Healthcare worker burnout was a top concern for health systems, hospitals, and physician practices before the coronavirus pandemic, and it has reached crisis proportions during the public health emergency.
Prior to the pandemic, burnout rates averaged in the range of 30% to 50%; now, average burnout rates range from 40% to 70%, a healthcare worker well-being expert recently told HealthLeaders.
At Bon Secours Mercy Health, physician burnout has increased during the pandemic, says Herbert Schumm, MD, vice president, and medical director of education and physician engagement at the Cincinnati-based health system.
"We do a physician engagement survey every fall, and through that we have our baseline burnout numbers for both our physicians and our advanced practice providers. We are pretty much in line with the national trends. When we compare early in the pandemic with last fall, year-over-year, we were up about 17 percentage points, which is consistent with national levels that are up about 21 percentage points," he says.
Awareness of healthcare worker burnout has increased dramatically, Schumm says.
"There are some practical reasons for this change. In particular, we have Lorna Breen, a physician who died of suicide at the beginning of the pandemic and received national attention. That raised awareness. Also, folks realize that healthcare professionals overall—nurses, respiratory therapists, physicians, and others—are experiencing burnout. Awareness is higher than it's ever been. When we look at some of the legislative work that is going on across the country, it is supportive of our healthcare professionals. It is also boosting mental health support for them," he says.
Tackling physician burnout
Bon Secours Mercy Health had several physician burnout interventions in place before the pandemic, including three programs, Schumm says.
Wellness: The health system has an employee wellness program that allows clinicians to make sure they are receiving healthcare and closing care gaps. The employee wellness program also offers the Life Matters program, which provides free counseling to employees and their family members, plus "convenience services," he says. "If you have a quick question about finances or a legal question, or you have a flat tire on the way to work, you can call them, and they take care of it."
Coaching: Bon Secours Mercy Health offers coaching to clinicians, Schumm says. "Some physicians might say, 'I don't need a counselor, but I am struggling with time management or struggling with closing my charts.' We offer life coaching—physicians can choose whatever coach they want."
Treatment: The health system makes sure clinicians have access to physician health programs in their states, he says. "Physician health programs are programs that help with substance use and behavioral health. They also help protect a physician while they are getting treatment. These programs provide treatment, it is confidential, and as long as physicians comply with the treatment, they can protect their license. We reached out to all of these programs in our states to make sure 1) that these programs were available to our physicians, and 2) make sure that our health benefits cover the service for our physicians. We make sure physicians have coverage for both treatment and for any short-term disability."
Bon Secours Mercy Health also has interventions to boost physician resilience, Schumm says.
"Within our Life Matters program and Be Well program, we have several options that clinicians can take advantage of. One example is Joyages, which is an app that can be used in real-time and on-demand, individually or as a team," he says.
"Another example is our employee wellness program has different activities that you can do with others on your team. You can do a challenge with others in your office that involves activities such as exercise or diet—something that can engage your whole team," he says.
The health system has a strong ethics program to support clinicians and foster resilience, Schumm says. "We often talk about moral distress as a factor in burnout. We have full-time ethicists who are available to discuss difficult cases and to give support to clinicians immediately. It helps to support clinicians and whatever needs they have in real-time."
Bon Secours Mercy Health has launched two clinician burnout programs during the pandemic, he says.
Psychiatric support: "About two months into the pandemic, a couple of our psychiatrists called me and said, 'What can we do to help our colleagues?' They got several psychiatrists together and offered to provide support 24/7 to any of their colleagues—simply a cellphone call away. There were 10 psychiatrists who made themselves available. They have had 300 physicians and advanced practice providers call them. Some just needed someone to talk to, some needed therapy," Schumm says.
Extending free counseling services: "We were able to provide free counseling for all of our associates and their family members. Early in the pandemic, we were able to extend this service to all of our physicians and advanced practice providers who were not our employees but worked in our hospitals. They were without mental health and supportive services."
The Coalition for Physician Well-Being has been a good partner for Bon Secours Mercy Health in addressing physician burnout, Schumm says. "They have a great program so you can measure your organization against about 50 standards to see how you are doing in supporting your physicians. During the pandemic, we were able to receive their Medicus Integra Award, which is a milestone. But more importantly, The Coalition for Physician Well-Being gave us standards for measuring ourselves and an opportunity to find out what we needed to work on more. We found out things that we were doing well that we had not recognized. For us, it helped us to pull our team together."
Gauging the state of healthcare worker burnout
Schumm says healthcare organizations are in a fragile state regarding burnout.
"To use a sports analogy, we are approaching the end of game and some players are injured. Everybody is tired. Some players are ready to go on—others are not. We need to give each other a little bit of grace. We are also in a society that is divisive and not open to conversation. To get past this point, we need to be able to talk with each other. There needs to be psychological safety, where we can have open conversations. We are in a fragile state, but we are also in a hopeful state. People are looking forward to not being in the pandemic. I was on a recent call with a chief clinical officer, and he said, 'Herb, we have zero COVID patients today.' It was a relief that we had gotten to that point for a day. That brings hope that we can push forward," he says.
Schumm is hopeful about physician burnout at Bon Secours Mercy Health.
