger enterprise as we handled supply chain issues such as managing personal protective equipment.
When I was able to return to work in April 2020, I helped to support our frontline teams, rounding on patients, and logistically working with partners such as Hospital for Special Surgery that assisted in receiving our recovering COVID patients to other facilities, which allowed us to increase our capacity and manage the acutely ill COVID-19 patients.
One of the things I so vividly remember during those early weeks was our team setting up call centers to ensure patients were able to speak to their loved ones because our visitation policy had restricted visitors.
NewYork-Presbyterian Queens Chief Medical Officer Amir Jaffer, MD, MBA. Photo courtesy of NewYork-Presbyterian.
HL: You have helped grow healthcare service lines at NewYork-Presbyterian Queens. What are the keys to success in managing service lines?
Jaffer: I have been fortunate in my time at NewYork-Presbyterian Queens to work very closely with our operational leaders to strategically grow our service lines including orthopedics, cardiovascular, neurosciences, pediatrics, women, cancer, digestive diseases, and primary care. I attribute our success to working collaboratively with our medical group to recruit world-class physicians and build clinical programs with amazing outcomes. In many cases, these programs require multiple disciplines to collaborate, along with equipment and technology that require capital investments. Each year, we build strategic plans with tactical and actionable interventions that have allowed increased market share in a very competitive landscape.
HL: You helped lead the transformation of NewYork-Presbyterian Queens from a 1-star Centers for Medicare & Medicaid Services (CMS) rank to 5 stars. What were the main elements of this transformation?
I am proud to be working with our president, Jaclyn Mucaria, on a team that supported the transformation of NewYork-Presbyterian Queens to become a CMS 5-star ranked hospital. This happened in part due to a cultural transformation where we set a clear vision and the goal of wanting to be a regional center of excellence and to be the first choice for patients, employees, and physicians.
As part of this work, we committed to putting patients first and outlining our values (respect, empathy, teamwork, innovation, and responsibility) that helped lay a strong foundation for our high reliability framework of tiered huddles and helped create a safety culture, which created psychological safety and the ability for people to speak up with leaders. Working in tandem with our care team and leadership team, we created transparency through scorecards and dashboards, and we held our leaders accountable across the board, which helped increase our scores over five years.
HL: What are the keys to success in care coordination?
Jaffer: In my experience, the key to success in care coordination is a 360-degree approach where we are constantly evaluating every individual at every portion of their wellness journey. If it has been determined that an individual's health is declining in the outpatient setting, we should work with them and ensure we can have the best possible team managing their care. Similarly in the inpatient setting, I believe we should be working with the full care team to develop a plan to bring patients back to their baseline health status—putting the patient's safety and ultimate transition back to a pre-illness state or improved as the end goal.
Good communication is paramount, including our doctors, nurses, case management, social workers, navigators, and care coordinators.
We are proud of our robust care coordination services that allow us to be successful and have low readmission rates, along with our navigator program that aids patients in being guided to additional services post-hospital stay.
HL: Your hospital serves a diverse patient population. What is the hospital doing to promote health equity?
Jaffer: NewYork-Presbyterian Queens is proud of the diverse patient population we serve. NYP launched the Dalio Center for Health Justice in 2020 with the aim of understanding and addressing the root causes of health inequities, and with the goal of setting a new standard of health for the communities we serve.
HL: You have a clinical background in internal medicine. How has this clinical background helped prepare you to serve in administrative roles such as CMO?
Jaffer: When I started my career, I thought I would eventually want to be a gastroenterologist but found that as a generalist, I had more opportunities to teach students and residents, which was my passion early in my career. I began taking on more responsibility in building innovative programming, and my generalist background allowed me to have a 360-degree view in working with different types of patients such as surgical, medical, inpatient, and outpatient. As an expert in hospital and perioperative medicine, I had the opportunity to work collaboratively with different specialties that allowed me to see the large spectrum of diseases.
Through my career and as a CMO working with every specialty and a variety of physicians across different specialties, I have gained a deeper understanding of the various disciplines. I am never shy to ask whether I can come and observe and round in their area. As a leader, this understanding helps me to address challenges they are experiencing and better understand how to help physicians and solve problems.
OU Health has achieved low turnover in the health system's supply chain team by hiring the right leaders as well as having clear roles and responsibilities, says Josh Bakelaar, MBA, vice president of supply chain.
Bakelaar has been vice president of supply chain at OU Health since May 2020. His prior experience includes serving as system director of strategic sourcing for UW Medicine.
HealthLeaders recently talked with Bakelaar about a range of issues, including the challenges of leading supply chain at OU Health, lessons learned during the coronavirus pandemic, and the role of physicians in the OU Health supply chain. The following transcript of that conversation has been lightly edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as vice president of supply chain at OU Health?
