Redlands Community Hospital has been offering inpatient behavioral health services since the mid-1980s.
Citing financial constraints and relatively low utilization rates, Redlands Community Hospital in California is closing its Behavioral Health Inpatient Adult Unit.
Financing is one of the top challenges for hospitals' behavioral health services. Primary strategies to address inadequate reimbursement of behavioral health services are subsidization and seeking grant funding.
Redlands has been offering inpatient behavioral health services since the mid-1980s. The Behavioral Health Inpatient Adult Unit, which features 18 locked adult beds, is set to close on Feb. 1. The closure will affect 27 staff members.
The hospital will continue to offer outpatient behavioral health services, including a partial hospitalization program.
The decision to close the Behavioral Health Inpatient Adult Unit was not taken lightly, James Holmes, Redlands president and CEO, told HealthLeaders. "Our decision to close the unit comes after a comprehensive review, including the assessment of multiple factors such as the cost of uncompensated care and a decline in patient volume."
Redlands is committed to continuing to offer outpatient behavioral health services, he said. "The inpatient and outpatient services have distinct purposes. Once a patient's mental health is stabilized, outpatient services can further assist the patient in their symptom management and treatment goals at a lower level of care with the goal of community integration. Our outpatient care programs help individuals get the services they need, while reducing the likelihood of hospitalization. Across the board, both culturally and medically, outpatient care is often the preferred method of care by patients and their families. We are committed to continuing to provide access to outpatient behavioral health services."
Redlands does not expect the closure of the inpatient unit to have a significant impact on mental health services in the region, Holmes said. "The Redlands Community Hospital inpatient volume has been down. Additionally, the Inland Empire has other behavioral health service providers that have larger capacity and specialize in a broader range of services. Redlands Community Hospital has informed these facilities of its closure to ensure a smooth transition."
Three hospitals in the region have larger inpatient behavioral health programs: Loma Linda Medical Center with 87 beds, Arrowhead Regional Medical Center with 90 beds, and the Community Hospital of San Bernardino with 99 beds.
Finances and related challenges were key factors in the decision to close the inpatient behavioral health unit, Holmes said. "Nationally and locally, hospitals and health systems have experienced financial challenges since the coronavirus pandemic began and Redlands Community Hospital is not immune. Like most industries, we have experienced staffing issues, supply chain disruptions, inflation, and the rising cost of doing business. The cost for uncompensated care is another factor in this challenging equation as we absorb additional costs post-pandemic."
Closing the inpatient behavioral health unit is in the best interest of the hospital and the communities it serves, he said. "Just as we did during the pandemic, by coming together, we are able to innovate and create initiatives that serve the greater good. We need to remain strong so we can keep individuals healthy and be there for our communities that depend on our services."
Redlands employs 1,700 staff members and about 300 physicians work at the hospital. The facility has an annual budget of $350 million.
The federal government buys a wide range of medical supplies, including hospital beds, surgical instruments, defibrillators, bandages, needles, and syringes.
The federal government spent more than $8.2 billion on medical supplies in fiscal year 2021, according to the Health Industry Distributors Association (HIDA).
The federal spending figure is one of the findings in HIDA's first-ever Federal Procurement Market Report. HIDA examined medical products within the North American Industry Classification System codes that showed federal government purchases. Among a wide range of products, these purchases included supplies such as hospital beds, surgical instruments, defibrillators, bandages, needles, and syringes.
Public-private partnerships are important in supply chain operations, Linda Rouse O'Neill, vice president of supply chain policy and executive branch relations at HIDA, told HealthLeaders. "The COVID-19 pandemic proved that the public and private sectors have complementary roles to play in supply chain operations. The private sector has expertise in the manufacture and distribution of medical products across the entire continuum of care. The public sector has greater resources and access to information to respond effectively to a pandemic. Private companies and government agencies must work together to ensure the seamless functioning of the medical supply chain."
HIDA represents the healthcare distribution network, which links global healthcare supply manufacturers and local care providers. HIDA members operate more than 500 distribution centers that bring critical products, supplies, and services to more than 560,000 healthcare settings across the country including hospitals and physician practices.
HIDA's Federal Procurement Market Report includes several key findings:
Compared to fiscal year 2020, federal government medical supply purchases decreased 38% in fiscal year 2021, but spending was well above pre-pandemic levels.
Nearly all of the federal government medical supply purchases (98%) were made by four departments: Department of Defense, Department of Health and Human Services, Department of Homeland Security, and Department of Veterans Affairs.
In fiscal year 2021, $2.4 billion in federal contracts for medical supplies were awarded to small businesses.
In fiscal year 2021, $1.35 billion in federal government medical supply contracts were awarded to diverse small businesses.