"I am optimistic because I can see how we have been able to invest in resources to help our clinicians. I also see a profound interest in the mental health of our physicians among our senior leaders. Top executives don't only want to know the state of burnout—they want to know what they can do. They want to know what is meaningful and how to approach it. I am optimistic because people are engaged and are looking at what we can do to support each other," he says.
New York hospitals must report sepsis-related data to the state Department of Health.
The establishment of mandatory sepsis protocols at all hospitals in New York State is estimated to have saved more than 16,000 lives between 2015 and 2019, according to the New York State Department of Health.
Sepsis develops in response to infection, and it can lead to tissue damage, organ failure, and death. Sepsis is the leading cause of in-hospital death in the United States. More than 1.7 million Americans are diagnosed with sepsis annually.
The mandatory sepsis protocols in New York were implemented in 2013 following the death of a 12-year-old boy from Queens, Rory Staunton, who succumbed to undiagnosed and untreated sepsis in a New York City hospital in 2012. The regulations requiring the sepsis protocols are known as Rory's Regulations.
Other states should follow New York's lead, says Jeffrey Hammond, deputy director of communications at the New York State Department of Health. "States should identify subject matter experts, hospitals, and physicians who can work collaboratively with the state to provide input and feedback on the program. Sepsis protocols should be evidence-based, including training of professional staff to implement the protocols and a mechanism for data collection and analysis."
The mandatory sepsis protocols are intended to improve rapid identification and treatment of sepsis. Rory's Regulations have five primary requirements for hospitals to adopt sepsis protocols.
There must be a process for screening and early recognition of patients with sepsis, severe sepsis, and septic shock.
There must be a process to identify and document patients for treatment with protocols for severe sepsis and septic shock.
There must be treatment guidelines, including early administration of antibiotics.
There must be training for healthcare providers to quickly recognize and treat sepsis in adults and children.
There must be reporting of sepsis-related data to the New York State Department of Health. The data is used to develop and evaluate risk-adjusted mortality rates.
The number of lives saved by Rory's Regulations was estimated by comparing the observed severe sepsis in-hospital deaths between Jan. 1, 2015, and Dec. 31, 2019, to the expected number of deaths among severe sepsis cases during the same timeframe, Hammond says.
"The expected number of in-hospital deaths was calculated by projecting the unadjusted severe sepsis in-hospital mortality rate observed in 2014 to all subsequent years' cases and the number of observed deaths was then subtracted from this figure to determine the estimate of lives saved. The analysis of adults and children shows an estimated 16,011 New York State lives saved from 2015 to the end of 2019, which is the most current year of validated data available," he says.
The mandatory sepsis protocols must be evidence-based, Hammond says. "Each hospital develops their own protocols based on accepted standards of care and then updates their protocols based on clinical evidence."
Implementing the protocols is an ongoing process, he says. "Hospitals should have internal review processes that use data to monitor their achievements, identify areas for improvement, and modify their protocols and procedures as needed to ensure performance targets are met."
A new study examines trends in physician practice consolidation and physician employment.
The coronavirus pandemic has accelerated trends in physician practice consolidation and increased the number of employed physicians at health systems, hospitals, and corporate entities, a new study found.
The purchase of independent physician practices by health systems, hospitals, and corporate entities has been going on for several years, as have the increasing number of employed physicians at health systems, hospitals, and corporate entities.
The new study was commissioned by the Physicians Advocacy Institute and conducted by Avalere Health. The Physicians Advocacy Institute is a non-profit organization that supports physician practices through advocacy, research, and educational tools for physicians. The primary source of data for the report was the IQVIA OneKey database.
In the report, corporate entities include health insurers, private equity firms, and umbrella corporate entities that own multiple physician practices. Physician practices are considered independent if they do not have a corporate parent.
The pandemic has had a profound impact on physician practice ownership and physician employment, Kelly Kenney, JD, CEO of the Physicians Advocacy Institute (PAI) said in a prepared statement. "COVID-19 drove physicians to leave private practice for employment at an even more rapid pace than we've seen in recent years, and these trends continued to accelerate in 2021. This study underscores the fact that physicians across the nation are facing severe burnout and strain. The pressures of the pandemic forced many independent physicians to make difficult decisions to sell their practices to hospitals, health insurers, or other corporate entities."
The consolidation trends raise concerns about the patient-physician relationship and the clinical autonomy of physicians, she said. "Regardless of practice ownership, it is important to preserve the patient-physician relationship and maintain physicians' clinical autonomy. PAI supports policies that promote these principles and allow physician-owned practices to compete with corporate and hospital-owned entities."
The study covers a three-year period from January 2019 to January 2022. The research features several key findings.
The number of physicians employed by hospitals or corporate entities rose steadily from 2019 to 2021, from 375,400 in January 2019 to 484,100 in January 2022. There was an 8.8% increase in the growth rate of physicians employed by hospitals or corporate entities during the pandemic, including rising from 404,100 in July 2020 to 484,100 in January 2022.
There was a sharp increase in the number of physicians employed by hospitals and health systems after the start of the pandemic, rising from 290,200 in July 2020 to 341,200 in January 2022.