Josh Bakelaar: I have been here about three years, and one of the biggest challenges is that our supply chain team had lots of opportunities for improvement. I have addressed three things. The first focus was governance. Our hospitals were functioning pretty independently in their decision making around supply chain. We had centralized services, but a lot of the decision making was happening at the site level as opposed to the system level. We addressed that so we could realize economies of scale and other benefits of being a health system.
Second, there was a lot of tribal knowledge around our processes. We didn't have a lot of documentation. So, there were many opportunities to close gaps around processes and efficiencies.
Third, there was a leadership and talent gap. Our hospitals were largely making independent decisions—they each had individual supply chain leaders. Plus, we had an off-site warehouse that had a different leader. There was not a singular guiding force across all of our supply chain teams strategically.
HL: How did you improve leadership across the supply chain?
Bakelaar: It was mainly redesigning the org chart. When we divested from HCA about five years ago, one of the things that was apparent to me coming in was that a lot of the central back-office functions just did not exist as part of OU Health. We did not have a complete supply chain. For example, we did not have inventory control. We only had a couple of contracting people and one value analysis person. There were limited informatics capabilities. We had to scale up and build out an end-to-end supply chain team.
Josh Bakelaar, MBA, vice president of supply chain at OU Health. Photo courtesy of OU Health.
HL: You became vice president of supply chain at OU Health during the beginning of the pandemic. What were the primary lessons you learned from leading the health system's supply chain during the pandemic?
Bakelaar: I started here in May 2020, a couple of months after the pandemic hit the United States, but it had not hit Oklahoma yet. What I learned was the importance of good supply chain leadership. We had to have a good governance structure in place around how decisions were made. You need to have clear roles and responsibilities. Sometimes, a disaster hits and there is scrambling to figure out who is going to do what. Having that ironed out ahead of time is valuable.
Remote working was an issue. Right now, there is a debate in this country about the feasibility of working remotely. When I started at OU Health and came in for my first day, there were only about three or four people in our supply chain office. Everyone else was working from home. I came into the office every day for many months, got to learn the operation but I also had to build a lot of relationships on Zoom and Teams.
Over the past three years, we have built our team in a largely hybrid and remote environment. Our purchasing team is classified as remote. Our informatics team is classified as remote—the director of that team lives in Florida. Our sourcing team is classified as hybrid—they work remote most of the time. With all of this remote work, we have thrived.
You have to have good documented processes for backorders and substitutions. Early on in the pandemic, personal protective equipment was not available but everything else was fine. Eventually, multiple suppliers started making PPE, and we had it coming out of our ears but we were running out of other supplies. So, going into the pandemic, it would have been better for us to have more documentation of the backorder and substitution processes.
HL: What have been the keys to success in having so many people working remotely?
Bakelaar: Leadership is critical. You need to have the right people in the right seats with the right mentality of how to manage people in the work environment. We round on our people regularly. For the people who report directly to me, we talk informally several times per day. We call each other on Teams. We put a lot of emphasis on having the camera on and being engaged as if you are working in person. We communicate informally but intentionally.
We make sure we are hearing from our teams—what's making them happy and what's not. We look for opportunities for improvement. Our turnover is really low.
HL: Why do you think you have low turnover in your staff?
Bakelaar: I have heard the phrase that people don't quit their jobs, they quit their bosses. I believe strongly in hiring the right leaders, getting them the right seats, and having clear roles and responsibilities. We also have done a tremendous amount of work around process discipline and process documentation. The expectation on our team is that we all get on the same page about what a process is, and we stick to it.
I have worked in supply chains where not everybody was on the same page, or there were different priorities. We have been intentional about removing things that are frustrating. We are accountable to creating a positive work environment.
HL: How does your group purchasing organization function?
Bakelaar: Vizient is our GPO, and there are several areas of benefits in working with them. First is cost savings. We have partnered with them and implemented cost savings over the past couple of years.
Vizient describes themselves as a performance improvement company, so they look beyond just the traditional GPO supply chain functions. They work on quality with their databases as well as patient safety. We are partnering with them to tackle catheter-associated urinary tract infection and central line-associated bloodstream infection reductions. We are tackling patient safety issues and clinical documentation improvement.
We use Vizient to help solve some of our governance challenges. They helped us get some governance models created around the supply chain function.
HL: How do you engage physicians in the supply chain?
Bakelaar: Physicians played a key role in the governance work that we did with Vizient. We set up some service line clinician-led groups. These service line groups meet monthly. Supply chain will facilitate the conversation, but, ultimately, we look to our physicians and clinicians to make data-informed decisions around the supplies we are going to contract for. At any given meeting, we might talk about some new products that are coming to market. Most meetings focus on looking at our portfolio of contracted products and making strategic decisions that maximize cost, quality, and outcomes for our patients.
HL: Your background includes experience in strategic sourcing and inventory control. How did this background help to prepare you to serve as a supply chain leader?