Interpreting the data
Regarding the drop in federal government medical supply purchases from fiscal year 2020 to fiscal year 2021, federal purchases related to the pandemic have followed a boom and bust cycle tied to public health priorities, a HIDA spokesperson told HealthLeaders. "The Administration for Strategic Preparedness and Response, which manages the Strategic National Stockpile, went from approximately $4.5 billion in purchases in FY 2020 to approximately $842 million in FY 2021. This accounts for approximately $3.7 billion of the approximately $4.9 billion federal government purchasing difference between FY 2020 and FY 2021."
The agency concentration of federal government medical supply purchases is not surprising, the spokesperson said. "With a total spend of $8.2 billion in contracts to healthcare distributors and manufacturers in 2021, the federal government is a major purchaser of medical supplies. It makes sense for the overwhelming majority of federal purchases in the medical supply chain to be made by agencies tasked with preparedness (Department of Homeland Security), agencies with significant patient needs (Department of Defense and Department of Veterans Affairs), or both (Department of Health and Human Services)."
Federal incentives for small businesses provide opportunities for many small and independent distributors and manufacturers in the medical supply chain, the spokesperson said. "Such support for all businesses—from national to local—diversifies the source of medical supplies, building resilience and capacity in the event of future surges in demand."
The level of federal purchases from diverse small businesses is substantial, the spokesperson said. "This reflects a significant federal strategic commitment to provide equitable access to purchasing and contracting opportunities for diverse businesses. Supplier diversity is an important goal for both the public and the private sectors. It promotes innovation, identifies new sources of talent, and rewards experience."
Mass General Brigham strives to not only be the best in the Boston market but also exceptional in the national and international markets.
The biggest clinical challenge at Mass General Brigham is coping with patient volumes in the inpatient and emergency department settings, says Chief Medical Officer Thomas Sequist, MD, MPH.
Sequist was announced as the health system's CMO in February 2022. He has been with the health system since 1999, when he started his residency at Brigham and Women's Hospital. He still practices as a primary care physician at the hospital, and before taking on the CMO role, Sequist served as chief patient experience and equity officer at Mass General Brigham.
Sequist recently talked with HealthLeaders about a range of issues, including the top clinical challenges at the health system, predictions for clinical care in 2023, and equity challenges at the health system. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as CMO of Mass General Brigham?
Thomas Sequist: The challenges of being CMO at Mass General Brigham reflect the broader challenges that we are experiencing across the health system. We have significant capacity challenges—the volume of patients who need care is substantial, and we are continuing to deal with the ebbs and flows of the COVID pandemic and the strain that creates.
HL: Tell me more about your capacity constraints.
Sequist: It is having enough beds in the hospitals for the patients who need to be hospitalized and having enough room in the emergency departments to take care of patients without long waits.
One of the drivers of the capacity challenges we are facing is the coronavirus pandemic—we are treating and managing those patients, whether it is in the emergency departments or the hospital setting, which creates a challenge in the inpatient setting.
Another capacity challenge is the process of admitting patients, caring for them, and discharging them in a timely way. When we are not able to manage the length of stay, we end up with not enough beds freed up for our new patients who need care.
Thomas Sequist, MD, MPH, chief medical officer of Mass General Brigham. Photo courtesy of Mass General Brigham.
HL: Mass General Brigham is in a competitive healthcare market. What are the clinical challenges of working in such a market?
Sequist: At Mass General Brigham, we are always striving to be the best—to be the top performer not just in the local market but also the national and international market. We consider ourselves to be world leaders, not just leaders in the Boston area. With that context, we are trying to lead in many important areas such as research and innovation as factors to drive our patient care. Another area is caring for the patients who are sickest and most complex. We are always developing new care programs at our academic medical centers to care for the patients with the most complicated care concerns.
Then I would move to a different area, which is how do we provide care for the larger population that has less-complex care needs but significant care needs. That is where we engage our entire integrated delivery system from the academic medical centers to the community hospitals and the ambulatory settings to provide comprehensive care. Across the country, that is a challenge as we move to more and more integrated delivery systems. How do you design those systems such that you can meet the most-complex care needs and at the same time deliver on population-based needs such as primary care?
HL: Do you have any predictions for clinical care in 2023?
Sequist: The biggest thing that is going to happen for the healthcare system in 2023 is learning how to meet the needs of all our patients—from the most complex to the most generic—while doing that in the context of what we have learned from the pandemic. We need to avoid having a foot in two canoes, where we are managing COVID patients separately from managing the rest of our patients. We will be learning how to treat both sets of patients in a more integrated fashion.
HL: You previously served as the patient experience officer for Mass General Brigham. What are the keys to success in patient experience?
Sequist: Patient experience and equity are linked to each other and hard to pull apart. We must acknowledge that we have to meet the patient where they are; and in order to that, we have to truly understand who our patients are, and we have to be engaged not only in delivering their care clinically but also understanding who they are as a person. This is how you develop a successful patient experience strategy. Then equity comes into play. What that ultimately will mean is that we need to avoid saying that our gold standard is treating everybody the same. Our gold standard must be assuring the same outcomes for everybody, which is often going to mean treating people differently based on what they need.
HL: What are the primary equity challenges at your organization?