There was a sharp increase in the number of physicians employed by corporate entities after the start of the pandemic, rising from 110,900 in July 2020 to 142,900 in January 2022.
The percentage of physicians employed by hospitals, health systems, and corporate entities rose significantly during the three-year study period, from 62.2% in January 2019 to 73.9% in January 2022. In other words, nearly 3 of 4 physicians are now employed by hospitals, health systems, and corporate entities.
There was a steady increase in the percentage of physicians employed by hospitals and health systems during the three-year study period, from 46.9% in January 2019 to 52.2% in January 2022.
There was a sharp increase in the percentage of physicians employed by corporate entities during the three-year study period, from 15.3% in January 2019 to 21.8% in January 2022.
There was a sharp increase in the number of physician practices owned by hospitals, health systems, or corporate entities, rising from 99,100 in January 2019 to 135,300 in January 2022. This represented a 36% increase. Most of this growth occurred after the start of the pandemic.
The number of hospital-owned physician practices increased 8% over the three-year study period, from 61,900 practices to 66,700 practices. Most of this growth occurred after the start of the pandemic.
The number of physician practices owned by corporate entities increased 84% during the three-year study period, from 37,200 in January 2019 to 68,500 in January 2022. Most of this growth occurred after the start of the pandemic.
By the end of the three-year study period, more than half of physician practices were owned by hospitals, health systems, or corporate entities, rising from 38.8% in January 2019 to 53.6% in January 2022. Most of this growth occurred after the start of the pandemic.
There was a modest but steady increase in the percentage of physician practices owned by hospitals during the three-year study period, from 24.3% in January 2019 to 26.4% in January 2022.
There was an 86% increase in the percentage of corporate entity-owned physician practices during the three-year study period, from 14.6% to 27.2%. Most of this increase occurred after the start of the pandemic.
The federal agency says Saint James School of Medicine lured medical students with deceptive marketing practices.
Citing deceptive marketing practices and violations of credit law, the Federal Trade Commission (FTC) has levied a $1.2 million penalty against a for-profit medical school in the Caribbean that is based in Illinois.
Saint James School of Medicine (SJSM) operates two Caribbean campuses: one in Anguilla and one in St. Vincent. The medical school also does business as Human Resource Development Services Inc. (HRDS), which has headquarters in Park Ridge, Illinois. A complaint filed recently in U.S. District Court names HRDS and Delta Financial Solutions Inc., which is affiliated with HRDS and shares the same headquarters, as "corporate defendants." Kaushik Guha, MBA, executive vice president of operations at HRDS, was also named as a defendant.
The $1.2 million penalty will go toward refunds and debt cancellation for students harmed by deceptive marketing, the FTC reported in a prepared statement.
The complaint features three primary allegations, the FTC prepared statement says:
The defendants misrepresented the pass rate of SJSM students on a key medical exam: "They lured consumers with false guarantees of student success at passing a critical medical school standardized test, the United States Medical Licensing Examination Step 1 Exam. In their sales calls, presentations, and marketing materials, the defendants falsely claimed that the first time USMLE Step 1 pass rate for Saint James students was very high. For example, the defendants distributed a brochure at their open houses that stated: '96.77% FIRST TIME USMLE STEP 1 PASS RATE.' … Since 2017, only 35% of Saint James students who have completed the necessary coursework to take the USMLE Step 1 exam passed the test."
The defendants misrepresented the residency match rate of SJSM students: "The defendants touted Saint James students' residency match rates and advertised the Saint James educational opportunities as 'the same' as American medical schools. For example, their telemarketers were instructed to tell consumers the match rate for Saint James students is 85-95%. … The defendants have also stated on their website that the residency match rate for Saint James students was 83%; in reality, the match rate for Saint James students is lower than touted, and lower than that reported by U.S. medical schools. Since 2018, the defendants' average match rate has been 63%.
The defendants used illegal credit contracts: "The defendants also marketed financing for tuition and living expenses used for attending their classes. The financing contracts contained language attempting to waive consumers' rights under federal law and omit legally mandated disclosures. Specifically, the defendants failed to provide a Holder Rule notice in their credit agreements, which requires that any seller that receives the proceeds of a purchase money loan include, in the underlying credit contract, a specific notice informing the consumer of their right to assert claims against any holder of the credit contract. The defendants also failed to provide a [Credit Practices Rule] disclosure in their credit agreements, which requires creditors to inform cosigners of their liability prior to obligating the cosigner, in a separate document using specific language."
Medical school's response to penalty
HRDS felt compelled to settle the case, Guha said in a prepared statement.
"We have chosen to settle with the FTC over its allegations that disclosures on our website and in Delta's loan agreements were insufficient. While we strongly disagree with the FTC's approach to this matter, we did not want a lengthy legal process to distract from our mission of providing a quality medical education at an affordable cost. However, we have added additional language and clarifications any time the USMLE pass rate and placement rates are mentioned. We are committed to being an industry leader for transparency and accountability and hope that our efforts will lead to lasting change throughout the for-profit education industry," he said.
Guha said SJSM provides value to students, many of whom who otherwise could not afford a medical education.