Bakelaar: I have come up through the ranks. I started in healthcare supply chain soon after high school. So, I have been doing this work for a long time. I have done many of the frontline jobs such as supply chain technician work, ordering, and receiving. I moved up through different management positions along the way. This experience has allowed me to lead with a lot of empathy when it comes to my team—I can put myself in their shoes.
When I round on the team and hear the frustrations that they have, it takes me back to when I was in their shoes doing that work. I make sure frustrations get fixed.
I have worked in supply chains where the senior leadership said "yes" to everything that came their way. That created pressures, and workload management issues would arise. What I try to do as a supply chain leader is to be mindful and protect my team along the way. If an executive asks me whether we can do something, I don't just say "yes." I say we can do it, but I may say that we will need more resources, or we may need to slow down another process. I am mindful to make sure that we are not over-promising and under-delivering. I am mindful to make sure we are not putting too much on our plate and stressing our folks.
University of Michigan Health and Newark Beth Israel Medical Center have increased hand hygiene compliance significantly.
The results of two technology-based hand hygiene improvement initiatives were presented this week at the annual conference of the Association for Professionals in Infection Control and Epidemiology.
In the hospital setting, hand hygiene is critically important to reduce hospital-acquired infections and to prevent surgical-site infections post-operatively. Despite the benefits of hand hygiene, achieving hand hygiene compliance among healthcare workers can be problematic.
In August 2018, Ann Arbor, Michigan-based University of Michigan Health switched from using static charts to monitor hand hygiene compliance to using electronic dashboards to visualize hand hygiene compliance in real time at its 1,100-bed campus. The technology-based initiative uses business intelligence software to generate weekly and monthly compliance reports that can be filtered by hospital unit and role such as environmental services and nursing.
A month after the initiative was launched, hand hygiene compliance at 19 hospital units improved from the high 80% range to 95%. Compliance rates dropped to 86% in March 2021 because the program was paused during the coronavirus pandemic, but compliance has risen to 98% as of April 2023 through reintroduction the dashboards and real-time data sharing.
Covert observers play a crucial role in the hand hygiene efforts, says Marissa Yee, MPH, an infection preventionist at University of Michigan Health. "We have covert observers who are trained to monitor hand hygiene. They walk around the hospital and look for hand hygiene opportunities, which focus on entry into a patient room or into a bay area as well as when a healthcare worker exits these areas. The covert observers can enter their hand hygiene observation data through a web-accessible database on their phones or iPads."
Once the data goes into the database, it is fed into the business intelligence software, which automatically refreshes the online dashboards, so staff can access their most current hygiene compliance, she says. "Staff can look at their hospital unit, environmental services unit, patient food and nutrition services, and any ancillary department. We want people to be able to access their data in real time, so they have many opportunities throughout a month to review their hand hygiene compliance. The business intelligence software has allowed us to get real-time data out to frontline staff as well as leadership throughout the institution so they can remind staff about hand hygiene during daily management huddles."
With the technology, the health system can target hand hygiene interventions, Yee says. "This initiative has allowed us to see whether we need to target specific shifts, units, or roles throughout the institution. We can educate staff on a timely basis because we can see what we are observing in real time."
Staff members have easy access to the hand hygiene compliance data, she says. "The dashboards are available on the health system website. There are different filters to view a specific unit or department, specific months, and our adult hospital or our children's and women's hospital. Staff can subscribe to a dashboard on a daily, weekly, or monthly basis with a particular filter and have the dashboard pushed to their email."
Newark Beth Israel Medical Center initiative
Newark Beth Israel Medical Center, a 665-bed hospital based in Newark, New Jersey, that is operated by RWJBarnabas Health, launchedan automated hand hygiene monitoring system in 2019.
After a 21-day baseline period in February 2022, the hospital deployed the automated hand hygiene monitoring system in eight adult inpatient units covering about 200 patient rooms. The monitoring system senses every opportunity for hand hygiene and counts actual dispenses of hand sanitizer to compute the compliance rate. Data from the intervention was collected from March 2022 to April 2023. During the intervention period, the median hand hygiene rate rose in all units, ranging from a 67% to 132% improvement compared to baseline. The average percent increase over baseline across the eight adult inpatient units was 98%.
As part of the intervention, the infection prevention team enlisted hand hygiene champions and unit managers who shared real-time data about their units during daily safety huddles with hospital leadership and during shift changes. The role of hand hygiene champions and unit managers in the initiative is focused on looking at hand hygiene behavior, says Ndubuisi Eke-Okoro, MSc, an infection preventionist and epidemiology specialist at Newark Beth Israel Medical Center.
"Taking full ownership of our hand hygiene is one of the tools to prevent hospital-acquired infections. Hand hygiene champions and unit managers cross check as soon as a healthcare provider or any healthcare worker is about to approach a patient space. That creates an awareness of hand hygiene when working in a patient space," he says.