Sequist: Our equity challenges are much like those at other health systems. I frame it in two ways. One, we continue to have a primary strategy of being united against racism. That is a monumental challenge, and it is not a problem that we will solve over the next year or several years. This is a problem that has a long history, and it is going to take us a long time to make progress.
Secondly, another core challenge that we have is that many of the equity concerns outside of the healthcare system relate to social risk factors that our patients have. They relate to factors such as housing stability, food insecurity, and economic stability, which are the strongest predictors of health outcomes. As a health system, we must figure out how we fit into the patchwork of the public health system as well as the broader society in terms of social risk factors contributing to health.
HL: How do you rise to that second challenge?
Sequist: We rise to that challenge by ensuring that equity is one of our core strategies and one of our core priorities. That is something that we have committed to across Mass General Brigham, and it allows everyone to focus on equity and anti-racism throughout our organization. It also allows us to weave and embed those concepts into everything that we are doing across our organization. So, we have a foundation that everyone understands—one of our core priorities is equity across every facet of what we do. Then we layer on top of that a core set of focused priorities within the space of equity and anti-racism.
HL: Give me an example of that core set of priorities.
Sequist: In the ambulatory setting, one of those focused priorities is hypertension control. We have had a data-driven approach to figure out the areas we are going to focus on, and when you look at the data, a primary source of excess mortality and morbidity among Black and Hispanic patients in the Boston area is cardiovascular disease. One of the leading risk factors for cardiovascular disease is poorly controlled hypertension. We know that among Black and Hispanic patients the rates of achieving good control of blood pressure are lower in those populations compared to White populations.
We have developed many work streams across our delivery system all with the focus on enabling better blood pressure control. We are developing electronic tools that are multilingual for our patients with hypertension, ensuring that they have home-based tools to manage their hypertension such as electronic blood pressure cuffs, creating a workforce of digital navigators who help our patients understand Internet-based tools for managing their blood pressure, and creating a workforce of community health workers who can help our patients deal with access to care and other social risk factors such as food insecurity.
We are setting specific blood pressure goals and creating an accountability infrastructure within our leadership team and among our clinicians to achieve those goals.
Researchers gauged PTSD and subthreshold PTSD levels among emergency department and emergency medical service workers.
In a recently published studyconducted during the coronavirus pandemic, 5.5% of healthcare workers met criteria for probable posttraumatic stress disorder (PTSD) and 55.3% experienced subthreshold PTSD symptoms (PTSS).
The pandemic has been associated with higher levels of burnout among healthcare workers. The pandemic has increased the risk of healthcare workers developing PTSD.
The recent study, which was published in the Journal of Psychiatric Research, is based on survey data collected from 852 healthcare workers from January 2021 to February 2021. The survey participants were recruited from emergency departments affiliated with the University of Pittsburgh Medical Center and emergency medical service agencies in several states, including Maryland, New Hampshire, New York, Ohio, Virginia, and West Virginia.
The study features several key findings:
Nursing and patient support services workers were less likely to be in the no symptoms group and more likely to be in the subthreshold PTSS group compared to ambulance and transport services workers.
Physicians and mid-level providers reported fewer physical health symptoms than any other job category.
Nursing and patient support services workers reported more sleep problems than all other job categories.
Survey participants who fell into the subthreshold PTSS group and the probable PTSD group were more likely to report health impairment than survey participants who fell into the no PTSS group.
The adjusted likelihood of having physical symptoms was 1.87 times more likely in the subthreshold PTSS group and 3.38 times more likely in the probable PTSD group than the no PTSS group.
The adjusted likelihood of having sleep problems was 1.36 times more likely in the subthreshold PTSS group and 1.96 times more likely in the probable PTSD group than the no PTSS group.
The three most common health impacts reported by members of the probable PTSD group were relatively common in the subthreshold PTSS group: 93.6% of PTSD group reported sleep problems and 69.4% of the PTSS group reported sleep problems, 74.5% of the PTSD group reported constant fatigue and 37.1% of the PTSS group reported constant fatigue, and 72.3% of the PTSD group reported weight change and 46.3% of the PTSS group reported weight change.
"The present investigation demonstrates the prevalence and significance of subthreshold PTSS in [healthcare workers] responding to the COVID-19 pandemic. Furthermore, it demonstrates that to promote [healthcare workers'] mental health, subthreshold PTSS must be accounted for and incorporated into the intervention approaches employed in this population," the study's co-authors wrote.
Healthcare workers who experience subthreshold PTSD symptoms are afflicted with significant health conditions, Bryce Hruska, PhD, assistant professor of public health in the Falk College at Syracuse University, said in a prepared statement. "Even though they weren't reporting symptoms indicative of a clinical diagnosis of PTSD, these workers were still feeling its effects."
As the pandemic ebbs and flows, healthcare workers remain at elevated risk of PTSD and PTSS, he said. "While the world tries to move on from the pandemic, our healthcare workers continue to face a significant mental health risk with every surge in cases, as is happening now."
