To the extent that quality work has been de-emphasized during the pandemic, patient outcomes have suffered, National Association for Healthcare Quality says.
The coronavirus pandemic has illustrated the value of quality professionals and their work in healthcare, according to a recent whitepaper from the National Association for Healthcare Quality (NAHQ).
The pandemic has posed some of the greatest challenges to the healthcare sector in generations, and quality professionals have played key roles such as operating crisis command centers, activating telemedicine programs, and developing safety protocols for healthcare workers and patients.
From a quality and safety perspective, there are three primary lessons learned from the pandemic, according to the whitepaper.
1. "Routine efforts to advance quality initiatives are highly effective, and when we stop or deprioritize those initiatives, health outcomes suffer. Any healthcare leader who has ever questioned the value of routine quality and safety work should take this as the signal that this work matters. And when it is deprioritized, even for a good reason, ground is lost," the whitepaper says.
2. "Reinstating, sustaining and advancing quality and safety initiatives is the path toward progress in healthcare. A 'new normal' in healthcare appreciates that we must be dependent on sustainable systems, process and structure to ensure continuity in the face of known and unknown challenges. Performance and process improvement—and quality management—must be hardwired into the work, so that when a crisis occurs, the focus is not shifted away from quality and safety," the whitepaper says.
3. "Deploying quality professionals to solve many of the biggest challenges that healthcare leaders face will result in the biggest impact to advance healthcare leaders' priorities. Healthcare quality leaders and professionals are uniquely qualified to solve problems. Whether leading or sustaining run-the-business quality and safety initiatives or leading in a crisis, these leaders have the tools and competencies to bring order and deliver results," the whitepaper says.
It is important to maintain routine efforts to advance quality, even during a crisis such as the pandemic, Stephanie Mercado, executive director and CEO of NAHQ told HealthLeaders.
"The run-the-business efforts save lives. When we take our foot off of the gas on those efforts, we can see that patient outcomes suffer. We saw many of these efforts get sidelined during the pandemic—generally speaking, everybody's attention was shifted to focus on a single clinical condition. The result is that we lost ground—turning back the clock on five years of progress to improve quality and safety metrics. There is recent data that shows there were significant year-over-year increases from 2019 to 2020 in hospital-acquired infections," she said.
Hardwiring performance and process improvement (PPI) as well as quality management in healthcare ensures that quality and safety efforts continue when a crisis occurs, Mercado said.
"Hardwiring PPI and quality management means that we are always looking for what is going right in healthcare, and we are always looking for what is going wrong in healthcare. It also means that we are engaging stakeholders to review their work and do it better. It also means we are activating improvements through a system in ways that are constantly eliciting change management and sustainable improvement throughout the whole system. We do not do quality work because we all of a sudden have time to do quality work. We do it because quality has become the work. It is the way that we have learned to function, and it produces better quality and safety outcomes for patients at a lower cost," she said.
Quality professionals are equipped to solve many of the biggest challenges that healthcare leaders face, Mercado said.
"Quality professionals do their jobs well because they have the training, the tools, and a deep-seated commitment to improvement as a mindset. That is what makes them a valuable resource in solving challenges in healthcare. … People who pursue a career as a quality professional have improvement as a mindset—it is part of their DNA. Quality professionals have the tools and the methods to understand a problem and create a solution. Just like firefighters rushing into a burning building, quality professionals with the right training can jump into any challenge. For example, health equity and population health are solvable problems with quality tools, methods, and mindsets," she said.
System sustainability
It is essential to focus on system sustainability in healthcare, Mercado said. "It is important to focus on system sustainability because quality can't wait. Quality cannot be viewed as just another priority in a long list of efforts that need to be accomplished in healthcare. Sustainable systems are important so that we make healthcare better for the patients and make healthcare better for the workforce."
System sustainability helps keep patients safe, she said. "When it comes to patients, we have lost ground during the pandemic on healthcare-associated infections, and it is important to focus on sustainability because patients do not expect to go into a healthcare environment after the pandemic and feel less safe getting care. But, in fact, they are less safe."
System sustainability also positions the healthcare workforce for success, Mercado said. "When we think about the healthcare workforce, sustainable systems will also make healthcare better for the workforce. … If we are going to bring back purpose for the workforce and activate the calling part of their career choice and build a strong culture, then we are going to have to put healthcare workers in situations where they have the best possibility for success."