Hospital leaders have played a pivotal role in the initiative, Eke-Okoro says. "As part of our journey to being a high-reliability organization, we have made hand hygiene a priority. As soon as we initiated the electronic monitoring system, all infection prevention departments announced the hand hygiene performance of the facility during the daily safety huddles. The senior leadership gave responsibility to unit leaders to announce hand hygiene compliance in their daily huddles. All leaders got involved if hand hygiene was going in the wrong direction."
A new study has found that very few patients hospitalized with alcohol use disorder are prescribed appropriate medications such as naltrexone.
Hospitalizations for alcohol use disorder (AUD) are an opportunity to begin treatment with medications for AUD (MAUD) but only a small percentage of patients receive MAUD within 30 days of discharge, a new study found.
About 29 million U.S. adults have AUD, and alcohol is a factor in more than 140,000 deaths per year, according to the National Institute on Alcohol Abuse and Alcoholism. Several AUD medications, including naltrexone, acamprosate, and disulfiram, have had U.S. Food and Drug Administration approval for decades.
The new study, which was published today in Annals of Internal Medicine, is based on AUD hospitalization data in 2016. The researchers examined more than 28,000 AUD hospitalizations for more than 20,000 unique patients.
The study features three key data points:
Only 0.7% of patients began MAUD treatment within two days of discharge
Only 1.3% of patients began MAUD treatment within 30 days of discharge
The most predictive demographic factor for MAUD treatment linked to an AUD hospitalization was younger age—18 to 39 years old versus more than 75 years old (adjusted odds ratio 3.87)
"In this national sample of eligible Medicare Part D beneficiaries who had not been treated recently and were hospitalized for AUD in 2016, MAUD treatment was rarely initiated during hospital discharge or follow-up care and was more likely among younger patients and those with involvement of psychiatry or addiction medicine," the study's co-authors wrote.
Interpreting the data
Clinicians are missing an opportunity to treat AUD patients, the study's co-authors wrote. "Hospitalizations allow for engagement with healthcare resources, such as clinicians and social workers, that may otherwise be difficult to access, and health vulnerability experienced by patients during hospitalizations may provide motivation for behavior change. Initiation of MAUD treatment should involve a long-term treatment plan, and if this is not feasible during hospitalization then referral for outpatient treatment may be a preferred alternative. However, the low rate of MAUD treatment initiation within 30 days of discharge indicates that initiation during follow-up rarely occurs."
MAUD is an effective treatment for AUD, the co-authors of an editorial accompanying the study wrote. "Currently recommended medications include naltrexone and acamprosate, which were approved by the U.S. Food and Drug Administration in 1994 and 2004, respectively, after showing benefits to patients with moderate to severe AUD. In recent meta-analyses, compared with placebo, naltrexone reduced the risk for return to heavy drinking (51% vs. 61%), whereas acamprosate reduced relapse in patients who had recently become abstinent (62% vs. 75%)."
The reported rates of MAUD treatment for patients hospitalized with AUD is "startling low," the editorial co-authors wrote. "Might there be legitimate reasons for this result? We do not think so. Although 90% of the patients had secondary diagnoses of AUD, the researchers recognized that AUD diagnoses affect hospital care and excluded patients identified as being in remission. Patients with a primary diagnosis of AUD had higher rates of initiation, but initiation rates were in the single digits."
Jesse Ehrenfeld acknowledges there are many challenges in healthcare, but he is optimistic.
Physicians are facing many challenges, including the fallout from a long pandemic, barriers to care, Medicare reimbursement cuts, and workforce shortages, says Jesse Ehrenfeld, MD, MPH, the new president of the American Medical Association.
Ehrenfeld, a practicing anesthesiologist in Wisconsin, was inaugurated as the 178th president of the AMA last week. He succeeded Jack Resneck Jr., MD.
This week, HealthLeaders talked with Ehrenfeld about a range of issues, including the top priorities of his AMA presidency, health equity, and physician shortages. The following transcript of that conversation has been lightly edited for clarity and brevity.
HealthLeaders: What are the top priorities for your AMA presidency?
Jesse Ehrenfeld: After three long years of dealing with the coronavirus pandemic, people are burned out in a lot of jobs but especially those of us who work in healthcare. We have had the COVID pandemic and a pandemic of bad information. Doctors and nurses have an important job to keep people healthy, but we have a healthcare system that is in crisis.
There are many barriers to care. We have insurance companies that are denying necessary care for patients. We have workforce issues where many doctors are saying they are going to reduce their hours or retire. We have Medicare cuts that are threatening the viability of practices. And, increasingly, we have legislators who are trying to impact the practice of medicine through acts that are being passed across the country.
We have to make sure that we can support physicians in recovering from the pandemic, and that is why the AMA adopted the Recovery Plan for America's Physicians. It is our top priority to make sure we are committed to rebuilding the nation's healthcare system.