"Saint James School of Medicine will continue to provide a high-quality medical education at a tremendous value, opening the door to a medical career to students who would otherwise find it impossible to become a doctor. Over 600 of our alumni are serving as licensed physicians in communities across the United States and Canada. Many are working to bridge the health equity gap in underserved areas in North America," he said.
Tuition at SJSM is relatively affordable, according to the FTC complaint. "Defendants charge consumers tuition ranging from about $6,650 to $9,859 per trimester (depending on campus and course study). Between 2016 and 2020, Defendants have had approximately 1,300 students enrolled in their schools each year."
Saint James has an ethnically diverse student population, which includes many U.S. citizens, the FTC complaint says. "Defendants market enrollment at their Caribbean medical schools primarily to consumers from the United States; they state that 68.64% of the student body are American citizens. SJSM brochures provide a demographic breakdown of the student body and state that 60% of SJSM students are African American, Asian, or Hispanic or Latino."
Research has shown that mental health conditions can have significant negative effects on physical health. For health systems and hospitals, the provision of mental health services can reduce healthcare costs such as lowering emergency department utilization.
UnityPoint Health is affiliated with seven mental health centers, says Aaron Mchone, MBA, director of behavioral health for the West Des Moines, Iowa-based health system.
"As of 2008, we had two affiliated mental health centers. Then the Affordable Care Act came, and the idea of value-based care got UnityPoint Health excited for a number of reasons. One of the things we saw was that to be successful in value-based care we needed to have partners on the community mental health center side, particularly for some of our vulnerable populations. From 2015 to 2019, we added five more community mental health centers to our service array, and most of our geographies had a community mental health center component," he says.
Five of the mental health centers are CCBHCs under a program administered by the federal Substance Abuse and Mental Health Services Administration (SAMHSA). UnityPoint Health embraced the CCBHC model mainly to limit variation in the services provided by the affiliated mental health centers, Mchone says.
"One of the challenges we faced during the major expansion period is that community mental health centers are usually unique. They provide different services and have different structures. So, it was hard for us as a health system to figure out how to work with seven different mental health centers to provide a systematic approach to [care] for our patients. That is when we became interested in the program that SAMHSA was piloting. They recognized the variability problem as well," he says.
CCBHCs are required to offer nine core services, according to SAMHSA:
1. Crisis services such as mobile crisis response by behavioral health emergency medical technicians who assess suicidality in the homes of patients
2. Treatment planning
3. Screening, assessment, diagnosis, and risk assessment
4. Outpatient mental health and substance use services
5. Targeted case management
6. Outpatient primary care screening and monitoring
7. Community-based mental healthcare for veterans
8. Peer, family support, and counselor services
9. Psychiatric rehabilitation services
At UnityPoint Health, participating in the CCBHC program has assured that the health system has the same services in all of its regions for behavioral health patients, Mchone says. "Today, five of our affiliated mental health centers are also CCBHCs. The other two have not been certified yet—they are still developing. We hope to certify our sixth CCBHC by the end of the year. Having CCBHCs has helped us coordinate care and to make sure that as patients come out of the hospitals that they are able to get the services that they need."
How CCHBCs are financed
In eight states, SAMHSA has established a prospective payment system model for CCHBCs similar to the payment model used at Federally Qualified Health Centers, Mchone says. "Under the PPS model, you typically get higher reimbursement per encounter, and you are not chasing fee-for-service payments, so you can deliver services based on what the patient needs without hopping through hoops to make sure you can cover your expenses."
The PPS model has not been introduced in any of the states that UnityPoint Health serves (Illinois, Iowa, and Wisconsin), so the health system's CCBHCs receive funding through three sources.
The first is fee-for-service reimbursement for commercial insurance, Medicare, and Medicaid patients.
The second is value-based payments. All five of UnityPoint Health's CCBHCs belong to accountable care organizations. "When we are successful in keeping our patients healthy and keeping our claims down, there are shared savings payments that come in that are distributed back to our CCBHCs," he says.
The third is grants. "These include federal government grants—SAMHSA grants each of our CCBHCs $2 million a year in a direct grant. We also utilize many other types of grants that oftentimes funnel through the states to our CCBHCs. Right now, we have 88 different grant projects for our CCBHCs that total about $29 million, which accounts for about 30% of all revenue for the clinics. We are thankful for the grants, but they are an administrative nightmare," Mchone says.
Reducing hospital readmissions and emergency room utilization
At UnityPoint Health, the CCBHCs have decreased hospital readmissions.
"We are having CCBHC staff go to the hospital, so that the patient can meet the CCBHC staff and make a connection before hospital discharge. Then we are ensuring that we have seven-day follow-ups to make sure that the patient has an appointment at the CCBHC. So far, and we are only a few months into this readmissions project, we have seen our psychiatric unit readmission rate drop 1.5%. The key to success is the connection point prior to hospital discharge, as opposed to having a phone number and date on the patient's discharge plan. We are making a physical, face-to-face connection with the next level of care before hospital discharge," he says.
There are two primary ways UnityPoint Health's CCBHCs have reduced emergency room utilization, Mchone says. The first is mobile crisis response.