The Centers for Medicare & Medicaid Services do not reimburse fall-related costs, so falls represent a significant cost burden for hospitals.
In a newstudy at two health systems, the average total cost of an inpatient fall was $62,521 ($35,365 in direct costs).
In hospitals, falls are the largest category of preventable adverse events, according to earlier research. Many hospital falls can be prevented through use of evidence-based programs. Falls represent a significant cost for hospitals because the Centers for Medicare & Medicaid Services discontinued fall-related cost reimbursement in 2008.
The new study, which was published by JAMA Health Forum, examined data from more than 900,000 patients, with 7,858 noninjurious falls and 2,317 injurious falls.
In addition to determining the average total cost of falls, the researchers assessed the cost effectiveness of the evidence-based Fall TIPS (Tailoring Interventions for Patient Safety) Program. The Fall TIPS Program features a three-step fall prevention process: conducting a fall risk assessment, developing a personalized fall prevention plan, and implementing tailored interventions coupled with universal fall precautions. In the new study, the Fall TIPS Program was used in 33 medical and surgical units at eight hospitals.
The new study includes four key data points:
Before the Fall TIPS Program was implemented, there were 2,503 falls and 900 injuries. After the Fall TIPS Program was implemented from June 2013 to August 2019, there were 2,078 falls and 758 injuries.
The average total cost of an inpatient fall was $62,521 ($35,365 in direct costs).
The implementation of the Fall TIPS Program resulted in $14,600 in net avoided costs per 1,000 patient days, with a total cost savings over the study period of $22 million.
The researchers estimated that the Fall TIPS Program could generate annual cost savings of $1.82 billion if implemented on a national scale, with intervention costs of $20 million.
"The findings of this study indicate that implementation of cost-effective, evidence-based safety programs was associated with lower cost and care burdens associated with inpatient falls and are a step toward safer, more affordable patient care," the study's co-authors wrote.
Interpreting the data
One of the key findings of the study was that the costs of falls with or without injury were not significantly different, the study's co-authors wrote. "This finding suggests that even in the absence of obvious injury, post-fall evaluation and testing are extensive, and [length of stay] is prolonged. Therefore, programs that prevent all falls provide the greatest cost-savings opportunities."
Injurious hospital falls result in a range of harm, the co-authors wrote. "Most major fall injuries…range in severity from those that cause temporary functional impairment (i.e., dislocated shoulder or broken teeth) to injuries associated with increased mortality (i.e., skull fractures and subdural hematomas)."
The study can guide decisions to implement evidence-based fall prevention programs at other healthcare organizations, the co-authors wrote. "This study analyzed the costs and benefits of preventing falls using the Fall TIPS Program from the healthcare system perspective. Findings can be used to assist other organizations in evaluating the decision to invest in implementing an evidence-based fall prevention program."
The results of the study show that the Fall TIPS Program is cost-effective, they wrote. "Resources to improve patient safety are limited, and the benefits associated with the Fall TIPS Program far outweigh the associated costs."
The safety and quality organization focuses on disparities and mental health conditions related to pregnancy.
The Joint Commission (TJC) has released two advisories aimed at addressing maternal mortality and morbidity.
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. According to a Centers for Disease Control and Prevention (CDC) report, the U.S. maternal mortality rate rose from 20.1 deaths per 100,000 live births in 2019 to 23.8 in 2020. The CDC report highlighted a racial disparity, with the maternal mortality rate for Black women at 55.3 deaths per 100,000 live births, which was nearly three times higher than the rate for White women.
This week, TJC released a Sentinel Event Alert and Quick Safety advisory on maternal mortality and morbidity. "We must address the maternal health crisis immediately, especially as the COVID-19 pandemic exacerbated racial disparities in pregnancy-related outcomes," Ana Pujols McKee, MD, executive vice president, chief medical officer, and chief diversity, equity and inclusion officer of TJC, said in a prepared statement.
Sentinel Event Alert: Eliminating disparities for pregnant patients
The Sentinel Event Alert focuses on disparities and how social determinants of health (SDOH) affect pregnancy-related mortality and morbidity. The SDOH impacting pregnancy include housing, food insecurity, lack of access to healthcare, insurance, transportation, low income, and racism. "The stress associated with living with these conditions contributes to pregnancy-related mortality and morbidity," the Sentinel Event Alert says.
The Sentinel Event Alert suggests six actions that healthcare providers can take.
1. Promote prenatal care access. Boosting access to prenatal care is especially important in rural communities and communities that have provider shortages and health disparities.
2. Screening patients during prenatal care. Providers should screen pregnant women for hypertension, hemorrhage risk, and socioeconomic risk factors. One key resource is TJC's Health-Related Social Needs Screening Question Bank.
3. Provide support and options that address the expectations of patients. Options should include home birth and birthing centers, while managing pregnancy complication risks. Pregnant women and their clinicians should share decision-making. Provide education and training for the interdisciplinary care team to reduce low-risk C-sections and promote vaginal birth.