HL: What are the top threats in the medical profession?
Ehrenfeld: We have real challenges around physician burnout. We have a Medicare payment system that is unsustainable and threatens healthcare access for seniors. We continue to have threats to safe care through the inappropriate expansion of scope of practice. We have real challenges around administrative hassles such as prior authorization, which places burdens on patients and practices as well as creates delays in care for individual patients. Those are the things that are continuing to threaten how we keep Americans healthy.
Jesse Ehrenfeld, MD, MPH, president of the American Medical Association. Photo courtesy of the AMA.
HL: What are some of the primary steps that need to be taken to advance health equity?
Ehrenfeld: Health equity is a priority for the AMA. Certainly, as we look at how care is delivered, we recognize there is much more that we need to do. As the first openly gay person to hold the office of AMA president, issues of LGBTQ health and equity are close to my heart and have long been a focus of my work in medicine.
The AMA continues to push forward a lot of work in this area. We need to make sure care is advanced in ways that eliminates longstanding inequities and improves outcomes for patients who have been historically marginalized. It requires us to address structural racism in the healthcare system. It requires us to equip physicians with the knowledge and the tools to confront health inequities and advance health equity across all aspects of the healthcare system.
There are important cases before the U.S. Supreme Court that likely will be decided this month, including the consideration of race in higher education admissions that will include medical schools. We have concerns about limiting the ability to consider race as a factor in admissions to colleges and medical schools, which could affect the ability to have a diverse physician workforce that we know impacts patient outcomes.
HL: How do you feel about being the first openly gay person to serve as AMA president?
Ehrenfeld: It is an exciting moment for the AMA. I know there are people in the country who are struggling because they happen to be gay or identify as LGBTQ, and I hope the visibility that I bring to my leadership of the AMA—the nation's oldest and most influential physician group—can give these people some hope and sense of possibility. I want to make sure that all patients can get the healthcare that they need, but that is only going to be possible if physicians and patients are able to make decisions together without the interference of lawmakers telling us how to do our jobs and second-guessing the science behind medicine.
HL: By multiple accounts, the labor market for physicians is tighter than ever. What can be done to reduce physician shortages?
Ehrenfeld: We need to make sure that we can expand the physician workforce. There are steps that we have long advocated for to expand the number of training slots particularly at the graduate medical education level as well as the expansion of medical school classes. These are important advocacy points at the AMA to make sure that we have the physician workforce that can meet the needs of our patients.
The AMA has invested significantly in our accelerating change in medical education portfolio of programs and grants over the past decade. We are trying to not only expand the workforce but also to transform how we train doctors today to make sure they can take care of patients tomorrow.
HL: Can physician assistants and nurse practitioners help address physician shortages?
Ehrenfeld: Absolutely! We strongly support physician-led, team-based care. Each team member has unique knowledge and makes valuable contributions to enhance patient outcomes. I experience this every week when I put on scrubs and go into an operating room to work with nurse anesthetists and anesthesia assistants.
However, it is important to point out that nurse practitioners and physician assistants, while valuable members of the team, are not a replacement for physicians and never will be. Removing physicians from a care team only results in higher costs and lower quality of care.
HL: What can be done to address physician burnout and mental health conditions among physicians?
Ehrenfeld: Unfortunately, we are at a crisis point. There continues to be stigma around accessing mental health services for physicians. Following the passage of the Dr. Lorna Breen Health Care Provider Protection Act last year, which is a bill we strongly supported, we continue to push for regulatory and legislative solutions to make sure we can direct more resources and more funding to support the mental health needs of physicians.
It is important to point out that the fundamental cause of physician burnout is not individual physicians having failures. It is working in a system that is ill-equipped to support the practice of medicine, and we need to have reform at the system level. We need to reduce burdens such as prior authorization and other administrative hassles that do not add value to what we do as care providers. We need to make it more enjoyable to practice medicine to reduce the burnout that people are experiencing.
HL: Are there things that health systems, hospitals, and physician practices can be doing to reduce physician burnout?
Ehrenfeld: Absolutely! The AMA has resources that can help health systems, hospitals, and practices address burnout. They can change workflows. They can reimagine how work is performed to better leverage tools and technologies. They can get physicians back in front of patients and reduce the amount of time they are doing administrative tasks.
HL: In your inaugural address, you said you embraced optimism regarding the challenges facing the medical profession. Why are you an optimist about these challenges?
Ehrenfeld: There are a lot of challenges, but I have seen physicians across the nation step up in incredible ways over the past three years in spite of the challenges and unbelievably difficult circumstances. They have been on the frontlines, working day in and day out to keep people healthy and to save lives. Among the residents and the medical students I work with, I see optimism and enthusiasm.