"We have established a hotline phone number for patients to call; then based on how the call goes, we can dispatch mobile crisis response including two behavioral health EMTs who go out to the patient, assess the patient, and work with the patient to come up with a plan of care, which may [include] bringing the patient to the hospital. Alternatively, the EMTs can help establish a plan of care with resources that does not involve a visit to the ER," he says.
The second way CCBHCs have reduced emergency room utilization is through managing behavioral health urgent care centers, Mchone says. "We have established behavioral health urgent care centers across a large swath of our organization that are generally managed by the CCBHCs. In that model, the behavioral health urgent care centers can accept walk-ins, which has been powerful because most patients would rather walk into a CCBHC to be evaluated than walk into the ER and deal with the trauma that can occur at an ER."
The CCBHCs are driving value at the mental health clinics, he says. "With the care continuum, we see that untreated behavioral health conditions lead to poor quality results for our patients and higher expense. By being proactive with all of the CCBHC services, we have been able to reduce our emergency department encounters and reduce our number of hospital admissions, which has led to greater quality and greater value for our patients and our third-party payer partners."
The president of the physician group says the new law is "unacceptable" interference in the patient-physician relationship.
The American College of Physicians is raising alarm over a new Alabama law that criminalizes the provision of gender-affirming healthcare to minors.
Alabama Gov. Kay Ivey recently signed a new law making it a felony for healthcare professionals to provide medical care including hormone treatment, puberty blockers, and gender reassignment surgery to minors. Violators of the law face as many as 10 years in prison.
The new law is a misguided intrusion in the patient-physician relationship, George Abraham, MD, MPH, president of the American College of Physicians said in a prepared statement.
"The American College of Physicians (ACP) strongly objects to laws and policies that interfere in the patient-physician relationship and prevent physicians from providing their patients with evidence-based medical services. This includes the legislation passed by the Alabama legislature, which would criminalize providing gender-affirming care to minors. Physicians should not be subject to threat for ensuring that their patients receive care that is in accordance with the recommendations of ACP and other medical organizations. Transgender individuals already face extreme barriers to accessing necessary healthcare, and this type of interference in the patient-physician relationship is unacceptable," he said.
Physicians should ensure that they have an effective relationship with LGBTQ patients, Abraham told HealthLeaders. "Physicians need to respect patients' choices even if they conflict with our own, treating them with respect, and being non-judgmental when addressing their needs."
The Alabama law is the latest in a string of attempted government intrusions in the patient-physician relationship, Abraham said. "Recent laws in Texas, Idaho, and Oklahoma as well as the recent challenges by multiple states to Roe vs. Wade are all examples of either legislatures or the courts inserting themselves in the exam room and interfering with a physicians' ability to offer the care that is in the best interest of their patient; additionally, they are a failure to recognize that the physician is best equipped to determine what their patient needs, in conversation with their patient."
It is important to protect the patient-physician relationship and allow physicians to provide their patients with evidence-based medical services, he said. "Physicians have the requisite training, education, and experience to address the healthcare needs of their patients, since that is their specialty and why they exist in that role and why patients turn to physicians for guidance. If that sacred relationship is now hampered and limited by legalities that interfere with the physicians' ability to offer the best care that their patients are eligible for, based on evidence-based medicine, then it limits patients' opportunity to get the best care they are entitled to, purely based on legalities and not based on medical scientific principles."
Trust is a primary element of an effective patient-physician relationship, Abraham said. "Patient trust in their physician and the physician's ability to spend the time needed to coordinate care, educate, and counsel as well as address all the elements of the often complex needs of their patient."
Nearly three-quarters of those surveyed reported that healthcare professionals never had brought up end-of-life planning.
End-of-life conversations needs to be a routine part of care for adults, a hospice expert says.
Advance care planning and documentation provides guidance about end-of-life decisions. Advance care planning helps to make sure that a patient's wishes on issues such a resuscitation are known by care teams and families before an end-of-life situation.
A new survey polled Americans about crucial advance care planning topics. The survey, which was commissioned by hospice provider VITAS Healthcare, polled 1,000 Americans in March 2022. The polling sample reflects the U.S. population based on gender, age, race and ethnicity, region, and education.
The survey generated several key findings:
Most (71.4%) survey respondents reported that healthcare professionals never had brought up end-of-life planning and a majority (54.9%) reported that no one had brought it up.
More people reported that they have documented their wishes this year (35.4% in 2022 versus 32% in the 2021 VITAS Healthcare survey). However, that is far less than those who say it's important or very important (68%) and those who have discussed their wishes (55.5%).
The top three reasons for not conducting advance care planning were not being sick or dying (34.7%), it is depressing to face (26.3%), and feeling not old enough to face these topics (21.9%).
The top four reasons for conducting advance care planning were desire to not burden family members with making decisions (56.4%), it was done for financial or estate planning (47.5%), experience of having a loved one who died with their wishes documented (23.1%), and experience of having a loved one who died without their wishes documented (19.4%).
Asian and Hispanic survey respondents were more likely to credit conducting advance care planning to clinicians raising the topic: Asian (24.2%), Hispanic (24.0%), White (11.8%), and Black (7.6%).