4. Prepare for hemorrhage and other medical complications. Hemorrhage is a leading cause of maternal mortality and morbidity. Quick action is essential because every second of delay increases blood loss and the risk of death.
5. Implement performance standards and improvement initiatives. For example, there should be regular huddles and post-event debriefings to assess outcomes and identify opportunities for process improvement.
6. Provide universal training to address unconscious biases of healthcare providers toward people of color. Providers should educate staff about healthcare disparities and health equity issues related to pregnancy. Providers should promote inclusiveness, interdependence, acknowledgment, and respect for racial and ethnic differences.
Quick Safety: Mental health conditions leading cause of maternal mortality
A CDC report found that mental health conditions are the top cause of pregnancy-related deaths. The report found that mental health conditions were the underlying cause of death in 22.7% of maternal mortality cases. Hemorrhage was the second-leading underlying cause of death at 13.7% of maternal mortality cases.
The Quick Safety advisory released this week features seven safety actions providers can take to address mental health conditions related to pregnancy.
1. Conduct perinatal screening for depression and anxiety using a validated tool. Conduct an assessment of mood and emotional well-being during the postpartum visit. Additional screening of new mothers should be conducted during the well child visit.
2. Closely monitor pregnant patients for mental health conditions. Providers should evaluate and assess pregnant patients who have depression or anxiety, a history of perinatal mood disorders, risk factors for perinatal mood disorders, or suicidal ideation.
3. Be prepared to start medical therapy or refer patients to behavioral health resources.
4. Have processes to ensure follow-up for further assessment, screening, diagnosis, and treatment.
5. During the interpregnancy period, screen for depression and substance use disorder as part of well woman exams and offer referrals and resources if appropriate.
6. Create a clinical workflow to identify suicidal ideation and behaviors. Elements of the workflow should include reducing access to lethal means, collaborative safety plans, and caring contacts such as hand-offs to skilled providers.
7. Train staff in the clinical workflow to identify suicidal ideation and behaviors.
The coronavirus pandemic will continue to ebb and flow, and it comes with related challenges such as workforce shortages, chief clinical officer says.
The coronavirus pandemic and related issues are still a leading concern for healthcare providers, the chief clinical officer of Banner Health says.
Marjorie Bessel, MD, has been with Banner Health for more than a decade. She has held many physician leadership roles at the health system, including serving as chief medical officer for several hospitals and working as chief medical officer of Banner Health's Arizona Division. Before taking on the chief clinical officer role, she served as vice president and chief medical officer of community delivery.
HealthLeaders recently talked with Bessel on a range of topics, including workforce shortages, potential challenges from the recent coronavirus surge in China, and her predictions for clinical care in 2023. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as chief clinical officer of Banner Health?
Marjorie Bessel: Going into 2023, it would be remiss if I didn't say that the coronavirus pandemic was the No. 1 primary challenge. Not only have we been in the pandemic, but the length of the pandemic has been long, which has led to fatigue in the care teams. There also is fatigue in the communities that we serve. Related to the pandemic are workforce challenges and financial challenges that the pandemic has created.
HL: How are you rising to these challenges?
Bessel: I have been rising to the challenges through several tactics, which is how I approach many things in life. One is reading a lot and sticking to science. I have been focusing on science and what can be done, while also not forgetting about the science of human behavior. There is a whole science around influencing and driving human behavior as well as the science of change management, which are part of my toolkit and help me have the best approaches for implementation and subsequent success.
At Banner Health, we have been talking about high-reliability organizations and the principles that drive that level of performance. One of the principles for an HRO is deference to expertise, which means always using the experts who are available to you to solve problems through a collaborative process.
HL: What kinds of workforce shortages are you experiencing at Banner Health?
Bessel: Workforce challenges are pretty much across the board. They are not only in frontline workers such as nurses and respiratory therapists; there are workforce challenges in many other parts of what it takes to run an integrated delivery network like Banner Health. That includes people who work in technology, people who work in culinary, and people who work in environmental services. Each one of our workforce shortages has a different twist to how you might go about solving them.
Clearly, those individuals who have a lot of training and education tend to require a lot more time to develop short-, mid-, and long-term approaches to how you can address workforce challenges. For individuals such as medical assistants, addressing workforce challenges includes creating a pathway for them to see a longer-term career within the organization, so you focus a lot on retention.
Addressing workforce shortages is a collaborative effort. It is not just the chief nursing officers' role to come up with ways to deal with nurse shortages. It is not just the chief human resources officer who addresses the workforce challenge. We are thinking collectively, with everyone in the organization functioning as one team, which is helping us come up with the right tactics to deal with the complex situation that we are facing.
Marjorie Bessel, MD, chief clinical officer of Banner Health. Photo courtesy of Banner Health.
HL: China is experiencing a coronavirus surge. How could this development impact healthcare providers in the United States?