System sustainability boosts healthcare worker morale, she said. "People in healthcare are seeing the same medical errors occur over and over again. It is depressing, and it causes burnout. So, a focus on training the workforce on how to help solve these problems before they happen and avoid the harm to patients is an important step in solving the culture and workforce problems that we are facing now. Sustainable systems are designed for the best success and for the types of experiences that elicit joy rather than sadness."
In Vera Whole Health's value-based financial model, healthcare providers are paid a flat rate much like a salary rather than volume-based compensation.
Vera Whole Health's advanced primary care model takes a comprehensive approach to patient care, with extended visit times and resource stewardship such as a disciplined manner of making referrals.
The fee-for-service model for primary care usually features short times for patient visits. The fee-for-service model for primary care has drawn criticism about access to care, with scheduling of visits with a patient's primary care provider often taking weeks to arrange.
Seattle-based Vera Whole Health operates primary care practices in eight states (Alaska, Arizona, California, Idaho, Nevada, Oregon, Texas, and Washington). In Vera Whole Health's value-based financial model, healthcare providers are paid a flat rate much like a salary. It does not matter how many patients they see or procedures they perform as long as their patients become healthier.
"With advanced primary care, we can be extremely comprehensive with the services that we are providing. We deliver care in a very patient-centric way, with high quality care that is also cost and time efficient for the patient, care team, and payers," says Jackie Riddick, MD, lead physician and primary care physician at Vera Whole Health-Fort Dent Tukwila in Washington State.
Vera Whole Health's advanced primary care is a sharp break from the fee-for-service model, she says. "It is not about seeing a volume of patients. It is about taking the best care of people. For our patients, they have flexibility in how they access their care, whether that is through video visits, the telephone, in-person visits, and care through the patient portal. We can provide many services virtually such as adjusting medications."
Vera Whole Health primary care providers have lower patient panels than many primary care practices and patients can often schedule an in-person visit with their primary care doctor within 48 hours, Riddick says. "At my previous primary care practice, the panel size was 1,800 to 2,200, which is medium-to-high for the industry. At my Vera Whole Health office, we are at 1,250 to 1,500 patients per provider. So, the patients can get same-day or next-day appointments with me. They are not waiting three weeks."
At Vera Whole Health primary care practices, in-person patient visits are 30 to 60 minutes long, depending on what the patient needs, she says.
"For our in-person care, it is the patient's needs that drive the agenda rather than the structure of the appointment. For example, in the fee-for-service world, if a patient makes a preventative care appointment covering things such as screenings and vaccinations, the moment the patient brings up something like knee pain we would have to interrupt them and tell them, 'We can't address your knee pain in this type of visit because of the billing and coding. You are going to have to come back and have a separate visit.' That is an administrative barrier. With advanced primary care, we have the flexibility to use the time we have for whatever the patient's needs might be. We can meet their needs more comprehensively in our visits."
Resource stewardship
Resource stewardship is a key component of advanced primary care at Vera Whole Health, Riddick says. "We are thoughtful about additional costs that we are going to incur in a patient's care. When we have more time in the visits to be thoughtful, then we can select more appropriate labs, imaging studies, and referrals, rather than being rushed and checking all the boxes to be sure we do not miss anything. We can tailor care much more specifically and determine what is needed—or what is not needed."
Having lengthy primary care visits tends to drive down specialist referrals, she says.
"In having more time with the patient, I generate fewer unnecessary referrals. At my previous practice, where I had 20-minute visits and as little as seven minutes with patients, a patient would come in with four things on their list and I may have been able to tackle only one condition such as shortness of breath. But for their ankle pain, I would have to refer the patient to sports medicine; and for their rash, I would refer the patient to dermatology. I would have to make those referrals because of time management. Whereas, when I have more time with my patients, I can diagnose and treat several issues myself all in one visit. That way, the patient does not have to make several appointments and pay more for the referrals."
Health coaches
Health coaches are an element of Vera Whole Health's advanced primary care model. At Riddick's primary care practice, there is one health coach for two patient panels.