At the AMA, I know we can have an impact. I know that we can make things better for all Americans, and I look forward to leading the AMA over the next year.
Despite our healthcare system being in crisis and despite so many of my colleagues being at their breaking point, I am optimistic about the future. We can get this right.
The expansion of Williamson Medical Center will add 50 beds to the hospital.
The $200 million expansion of Franklin, Tennessee-based Williamson Medical Center includes medical staff and service line growth, says Andy Russell, MD, MBA, chief medical officer of Williamson Health.
A board-certified emergency medicine physician, Russell was named CMO of Williamson Medical Center in 2018. He served as an emergency medicine physician at Williamson Medical Center starting in 2004 and was promoted to medical director of the hospital's emergency department in 2010.
HealthLeaders recently talked with Russell about a range of topics, including the challenges of serving as CMO of Williamson Health, safety and quality, and issues related to the expansion of Williamson Medical Center. The following transcript of that conversation has been lightly edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as CMO of Williamson Health?
Andy Russell: The biggest challenge but also the most fun challenge is working in the constantly changing landscape of healthcare. The speed at which things were changing during the pandemic was unlike anything I had experienced before. That experience gained during the pandemic combined with the rapidly evolving technological advances means that the fast pace of a continually changing healthcare environment is here to stay.
At this point, my days are filled with projects focused on continual improvement to our patient safety initiatives such as hospital-acquired infections and fall prevention. We are developing new and higher-acuity service lines. We are incorporating more technology in areas such as telemedicine. We are onboarding new physicians and much more. No two days are the same.
HL: How do you rise to the challenge of a rapidly changing healthcare landscape?
Russell: You must remain flexible and nimble. I'm constantly participating in webinars and attending presentations to learn about the newest technology to help keep us at the forefront of an ever-changing landscape.
HL: In what ways are you focusing efforts on safety and quality now that the crisis phase of the coronavirus pandemic has passed?
Russell: We never lost focus on safety and quality during the pandemic. Safety and quality were at the forefront of everything we did during the pandemic, but we did have to shift and modify policies frequently throughout the pandemic as things changed. Obviously, COVID was a novel disease—something we had never dealt with before. While we had policies in place to deal with various infectious diseases, we were constantly having to shift and change as new information about COVID came out. Some of our policies and procedures that we had in place for years had to be modified.
Coming out of the pandemic, we now have many new staff members who do not know how we did things prior to COVID. We are constantly re-evaluating our quality and safety metrics. We are looking at where we were historically and where we are now, and we are continually adjusting where needed.
Over the past few months, we have put in initiatives and protocols for hand hygiene, central lines, urinary catheters, and order sets for pre-operative and post-operative care. These efforts have been focused on reducing infections within the hospital and making this a safer place for the patients.
HL: You have been involved in a $200 million expansion project for Williamson Medical Center. How is the expansion project impacting recruitment of medical staff?
Russell: The expansion project has brought a whole new energy to the hospital, which has been fantastic coming out of the pandemic. It's nice to have something new and positive for everybody to experience. Staff are excited to come to the hospital.
We have been focused on expanding several service lines, including cardiology, obstetrics-gynecology, the neonatal intensive care unit, critical care, and the emergency department. We are growing our primary care clinics as well as our orthopedic group. We have hired several doctors in each one of those specialties.
The mission of our health system sells itself to new physicians. Franklin is a great place to live and a great place to work. People want to come here and work in the community they live in and take care of the patients they see every day in the community.
We have two new orthopedic surgeons joining this year. We have brought in three new cardiologists. We have three new OB/GYN physicians. We have two new neonatologists and new neonatal nurse practitioners who have started in the past year. We will be bringing on two new providers in the emergency department by the end of the year. With the growth of the hospital, we must expand the medical staff to keep up with the patient volume.
HL: With a healthcare workforce shortage across the country, how have you risen to the medical staff recruitment challenge?
Russell: That is an ongoing process. While we have better staffing levels than we did a year ago, we are still not where we want to be. We have been rising to the challenge with increased salaries, improved benefits, flexible scheduling, and promoting our vision and expansion project.
Andy Russell, MD, MBA, chief medical officer of Williamson Health. Photo courtesy of Williamson Health.
HL: You mentioned service line growth. How has the expansion project affected service line development?
Russell: We are expanding our bed count by more than 50 beds, and we knew we were going to have to increase the staff to handle the increase in patient volume. Obviously, with the expansion and increased staffing there is increased cost, and we must increase revenue to cover those costs. Some of the service lines grow themselves such as the emergency department. With the continued growth of the community, emergency room visits have increased, and we have had to hire new emergency physicians.
At the same time, with more people in the ER, you have more patients with conditions such as chest pain who need cardiology services. There are more pregnant women who need obstetrics services. There are more patients who need surgical procedures. With the increased population in the area, that drives volume throughout the hospital, and we are trying to meet the needs of the community. We have been developing service lines to meet those needs.