Bessel: One of the challenges ahead is related to the coronavirus surge in China, which is going to have repercussions for all of us across the world. There is likelihood of emerging coronavirus variants that may or may not be more infectious, may or may not evade vaccine immunity, and may or may not be more lethal. What is happening in China is also likely to create supply chain disruptions.
HL: How can you overcome those supply chain problems?
Bessel: The healthcare industry was not immune to supply chain disruptions before the pandemic. Those disruptions were less lengthy and less numerous. What we have found is if you utilize your structures and your systems to bring the right kind of experts together in a collaborative environment and identify your problems, then ask those experts to work together to come up with possible solutions, you put yourself in the best possible position to be flexible as you approach and experience supply chain disruptions.
A good collaborative approach builds trust up and down your organization as well as resiliency because you have a structure and process to approach difficult problems in a timely fashion.
HL: Do you have any predictions for clinical care in 2023?
Bessel: There are going to be several things we are going to continue to experience. We will have ups and downs with COVID, which will be impacted by what is happening in China. We will continue to experience coronavirus vaccine challenges, which will spur us to focus on preventative measures and building trust between our patients and clinicians, who are the ones having those conversations, to bring science and rational thinking to preventative measures.
I expect we will have stabilization of the female reproductive health challenges that we have been experiencing. Our clinicians will have better ability to have those important conversations with their patients to make decisions about the holistic approach to care, which is what clinicians want to do and what patients are seeking.
HL: You have a clinical background as a hospitalist. How did serving as a hospitalist help prepare you for your role as chief clinical officer at Banner Health?
Bessel: Nothing prepares you for a pandemic like the one we have been experiencing. While I trained in some table-top exercises and I had read about pandemics, we know that the flu pandemic that was at the scale we have experienced with COVID was 100 years ago.
However, being a hospitalist has been helpful for me as a background because a hospitalist has a good overview of the entire care delivery spectrum. A hospitalist also often works in a crisis-management type of environment. You start your day with a list of patients that need to be seen. You may start on one floor expecting to see patients, then you get a page because a patient is not doing well on another floor that you were not expecting to go to yet. You go to that floor, then you get a call that takes you down to the emergency department.
So, your day as a hospitalist must be flexible as you are constantly prioritizing and re-prioritizing the work that needs to be done. The pandemic created similar demands—we needed to manage crises, we needed to respond to the most important item of the day or the hour, and we needed to be able to pivot in a different way than you thought your day was going to go.
Another way being a hospitalist was good preparation for working during the pandemic is a hospitalist works in a team model. While I may have been the physician assigned to work with patients, I worked in a team model with pharmacists, nurses, patients, families, and many other individuals in the hospital. Working in a team model was incredibly important during the pandemic.
Increasing the number of telehealth visits for cancer patients could reduce the financial toxicity of oncology services.
Telehealth visits generate significant cost savings for adult cancer patients younger than 65, according to a new research article.
Cancer is among the most expensive medical conditions to treat in the United States, according to the National Cancer Institute (NCI). Direct costs include multiple types of treatments such as surgery, chemotherapy, and radiation therapy. Indirect costs include travel expenses and lost employment productivity for clinical visits.
The new research article, which was published by JAMA Network Open, examines indirect cost savings for more than 11,000 patients with more than 25,000 telehealth visits at Moffitt Cancer Center, the only NCI-designated Comprehensive Cancer Center in Florida. The telehealth visits were conducted from April 1, 2020, to June 30, 2021.
The study accounts for two indirect costs: roundtrip car travel and loss of productivity because of travel and the additional time associated with in-person visits compared to telehealth visits. The researchers divided visits in three categories: new visits for patients who had not received previous care at the cancer center, established visits for patients who had received previous care at the cancer center but were referred to a new subspecialty for consultation, and follow-up visits for patients who had visits for care in the same subspecialty they had received previous care at the cancer center.
The study has several key data points:
Based on two cost models for telehealth visits, the mean total saving in indirect costs ranged from $147.4 to $186.1 per visit
For new and established telehealth visits, the mean total cost savings per visit ranged from $176.6 at $0.56 per mile of travel to $222.8 at $0.82 per mile of travel
For follow-up telehealth visits, the mean total cost savings per visit was $141.1 at $0.56 per mile of travel to $178.1 at $0.82 per mile of travel
About 3,790,000 roundtrip miles were avoided, which generated more than 75,000 hours of savings in total driving time
Telehealth visits generated about $1,170,000 savings in lost income because of driving time and about $467,000 savings in lost productivity because of visit time
The mean driving cost savings per telehealth visit ranged from $83.2 at $0.56 per mile of travel to $122.0 at $0.82 per mile of travel
"These findings suggest that telehealth saves time, travel, and money for patients, which could improve care delivery and may reduce the financial toxicity of cancer care," the study's co-authors wrote.
Interpreting the data
The indirect cost savings from cancer telehealth visits are substantial, the study's co-authors wrote. "Telehealth was associated with a total savings of 3,789,963 roundtrip travel miles, which equates to traveling 152.2 times around the earth, and a total savings of 75,055 roundtrip drive hours, which equates to 8.6 calendar years. An additional 3.4 calendar years (29,626 hours) were saved in clinic visits by using telehealth."