"The health coaches are specialists in navigating change with patients. They can identify practical and realistic goals that the patient can pursue. They can break down changes to make them attainable, then have an accountability partner on the journey toward success. So, patients have a concrete plan with a health coach, with whom they check in periodically to make sure that they are making progress. That makes a huge difference for people to make lifestyle changes," she says.
The health coaches take an individualized approach in working with patients, Riddick says.
"There are many issues a health coach can help address such as nutrition, exercise, and smoking cessation, but there are other issues that may not seem as directly linked to health such as sleep habits and stress management. Health coaching is about identifying what is truly meaningful for each person and joining them on that journey, rather than being prescriptive. For example, I do not tell a patient they need to go meet with the health coach and do X, Y, and Z until they meet a blood pressure goal. It is more about there being dozens of ways to reach an endpoint, and we need to figure out what works for the patient."
Preventive care
Vera Whole Health patients are incentivized to have an "annual whole health evaluation," which has three pieces, she says. "First is biometric screening. Second is the provider wellness visit, which is a 60-minute extensive visit with a provider. Third is a 'coaching connection,' which is a brief introduction to our health coach and how coaching works."
The biometric screening is conducted by a medical assistant, Riddick says. "When a patient comes in for a biometric screening, we measure height, weight, body mass index, abdominal circumference, cholesterol, and blood pressure, and we conduct two forms of diabetes screening and a physical activity assessment. We use that data to calculate the patient's cardiovascular risk score, which is their likelihood of having a heart attack or stroke in the next 10 years."
Researchers expected to find a big increase in cancer screenings in 2021 to make up for a dramatic drop in cancer screenings at the onset of the coronavirus pandemic.
Cancer screening rates remain below levels prior to the coronavirus pandemic, according to a recent research article published by Epic Research.
At the onset of the pandemic, there was a dramatic drop in routine cancer screenings as patients avoided doctor offices out of fear of contagion and healthcare organizations focused on COVID-19 testing and cases. An earlier study published by Epic Research found breast cancer and cervical cancer screenings decreased 94% at the beginning of the pandemic and colon cancer screenings decreased 86%.
The recent research article is based on information collected from a database with more than 126 million patients from 156 Epic organizations, including 889 hospitals and 19,420 clinics. The researchers looked back at breast cancer, cervical cancer, and colon cancer screening rates to 2017 to establish a pre-pandemic screening rate baseline.
The recent study features several key data points for the period from January 2021 to October 2021.
The breast cancer screening rate was 2.7% below the pre-pandemic screening rate baseline
The colon cancer screening rate was 3.4% below the pre-pandemic screening rate baseline
The cervical cancer screening rate was 10.0% below the pre-pandemic screening rate baseline
These screening rates result in an estimated 68,000 missed breast cancer screenings, 27,000 missed colon cancer screenings, and 9,000 missed cervical cancer screenings
"Despite many clinics reopening in the spring and summer of 2021, we still see lower than expected rates of routine cancer screenings. Further delays in cancer screening could lead to delayed cancer diagnoses, which could increase morbidity and mortality and exacerbate existing healthcare disparities, as well as increase healthcare costs. Ongoing efforts to increase patient access to affordable screenings are important to our nation's COVID recovery," the study's co-authors wrote.
Interpreting the data
The recent study is the fourth study Epic Research has conducted on cancer screening rates before and during the pandemic, the lead author of the recent study told HealthLeaders. "We have looked at how cancer screening rates have evolved since the pandemic began. Initially, there was a dramatic decrease, then there was a subsequent rebound, although cancer screening rates are still not quite at where we expected them to be," said Chris Mast, MD, vice president of clinical informatics at Epic Research.
Having cancer screening rates below the pre-pandemic baseline is concerning, he said. "Across the board, anytime that you are potentially missing cancer screening, that is troubling. Screening is designed to detect cancer early while it is ideally small, not at an advanced stage, and more easily treatable so that you can have better outcomes."
Mast's research team had expected to see higher cancer screening rates in 2021, he said.