Most survey respondents said they were comfortable having end-of-life planning with family members: partner or spouse (52.6%), children (32.4%), primary care physician (27.1%).
Most survey respondents were comfortable having end-of-life planning discussions at home: home (60.1%); legal, financial, or other formal non-medical setting (26.0%), primary care clinic (24.6%).
Encouraging patients to conduct advance care planning
"Patients are ready for these conversations," says Joseph Shega, MD, executive vice president and chief medical officer of VITAS Healthcare.
For clinicians, holding end-of-life discussions is a long-term effort, he says. "I encourage healthcare professionals to initiate advance care planning conversations by simply bringing it up with their patients. It's important to note, however, that advance care planning is not a one-time task—it should be treated as an ongoing conversation that a patient has with their physician, family and loved ones. As healthcare professionals, it's our responsibility to help encourage these conversations by normalizing them and making the conversations a routine part of care."
Physicians have an important role to play and need to get more involved, Shega says. "Americans reported they would be comfortable having these conversations with their doctor—and many times are looking for their doctor to raise the issue. But many times, these conversations are not happening. In fact, 71% of respondents said that a physician has never broached the subject of advance care planning with them. That tells us there is a gap."
VITAS Healthcare recommends that physicians keep the SPIKES method in mind when having advance care planning conversations with patients, he says.
Setting: Choose a private setting where you can sit face-to-face with the patient and a family member or confidant. If the patient does not speak English, rely on a professional interpreter rather than a family member.
Perception: Ask the patient how much they know, perceive, or suspect before you begin the conversation.
Invitation: Subtly invite the patient to provide clues about willingness to receive more information. Ask whether they would like to talk about issues such as test outcomes and treatments. If the patient does not respond favorably, suggest that you talk again later that day or the next. Then follow through.
Knowledge: Share information directly and simply. After you have opened the conversation, stop talking. Listen to the patient's responses and take note of their emotions.
Empathy: Identify with the patient's emotional reaction in a kind way that suggests you understand and appreciate their response and are concerned about their future.
Summation: Summarize the conversation and recommend hospice care.
"No matter what, every end-of-life conversation must be rooted in respect, compassion, and empathy. Healthcare professionals must take the time to understand the whole patient and consider how their age, race, ethnicity, religion, and relationships shape their views and values," Shega says.
Why advance care planning matters
Advance care planning benefits patients, he says. "By knowing a patient's wishes and values, healthcare professionals and families can ensure that the kind of care that person receives at end of life aligns with their goals, preferences, and spiritual beliefs."
The absence of end-of-life planning is problematic for patients and their care teams, Shega says. "One of the most difficult situations is when the families we serve don't know their loved one's wishes or values. The VITAS survey found that almost a quarter of people (24.3%) had either a loved one who was seriously ill or one who had passed away without knowing their wishes or values for end-of-life care. VITAS believes it is vitally important that patients make their wishes known so that they can be honored, while also relieving the burden of decision-making on loved ones."
A study makes estimates with and without COVID-19 vaccination in the United States for deaths, hospitalizations, infections, and healthcare costs.
The COVID-19 vaccination effort in the United States has averted millions of deaths and hospitalizations, according to a new study by The Commonwealth Fund and Yale University.
COVID-19 vaccination has been shown to reduce hospitalization and death rates. Compared to vaccinated Americans, unvaccinated Americans have higher rates of hospitalization and death.
The new study is based on a model that accounted for the characteristics of four coronavirus variants—Alpha, Delta, Iota, and Omicron. The model's parameters included U.S. population demographics, pandemic mobility patterns, and age-specific risks of serious health outcomes linked to COVID-19.
In addition to estimating hospitalizations and deaths with and without vaccination, estimated the number of infections and direct healthcare costs associated with COVID-19 with and without vaccination. The cost calculation accounted for expenses related to outpatient visits, hospitalizations, intensive care, emergency medical services calls, and emergency department visits.
The study features four key data points for the period from Dec. 12, 2020, to March 31, 2022:
Deaths averted: 2,265,222
Hospitalizations averted: 17,003,960
Infections averted: 66,159,093
Healthcare costs averted: $899.4 billion
The study builds on data generated from an earlier study conducted by The Commonwealth Fund and Yale University that was published in December, the study co-authors wrote in a blog post. "Our findings highlight the profound and ongoing impact of the vaccination program in reducing infections, hospitalizations, and deaths. As we noted in our December analysis, vaccines spared the U.S. healthcare system an overwhelming number of COVID-19 hospitalizations. The current analysis confirms and extends the earlier results. Investing in vaccination programs also has produced substantial cost savings—approximately the size of one-fifth of annual national health expenditures—by dramatically reducing the amount spent on COVID-19 hospitalizations."
Congress should continue to support vaccination and booster shot efforts, the co-authors wrote. "The success of the vaccination program in preventing deaths and hospitalizations is obscured somewhat by the nearly 1 million COVID-19 deaths that have occurred since the start of the pandemic. As Congress considers the costs and benefits of extending COVID-19 vaccination, our results show that continuing to vaccinate and boost Americans can produce substantial health benefits and financial returns to the country."