Travel is a significant factor in cancer care, the co-authors wrote. "The burden of travel has been identified as an important factor that can change access to diagnosis, treatment of cancer and participation in clinical trials. Transportation is a key determinant of healthcare access and has been identified as an important source of out-of-pocket nonmedical costs for patients receiving cancer care. Patients without adequate transportation are more likely to miss appointments and rely on emergency department care, and there is substantial variability in the estimated parking costs throughout cancer treatment."
Rural cancer patients could benefit most from telehealth, the co-authors wrote. "A recent study noted that the number of rural hospitals has decreased over the last decade, resulting in almost double the number of people living outside a 60-minute radius of major hospitals and longer drive times to receive care. Thus, telehealth could be beneficial among rural patients in particular."
The study underestimates the indirect cost savings generated by telehealth cancer care, the co-authors wrote. "We did not consider the cost savings of telehealth for cancer caregivers. Caregivers for patients with cancer spend substantial time and effort to coordinate and attend appointments with patients. … Therefore, savings from telehealth would be even higher if caregivers' savings from lost productivity were accounted for, especially when telehealth has the ability for multiple caregivers to join the same appointment from various geographical locations."
Monogram Health employs more than 1,000 clinicians and operates in 34 states.
Monogram Health, a polychronic care provider that specializes in home-based treatment of chronic kidney and end-stage renal disease, has raised $375 million in growth funding.
In chronic kidney disease, the kidneys are damaged and have a compromised ability to filter blood, according to the Centers for Disease Control and Prevention (CDC). About 37 million adult Americans have chronic kidney disease, the CDC says. In end-stage renal disease, chronic kidney disease advances to the point of kidney failure, according to Mayo Clinic. In 2019, treating Medicare beneficiaries with end-stage renal disease cost $37.3 billion, the CDC says.
In addition to treating chronic kidney and end-stage renal disease, Monogram Health treats all related conditions, Michael Uchrin, MBA, CEO and co-founder of the company, told HealthLeaders. "To go upstream and effectively treat chronic kidney disease, you have got to stabilize patients' blood pressure. You have got to stabilize their diabetes. You have got to get cardiovascular and pulmonary issues stabilized. We have gotten good at providing care for those other conditions."
The Brentwood, Tennessee-based company, which was founded in 2018, operates in 34 states and employs more than 1,000 clinicians, he says. "Our nationally scaled nephrology practice is akin to a multispecialty practice. We have nephrologists, who are kidney specialists, but we also have endocrinologists, cardiologists, and palliative care specialists. Many of our patients have end-stage comorbidities, and they do better on palliative care rather than dialysis. We also have internists who develop personalized treatment plans for each of our patients and oversee our nurse practitioners. So, each patient has an interdisciplinary care team of clinicians based upon their conditions."
Monogram Health also employs registered nurses, social workers, pharmacists, and care management teams. Utilization management teams focus on hospitalizations and discharge management.
Several organizations contributed to the $375 million growth funding, including CVS Health, Cigna Ventures, Humana, Memorial Hermann Health System, TPG Capital, Frist Cressey Ventures, Heritage Group, Pura Vida Investments, and Norwest Venture Partners.
The growth funding will be used to expand the company and invest in technology, Uchrin says. "Most of the growth funding that the company will utilize will go to continue the widespread deployment of our clinical programs. We will continue to build out our clinical infrastructure and workforce as well as continue to invest in technology. We are big believers in technology to enable our care delivery and deliver more effective care at the right place and right time. We are going to continue to improve our analytics and our artificial intelligence as well as the systems that our clinicians use, including the electronic health record our physicians and nurse practitioners utilize."
Clinical care model
Home care is an essential element of Monogram Health's care model, he says. "We are big believers in providing care in the home, especially for individuals as sick as our patient population. More than 90% of our visits are in the home, with the rest of the visits conducted via telehealth. Whether it is our nurse practitioners or even our care managers such as RNs and social workers, they are all engaging our patients in their communities. First and foremost, our care model enables better access to care. In many underserved communities, we are creating access where other specialists did not have brick and mortar facilities."
Monogram Health treats a range of comorbidities, Uchrin says. "We take a whole person, polychronic view of the treatment plan. We do not silo kidney care from cardiovascular disease or pulmonary disease—we treat the patient. On average, prior to coming to Monogram, one of our patients had seen seven specialists, which exacerbates fractured care. Our patients can just work with Monogram, whether it is kidney, cardiovascular, or any other condition—they know they can trust Monogram."
Providing polychronic care distinguishes Monogram Health from most home health providers, he says. "Rather than focusing on one specific need, we act as an individual's physician to treat all of their needs. Home health may come to the home for a six-week, finite episode of care to treat a wound. We are much more longitudinal. Not only do we treat the patient directly and handle all of their conditions, but we also manage their care across the healthcare delivery continuum. So, if an individual does need home health such as IV antibiotics, we will engage a home health provider and oversee the care to ensure that the treatment works as expected."