"There was an initial big dip in cancer screenings. What we thought might happen was a 'catch up' in screenings after the initial decrease. At some point, when people felt better about going back to their doctors for their routine visits and healthcare organizations had their feet under them, we thought that we might see a big spike among people who had not gotten their routine screenings. We did not see a big spike in routine screenings. We saw some seasonal patterns such as more breast cancer screening during Breast Cancer Awareness Month. But we did not see a big increase in screening across the board, with people saying, 'Now I can go back and catch up.' We have seen screening return close to baseline but that implies that many screenings have just not gotten done."
The potential for cancers going undetected because of reduced screening has implications for healthcare costs, Mast said. "In addition to the human toll of not detecting cancer early, when cancers are found at an advanced stage, they are more extensive, more likely to spread to other parts of the body, and more difficult to treat, which leads to higher expense in treatment. It is intuitive how advanced cancer could certainly require more intensive treatment, longer duration of treatment, and potentially more complications as part of the treatment. All of those things contribute to increased healthcare costs."
Encouraging people to get cancer screening
Healthcare professionals should seize on opportunities to encourage their patients to get routine cancer screening, he said.
"There is no one best way to get into contact with patients or to encourage them to get cancer screenings done. What works is doing everything. We need multichannel communication. Every contact with patients becomes an opportunity not only to address the concern that brought them to you but also to encourage them to look at their health maintenance items such as cancer screenings. When there is contact with any healthcare provider, they should be encouraging patients to get their cancer screenings done."
A little bit of encouragement can go a long way, Mast said.
"Smoking cessation is a good example. We find that when a trusted person in the patient's care team such as a physician brings up the topic of smoking cessation with the patient, that can be the incentive that the patient needs to pursue smoking cessation. The same thing is true of cancer screening. Health systems, hospitals, physician practices, and, even more broadly, home health workers and pharmacists, can do a small part to remind people to get their screenings done. In aggregate, that helps move the needle and activate more patients to get their screenings done."
The Chicago-based health system has utilized a range of technology to connect with patients and restructured case management, social work and physician advisors.
In recent years, UI Health has taken several steps to better serve underserved communities.
Health equity has emerged as a pressing issue in U.S. healthcare during the coronavirus pandemic. In particular, there have been COVID-19 health disparities for several racial and ethnic groups that have been at higher risk of getting sick and experiencing relatively high mortality rates, including Black, Hispanic/Latino, American Indian, and Alaska Native communities.
At UI Health, serving underserved communities is a priority at the Chicago-based health system, says Rani Morrison, MS, MSW, chief diversity and community health equity officer. "With our payer mix, a lot of our patients could be considered underserved—we have nearly a 50% Medicaid payer mix. So, we have to be creative in how we connect with our patients."
UI Health is utilizing a range of technology to connect with patients, she says.
"Nearly five years ago, we partnered with CipherHealth and that is how we updated doing post-discharge calls. We were doing manual calls to our patients after discharge to make sure that they understood their discharge instructions and hopefully reduce readmissions. We switched to an automated system with CipherHealth, which increased our reach rate to our patients and allowed us to have different options to reach patients. We can reach them in the language that they prefer. We can reach more people. We can reach them at different times of day. If there is a problem or an issue that is identified, we make a call with a nurse within hours to problem-solve. That is a way that we have leveraged technology to work with our patients who may not have the full range of technology or be sophisticated with the patient portal."
A new patient portal has also boosted contact with patients, Morrison says. "We switched to Epic as our electronic health record 15 months ago, and we have been proud that we have had a high level of adoption of our patient portal. We have been able to do things like send reminders to patients through the patient portal. We can take payments through the patient portal. We were able to leverage the portal heavily for coronavirus vaccines when we did our mass vaccination clinic last winter and spring."
In addition, UI Health is utilizing "soft technology" to connect with patients, she says. "You can call our call center, which we also used for our mass vaccination clinic. We did reverse calling for those who did not have the Internet and could not navigate the patient portal. We try to do a balance of outreach because we know that not all of our patients are similarly situated."
Restructuring case management
In March 2020, UI Health initiated a restructuring of case management from a dyad model to a triad model, Morrison says. Under the dyad model, a team of nurses managed both the discharge planning and the utilization review function for patients. Under the triad model, the nurses have split responsibility with a team of nurses that just does utilization review, a team of nurses that just does discharge planning, and social workers who focus on psycho-social needs and discharge planning specific to skilled nursing facilities and sub-acute rehab.