Now is not the time to pull back on vaccination, the co-authors wrote. "Redoubling efforts to increase vaccine uptake, especially among the elderly and other vulnerable groups, will be critical to avert outbreaks as pandemic restrictions are lifted. With continued spread of the [Omicron] BA.2 subvariant, our findings point to the tremendous power of vaccination to reduce disease burden from COVID-19. This may be even more important if newer variants arise or population immunity ebbs."
Teresa Malcolm says the "belonging" part of her job title attracted her most to the new position.
Healthcare organizations need to appreciate the benefits that are associated with diversity, the new vice president of diversity, equity, inclusion, and belonging at Dartmouth Health says.
Teresa Malcolm, MD, MBA, began her work in the new role at the Lebanon, New Hampshire-based health system on April 4.
Malcolm, who is a board-certified obstetrician/gynecologist, has more than a decade of experience cultivating inclusion in healthcare settings.
Prior to joining Dartmouth Health, Malcolm served as CEO of the coaching firm Master Physician Leaders. Her physician executive experience includes serving as a chief medical officer at Banner Health in Arizona, where she played a clinical leadership role at a tertiary care center offering inpatient, emergent, and same-day services provided by more than 1,000 specialty physicians.
HealthLeaders recently talked with Malcolm about a range of topics including: her new role; the primary diversity, equity, and inclusion considerations for a healthcare organization's workforce; and the main elements of a culture of inclusion.
The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: How does the "belonging" element of your title fit into your role?
Teresa Malcolm: It was one of the words in the title that attracted me most to this position because belonging is the piece about how individuals feel when they are part of an organization. They feel a sense of connectedness. They feel a sense of attachment. Belonging digs into how you feel emotionally connected, to be able to say, "I belong here. I belong to this workplace." That was appealing and attractive to me because it is much more than having diverse individuals with different ethnic or racial backgrounds, or different clinical backgrounds, or just different skills.
Part of my role is helping us to explore how each of us as individuals can say, "I feel part of this. I feel I belong here." A lot of times, when people leave an organization, part of what they will say is, "I didn't feel that I belonged there." We are hoping people will feel they belong when they are part of the Dartmouth health system, whether they are a patient, an employee, a leader, or member of the community. We want them to feel that who they are is respected, honored, and valued.
HL: You are the first vice president of diversity, equity, inclusion, and belonging at Dartmouth-Hitchcock Health. What are your top priorities in this new role?
Malcolm: I want to start with listening. I want to start by understanding what is important to the members of this organization. I want to know what they think works well—what is Dartmouth Health already excelling at in the areas of diversity, equity, inclusion, and belonging? Once we identify what is working well, I want to propel that forward.
On the opposite end, I want to know what is not working. What do we need to let go of? What do we need to abandon because it may have served us well in the past, but it is not serving us well now in terms of the goals that we have for diversity, equity, inclusion, and belonging?
I want to understand what words describe this organization and what words do we want to use to describe us going forward. I want to know where we are at today, then find out where we want to be a year from now. What do we want to be able to say about ourselves one year from now after we have intensified this work?
HL: What are the primary diversity, equity, and inclusion considerations for a healthcare organization's workforce?
Malcolm: It starts with diversity and appreciating what diversity brings to the organization. Diversity makes us a stronger organization. It increases our bottom line. It attracts more individuals to the organization. It improves innovation. It improves creativity. There are many benefits from diversity alone, but it doesn't stop with just diversity.
Diversity must be activated. You must put it into place. It is not enough just to say, "We have diversity metrics, and we are going to meet these metrics." We must be able to move from just diversity metrics to a sense of inclusion. We must move to a place where people are speaking up and saying things that may have not been said before. We need to challenge the status quo. We need to redefine the culture and move beyond where we are right now.
HL: What are the primary elements of a culture of inclusion?
Malcolm: One of the primary elements is psychological safety. There needs to be a sense that you can speak aloud about mistakes and about differences of opinion. You should be able to raise objections without retribution and knowing that you will not be punished. Psychological safety allows for openness of dialogue.
Empathy and compassion are essential. We must understand the positions and perspectives of others that are different from our own. We must extend empathy to others who may not be where we are and may not share our beliefs. We also must extend empathy and compassion to ourselves if we are not where somebody else is. We are all on a journey. We are all on a continuum. We need to give ourselves grace and space as individuals, as departments, and as organizations for wherever we are on that journey and that continuum.
Another element is striving for excellence, which is different than striving to be the best. There is not an endpoint for inclusion. There is not a final destination where we can pat ourselves on the back and say, "Job well done!" There is going to be constant and continuous effort, energy, and intention that we need to put toward inclusion because we are going to be making incremental progress.
HL: What are the keys to success in coaching leaders and care teams to build a culture of inclusion?
Malcolm: People need to know that we all play a role in this work. This is not one person's responsibility or one department's responsibility. We are all responsible for this work and we all need to hold each other accountable.
We are blessed to be able to be in the positions we have and to make the kind of impact that we want to make. We need to make an inclusive culture where people feel they are a part of providing care to others. There are small things that we can do to help benefit inclusion and small things that we can do to impede it. We need to use the energy we have to make positive small changes.