Financial model and partners
Monogram Health's financial model is focused on providing value-based care, Uchrin says. "We have a value-based care delivery economic model, where we partner with health plans and other risk-bearing entities such as forward-leaning health systems. We work with health plans to assume full medical-expense risk. We offer access and better affordability. We charge a fee for our services that is based on per-member-per-month fees on populations, and the value we create is better affordability around the total cost of care for the populations we have taken responsibility to treat."
The company works predominantly with Medicare Advantage health plans, but it has other partners as well, he says. "Medicare Advantage payers have leaned into our solution, and we have tremendous relationships with Cigna as well as Humana. We also work with forward-leaning health systems, including AdventHealth and Banner Health. We work with health systems that have value-based care relationships with their payer partners. We partner with those health systems to provide treatment for their chronic kidney and end-stage renal disease patients. We help to improve access to care, boost outcomes, and increase affordability."
Researchers found that 22.7% of adverse events among inpatients were preventable.
Despite three decades of efforts to improve patient safety in the hospital setting, adverse events remain common, according to a new journal article.
The Harvard Medical Practice Study(HMPS), which was published in 1991, was one of the first comprehensive examinations of patient safety in the hospital setting. The study found there were 3.7 adverse events per 100 admissions, with 28% of the adverse events caused by negligence.
The new journal article, which was published by the New England Journal of Medicine, is based on data collected from 11 Massachusetts hospitals with beds ranging from fewer than 100 to more than 700. The researchers examined a random sample of 2,809 admissions.
The journal article has several key findings:
There was at least one adverse event in 23.6% of the 2,809 admissions
Out of the 978 adverse events identified, 22.7% were deemed to be preventable and 32.3% were considered serious (causing harm that required intervention or prolonged recovery)
Among the preventable adverse events, 19.7% were serious, 3.3% were life-threatening, and 0.5% were fatal
Adverse drug events accounted for 39.0% of adverse events, followed by surgical or other procedural events (30.4%), patient-care events such as falls and pressure ulcers (15.0%), and healthcare-associated infections (11.9%)
The mean length of stay for inpatients experiencing at least one adverse event was significantly longer than for inpatients who did not experience an adverse event (9.3 days versus 4.2 days)
Adverse events resulting from a surgical or other procedure were most likely to be life-threatening, and healthcare-associated infections were most likely to be fatal
Patient-care adverse events and adverse drug events were more likely to be preventable than other types of adverse events
Adverse events remain common, and more work is needed to reduce them, the journal article's co-authors wrote. "Adverse events were identified in nearly one in four admissions, and approximately one fourth of the events were preventable. These findings underscore the importance of patient safety and the need for continuing improvement."
Interpreting the data
Adverse events remain a serious problem at hospitals more than three decades after the publication of the HMPS, the journal article's co-authors wrote. "Three decades after the HMPS drew attention to the issue of health care–associated patient harm, in-hospital adverse events continue to be common, and although only approximately one fourth of the adverse events identified in this study were deemed to be preventable, all adverse events negatively affect medical care and outcomes."
Although there have been many advancements in healthcare since the publication of the HMPS, patient safety remains a concern, the co-authors wrote. "Over the course of this 30-year interval, care has become more complex, and diagnostic and therapeutic options to treat disease and alleviate human suffering have advanced. The healthcare delivery system itself has changed dramatically with the advent of [electronic health records] and the movement of complex care to ambulatory sites, which has resulted in the most severely ill patients being treated in acute care hospitals. Despite stunning advances in medical science, we still have important gaps in patient safety."
Hospitals need to improve methods of identifying and assessing some adverse events, the co-authors wrote. "Measuring adverse events in a reliable and efficient way and developing standard approaches to the identification of and focus on preventable adverse events are critical to supporting persons charged with improving safety. Some types of adverse events, such as health care–associated infections, can be identified much more effectively than others, which suggests a need to improve routine tracking, especially for events such as adverse drug events."
There are several opportunities to improve patient safety, the co-authors wrote. "There is considerable variability among hospitals in adverse event rates, with larger sites having rates of approximately 40% or higher; this finding suggests that if hospitals had data that were more reliable and more routinely collected, it is possible that monitoring could be improved, adverse event rates could be reduced, and improvement strategies could be shared through careful study of interventions. Other key organizational elements such as safety culture and strong leadership with respect to safety and quality are also needed to advance performance."
The new research should be considered a rallying cry, they wrote. "Our findings are an urgent reminder to all healthcare professionals of the need for continuing improvement in the safety of the care we deliver."
Thomas Sequist, MD, MPH, chief medical officer of Mass General Brigham. Photo courtesy of Mass General Brigham.
Marjorie Bessel, MD, chief clinical officer of Banner Health. Photo courtesy of Banner Health.