Effective case management is crucial to serving underserved communities, she says.
"The great thing about case management is that it is truly designed to serve underserved communities because case management is about holistic care. We are supposed to be assessing the patient, their environment, their supports, and what they are going to need to successfully transition from the hospital setting to whatever the next appropriate setting is. When case management is done properly, it is supposed to evaluate the people who have the least amount of resources to make sure that they can go to the most supportive environment. Case management is well-suited for those who are underserved or do not have as many resources as other patients."
The educational role of case managers is pivotal for underserved communities, Morrison says. "Education is critical, particularly for the underserved because sometimes their understanding and knowledge of the different post-acute care options may be less than other patients in terms of understanding the concepts of healthcare and health literacy. We must educate them to make sure they understand everything that we give them at discharge and their options. We want patients to be involved and engaged, so they feel they are part of the process no matter their resources and no matter their baseline health literacy."
Improving social work resources
At the same time that case management was revamped, UI Health improved inpatient and outpatient social work services, she says.
"We increased the social work complement during our restructuring effort. We drove down caseloads of the social workers on the inpatient side who are the counterparts of the nurse case managers. We also added some additional assessment tools that social workers have to better assess the psycho-social needs of patients. We have adopted some additional resources to give us information about different social service options so that social workers can access better referral information. So, if a patient needs mental health resources or substance use resources, we have more referral information and we have leveraged technology to provide referrals to the patients via text or in their discharge summary."
Revamping physician advisor program
UI Health has also improved the physician advisor program at the health system's hospital, Morrison says.
"We increased the number of physician advisors. We identified a new lead physician advisor, who was a member of the faculty. They have been able to leverage reporting and data so that they understand the trajectory of the patients. We gave the physician advisors new training to make sure everybody understood the ideal model. The physician advisors have increased their involvement—they are attending multidisciplinary rounds every day with the attending physicians, residents, case managers, social workers, physical therapists, and the nursing staff. They give feedback, ask questions, and give input into the progression of care for patients. They are also heavily involved in the utilization management committee to make sure that we are keeping an eye on the ball when it comes to our patients, how we are doing in terms of managing patients, and making sure that they understand our contracts, such as our Medicaid managed care contracts."
Physician advisors play a key role in helping to serve underserved communities, she says. "The physician advisors have been instrumental in pushing systemic changes around our patients and our patients' needs, which has been helpful to our underserved patients because the physician advisors can identify issues and take a step back to have a 360-degree view. They are also practicing physicians with inpatient and emergency department duties—they are seeing what is in front of them as attending physicians and can give feedback."
Researchers collected data from 31 health system-affiliated physician organizations associated with 22 health systems in four states.
Despite the push to shift from fee-for-service to value-based payment (VBP) in U.S. healthcare, physician compensation remains overwhelmingly based on volume of services rather than value, a new research article says.
Over the past decade, public and private payers including Medicare have introduced alternative payment models (APMs) and VBPs to encourage healthcare providers to provide services based on value rather than volume. A primary goal is to shift healthcare providers away from providing care only when patients are sick toward more preventive and wellness-oriented care.
The new research article, which was published by JAMA Health Forum, is based on data collected from 31 health system-affiliated physician organizations (POs) associated with 22 health systems in four states (California, Minnesota, Wisconsin, and Washington). The study was conducted by the RAND Center of Excellence for Health Care Performance with funding from the Agency for Healthcare Research and Quality.
The study includes three key data points.
Volume-based compensation was the most-common type of base pay for more than 80% of primary care physicians and for more than 90% of physician specialists.
Although quality and cost performance financial incentives were used by health systems, the percentage of total physician compensation based on quality and cost was only 9% for primary care physicians and 5% for specialists.
Increasing the volume of services provided was the most commonly reported method for physicians to increase their compensation, with 70% of POs having such an arrangement. Among these POs, volume-based incentives accounted for more than two-thirds of compensation.
"Performance-based financial incentives for value-oriented goals, such as clinical quality, cost, patient experience, and access, were commonly included in compensation but represented a small fraction of total compensation for [primary care physicians] and specialists in health systems, operating at the margins to affect physician behavior. Taken together, these findings suggest that despite growth in APMs and VBP arrangements, these value-based incentives were not commonly translated into health system physician compensation, which was dominated by volume-oriented incentives," the study's co-authors wrote.