HL: You have served on Williamson Medical Center's Medical Executive Committee. How does the committee function?
Russell: I have been involved in the Medical Executive Committee for about 15 years. For the first 10 years, I was involved in the MEC as a function of my role in the emergency department. Since I have moved into the CMO role, I have been involved in the MEC in more of an administrative capacity.
Williamson Medical Center is a physician-driven and physician-directed hospital. The MEC sets medical policies and procedures. The committee oversees the medical credentialling of clinical staff. The MEC reviews the professional practice evaluations of all new physicians as well as ongoing professional practice evaluations to make sure that our staff is up-to-date on the latest advances in medical care. The MEC also serves as the disciplinary board for our medical staff.
HL: What role do physicians play on the MEC?
Russell: The committee is made up of 100% physicians. Our chief of staff is the chair of the MEC. The CEO and I are non-voting members of the committee. The physicians on the committee are the ones setting medical policies and standards for the hospital.
HL: You have a clinical background in emergency medicine. How has this clinical background helped you serve in the CMO role?
Russell: Working in the ER, you get to know everybody in the hospital. I worked in the ER last night, and I worked with general surgeons, I worked with obstetrics, I worked with internal medicine doctors, and I worked with cardiology. I had to go to two different floors in the hospital to take care of patients who were not doing well, so I get to work with staff all over the hospital.
In emergency medicine, you learn about how the different hospital departments work together to make one, unified organization. In my time working in the emergency department, I have developed a network of colleagues across all of the specialties in the hospital. It has taught me how to work together and develop compromises. When I am in the ER, I am constantly calling doctors, and it is almost always with bad news. I need them to come to the ER to see a patient, or I need to admit a patient they need to work with the following day. I must be able to explain situations to them, so they understand the patient's needs. I have learned how to have difficult conversations.
Moving into the CMO role, I must bring people together and bring different departments together. I am continuing to build relationships and allowing everybody to work together for the greater good of the hospital.
A new survey developed at One Brooklyn Health gathers valuable data that shines light on equity for the health system's patients.
One Brooklyn Health is implementing a health equity initiative that focuses on patient experience.
Health equity has emerged as one of the pressing issues in healthcare. Last year, Health equity was proposed as the fifth element of a Quintuple Aim to guide healthcare improvement efforts.
At One Brooklyn Health, the Brooklyn, New York-based health system has launched the DEI Outreach Program to help address health equity, says Gwendolyn Lewis, DNP, RN, principal investigator at One Brooklyn Health and vice president of ambulatory care at Interfaith Medical Center in Brooklyn.
"This project started so that we could look at how health equity impacts the patient experience as well as health outcomes. We started with focus groups that included members of the community and patients. They shared with us their experiences with facilities in north-central Brooklyn. Based on the feedback that we received, we developed a 10-question survey. We partnered with CipherHealth, so the surveys could be sent out electronically to patients who were discharged from either the inpatient setting or outpatient setting," she says.
The survey, which is called the Brooklyn Health Equity Index, is different than other patient experience surveys, Lewis says. "We take this tool a step further than Press Ganey's tool regarding patient experience. Press Ganey's tool does not address whether a patient is discriminated against. Press Ganey's tool does not address whether the patient's needs beyond a hospitalization or a clinic visit are taken into consideration. The Press Ganey tool does not address whether the patient could comply with the medical regimen that was decided in either their hospital or outpatient encounter. Our survey tells us what real-life experiences are like. For example, did the doctor look at how difficult it is for the patient to apply what they have been told?"
The Brooklyn Health Equity Index has been deployed in two stages, she says. In the first stage, more than 4,000 surveys were sent to One Brooklyn Health patients. In the second stage, more than 10,000 surveys were sent out to One Brooklyn Health patients.
The Brooklyn Health Equity Index is collecting key data, says K. Torian Easterling, MD, MPH, senior vice president of population and community health as well as chief strategic and innovation officer at One Brooklyn Health.
"For us to address injustice, we must be able to shine a light on it. We must be intentional about trying to identify where injustice is showing up, so that we can ensure that our patients are having the best experience that will lead to optimal health. That is the big picture. This survey put us in the right direction of getting there. We can identify where there might be inequities and where there might be negative experiences. Then, it is on us as a health system to apply the right kinds of tools to address those gaps," he says.
One Brooklyn Health is committed to the long journey required to address health equity, Easterling says. "Before the new survey, we were using our performance improvement activities and working with our chief quality officer to achieve practice improvement in our ambulatory centers and inpatient units. Our previous surveys did not ask questions like this new survey. They did not ask about getting treated unfairly. They did not ask about whether the care team recognized patients in a warm and welcoming way. So, while we are in the initial phase of making sure the new survey is valid, our next step is going to be to couple the new survey with practice improvement activities."