HL: Diversity, equity, and inclusion can be sensitive topics for healthcare organizations. How can healthcare organization leaders be encouraged to tackle diversity, equity, and inclusion challenges?
Malcolm: It is important to remember that unless we talk about these issues, we cannot achieve change. If we cannot talk about creating an inclusive environment, if we cannot talk about racial differences, if we cannot talk about ethnic differences, if we cannot talk about gender differences, if we cannot engage in healthy and crucial conversations about our differences, then how are we going to be able to move forward as an organization?
While these might be sensitive topics, how can we expect that anything will change if we do not address them? If we come into these conversations with a level of humility—recognizing that we do not have all the answers and we are here to learn—and if we can enter these conversations with less of a desire to be right and more of a desire to learn, then we can move the organization forward.
Healthcare organization leaders need to understand that there is no absolute way that they need to engage in this work. They need to come with an open heart and an open mind and be willing to listen and to learn from people who have different perspectives.
A new website provides information on Food is Medicine services across The Bay State.
The Massachusetts Food is Medicine Service Inventory website has been launched to connect individuals, healthcare providers, and community-based organizations to Food is Medicine services in their communities.
The service inventory website was created by Community Servings and the Center for Health Law and Policy Innovation (CHLPI) at Harvard Law School in Boston. "Diet quality is the Number One risk factor for death in the United States," says Katie Garfield, JD, director of whole person care and clinical instructor at CHLPI.
The Massachusetts Food is Medicine Service Inventory has information on the four types of Food is Medicine interventions, which can be conceptualized as a pyramid.
1. Medically tailored meals: At the top of the pyramid are medically tailored meals, which are designed for individuals with the highest healthcare needs who need the most intensive intervention. Medically tailored meals are meals developed by a registered nutritionist to address the dietary needs of an individual's medical condition, and individuals are referred by a healthcare provider or health plan.
2. Medically tailored food packages: The next category of nutrition intervention programs is slightly broader. Medically tailored food packages include a selection of minimally prepared grocery items selected by a registered nutritionist or other qualified nutrition professional as part of a treatment plan for an individual with a medical diagnosis. This is an intervention for someone who can shop and cook for themselves, but they have a specific medical diagnosis and nutrition needs, so they need some assistance in making sure that they are eating foods that benefit their health.
3. Nutritious food referrals: Instead of directly providing food, nutritious food referrals tend to provide funds for nutritious foods that may be redeemed in a variety of retail environments such as farmers markets or grocery stores. The most common example of a nutritious food referral is a produce prescription program, where a healthcare provider can refer a patient to programs that provide a voucher or gift card that is designed for the purchase of fruits and vegetables to address a health condition.
4. Community-level healthy food programs: The broadest category of Food is Medicine interventions is community-level healthy food programs. These programs provide nutritious food for a population that currently has or is at increased risk for chronic disease associated with food insecurity. These programs are done in partnership or consultation with a healthcare stakeholder such as a healthcare payer, provider, or nutrition professional. For example, there could be a mobile market that is providing healthy food at a community health center or another healthcare facility.
How the Massachusetts Food is Medicine Service Inventory works
Three years ago, CHLPI, Community Servings, and a range of other organizations across Massachusetts developed the Food is Medicine State Plan, and the service inventory is a fruit of that labor, Garfield says.
"As part of that effort, we surveyed more than two hundred organizations across Massachusetts and held 11 regional listening sessions across the state. Our goal was to understand what access to Food is Medicine interventions looked like, how that compared to the need, and what we could do to expand access. Through that process, a common theme that we heard was that healthcare providers and other organizations were interested in connecting patients to Food is Medicine interventions, but they did not know where to find them," she says.
A key feature of the Massachusetts Food is Medicine Service Inventory is an interactive map, Garfield says. "The interactive map shows where programs exist across the state. You can click on an icon and see the contact information for programs and see where they are located."
The website also provides a much more detailed searchable list of programs, she says.
"When you do a search, you get a list of programs meeting your criteria and detailed information on what those programs look like. For example, you can filter the list by what age groups the programs are serving, by the type of intervention based on the four types of Food is Medicine interventions, and by county to get a sense of service areas. When you click on a program, you get detailed information, including information on eligibility requirements, service areas, what health conditions the programs can be tailored to address, and the best way to get in contact with the program to see whether you can enroll," Garfield says.
Food is Medicine impact
Food is Medicine has a positive effect on health outcomes, she says. "We are seeing some great research that shows Food is Medicine services, which include medically tailored meals, medically tailored food packages, and produce prescriptions, can make a big impact on improving diet and health. For example, studies have shown that connecting seriously ill patients to programs such as medically tailored meals can result in a huge drop in the need for hospital admissions and emergency department visits."
Food is Medicine also drives down healthcare costs, Garfield says.
"Because food insecurity and diet quality are linked to chronic illness, they are important drivers of healthcare costs. For example, a Massachusetts study found that food insecurity increases healthcare costs in the state by $1.9 billion each year. … A recent study has shown that providing medically tailored meals can result in a 16% net reduction in healthcare costs—that is net, so it includes the cost of the meals. There is research that is forthcoming that is looking at the impact on healthcare costs for other Food is Medicine interventions," she says.