Previous equity work at One Brooklyn Health
Some practice improvement through a health equity lens has already been done at One Brooklyn Health, Easterling says. "We have been ensuring that individuals have the resources they need to improve their care. We have the Diabetes Center of Excellence, and we have been removing barriers to make sure that patients have access to continuous glucose monitors and are able to test their blood sugar on a regular basis. We are doing this while being responsive to our patients' needs. Our nurse practitioners can engage patients on a timely basis."
The health system has been using technology to address health equity, he says. "We have also been using MyChart—a digital technology that allows the patient to interact with their physician or nurse practitioner in real time. Patients can get a response without having to visit an office."
These kinds of efforts are systematically removing barriers and ensuring that all patients have good quality care, Easterling says.
"One, we are listening. Two, we are making sure we are incorporating the ways in which patient experience is important. Three, we are making sure our practice overall is standard in a way that matches the services offered in any other health system. Four, we are using our data. Our data is important because that is going to be the roadmap to continue to improve upon the type of work that we are doing. We are collecting race and ethnicity data. We are collecting social determinants of health data. These are the ways we are advancing health equity and eliminating health inequities in the health system."
Recently published research shows that about 13% of people are aware of the 988 Suicide & Crisis Lifeline.
More efforts are needed to raise awareness about the 988 Suicide & Crisis Lifeline, says Andrew Sassani, MD, corporate vice president and chief medical officer of California behavioral health services for Magellan Health.
The 988 Suicide & Crisis Line was launched last July. Formerly known as the National Suicide Prevention Lifeline, the 988 Suicide & Crisis Line offers free and confidential support to people facing a suicide crisis or emotional distress.
Awareness of the 988 Suicide & Crisis Line lags far behind awareness of 911, Sassani says. "Certainly, there is more awareness now than there was a year ago, when the line was being born. But even though awareness is more than it used to be, the line is not commonly known to the extent that it should be. As research recently showed, about 13% of people are aware of the 988 line, whereas everybody is aware of 911. People know 911 probably from the time they are 5 or 6 years old. We are certainly far from that level of awareness about 988."
Despite the lack of awareness, the 988 line is making a difference for people in behavioral health crises, he says. "If we look at the data of how many calls and texts have been made to 988, we are on track to reach about 5 million contacts by the line's one-year anniversary. That is a promising sign, but the fact that the awareness is less than 15% points to additional efforts needing to be made for awareness."
Raising awareness about 988
New approaches need to be developed to raise awareness about the 988 line, Sassani says.
"NBC used to have 'The More You Know' public service announcements. We need a nationwide campaign of these kinds of public service announcements to make people aware of the availability of 988. We cannot rely on individual healthcare providers or other people 'in the know.' Mental health providers know about 988 and perhaps they will tell their patients about 988. The fact that only 13% of the population is aware of 988 is partly due to the absence of a wide campaign with the specific goal of raising awareness across the nation about 988."
A national approach to raising awareness about the 988 line is crucial, he says. "There have been local efforts to raise awareness by media and healthcare providers, but there has not been a general, nationwide campaign to raise awareness. Television and social media campaigns would be helpful."
988 fills a critical need
Being able to call 988 is an easy way to access help when people are facing a behavioral health crisis. Sassani says.
"Many of the calls to 911 are for when a fire breaks out, a car accident happens, or some other physical emergency occurs, and a dispatcher sends an ambulance, fire trucks, or police officers to the scene. The 911 dispatchers are not mental health or substance abuse savvy. The 988 line was created to specifically be able to handle the calls or texts that are made related to mental health and substance abuse crises. The skillset of deciphering and dispatching resources for a fire is quite different than the skillset for dealing with someone experiencing a behavioral health crisis. So, the 988 line was specifically created to be able to address behavioral health calls more professionally by trained dispatchers," he says.
In addition to having 988 operators trained to address behavioral health crises, the operators play a key role in connecting people to local services, Sassani says. "When a call or text is made to 988, depending on how the communication transpires, one of the best parts of 988 is that a transfer can be made to a local resource, so a local professional in mental health or substance use can take the call or text, then engage with the person and provide needed services."
The 988 operators are prepared to deal with behavioral health crises, he says. "When someone calls 911, a dispatcher picks up and says, 'What is your emergency?' When someone calls 988, the operator knows that the incoming call is going to be related to a mental health or substance use crisis. That's why you call 988—you don't call 988 to say that a fire has broken out. The 988 operators are trained and skilled to process and engage a person in a mental health or substance use crisis in a professional way to help that person get out of the crisis mode. The goal is to stabilize the person then hand them off to a behavioral health provider who can provide services."
Josh Bakelaar, MBA, vice president of supply chain at OU Health. Photo courtesy of OU Health.
Andy Russell, MD, MBA, chief medical officer of Williamson Health. Photo courtesy of Williamson Health.