The research found that physician compensation is geared more toward volume of services than value to drive health system revenue, the lead author of the study said in a prepared statement. "Despite growth in value-based programs and the need to improve value in healthcare, physician compensation arrangements in health systems do not currently emphasize value. The payment systems that are most-often in place are designed to maximize health system revenue by incentivizing providers within the system to deliver more services," said Rachel Reid, MD, MS, a physician policy researcher at RAND.
The New York-based limited liability company has a network of more than 500 organizations serving 22 counties.
A limited liability company formed as part of the Medicaid redesign in New York State is helping managed care organizations and healthcare providers to connect patients with social determinants of health needs with social services.
Social determinants of health (SDOH) such as housing, food security, and transportation can have a pivotal impact on the physical and mental health of patients. By making direct investments in initiatives designed to address SDOH and working with community partners, healthcare organizations can help their patients in profound ways beyond the traditional provision of medical services.
The Alliance for Better Health was founded in 2015 as part of the Medicaid redesign in New York State. In 2018, Alliance for Better Health formed Healthy Alliance IPA as an affiliated limited liability company. The independent practice association helps managed care organizations and healthcare providers to connect patients with social determinants of health needs with social services.
"We have a network of participants, which includes clinical affiliates such as health systems in addition to social care providers. We have more than 500 of those organizations in the network, spanning 22 counties, with more than 1,000 social services. The services include transportation, food, housing, and job training," says Erica Coletti, CEO of the Troy, New York-based Alliance for Better Health.
Healthy Alliance IPA has many healthcare providers in its network, she says. "We have several health systems in our network such as St. Peter's Health Partners and Ellis Medicine. We have many primary care practices in our network. We also work closely with federally qualified health centers."
Healthy Alliance IPA plays an intermediary role between managed care organizations and healthcare providers and their patients, Coletti says. "We are a convenor that has put together a network of social service providers. We are providing the support and function around the social services network. … We work with multiple social service providers—we meet with them monthly to give them data on services they have provided through our network."
People are referred to Healthy Alliance IPA for social services in several ways, she says. "We get referrals from managed care organizations, health systems, hospitals, and physician practices. We also get referrals from community organizations—if they are working with an individual and they do not provide a service that the individual needs, they can make a referral to us."
Decreasing medical costs and improving health equity
Connecting people with social determinants of health needs with social services can reduce medical costs, Coletti says.
"A good example is someone who has diabetes with a blood sugar problem who has to go to the emergency room. If they had access to healthy food and nutrition counseling before they reached a crisis point, they could save significant medical dollars. Another example is someone with an addiction who needs to go to Narcotics Anonymous and transportation becomes a barrier for them. Unless you can provide a transportation service, that person can end up in an acute care setting. Addressing that barrier of transportation makes a big difference," she says.
Healthy Alliance IPA is also addressing health inequities, Coletti says.
"Our focus is on improving the health of the underserved. By addressing social issues that end up resulting in health issues, we expect to level the playing field by reducing social care barriers, which in turn will support health equity. The underserved disproportionately includes racial and ethnic minorities, and they have many more social determinants barriers than others. So, by removing those barriers and getting the underserved appropriate social supports, we are helping to level the playing field," she says.
Measuring the impact
Stanford University is going to be conducting a study to measure the impact of Healthy Alliance IPA, Coletti says.
"The Stanford University study is an economic study, so we will be looking at the past three years of data for people who are involved in our network and seeing whether the network bends the cost curve on medical utilization. So, we will be looking at cost of care, acute care utilization such as avoidable emergency room visits and hospitalizations, and health outcomes for people in the network versus comparable people who are not in the network. We will also be looking at the impact based on race and ethnicity."
During the omicron surge, Children's National Hospital is admitting about three times as many children with COVID-19 than in earlier phases of the pandemic.
The omicron coronavirus variant is having a significant impact on children and parents should be getting their school-aged children vaccinated, the president and CEO of Children's National Hospital told The Washington Post this week.
Children have not been as severely impacted by COVID-19 as adults. Children have had lower hospitalization and death rates.
Children's National Hospital has been treating a higher number of children with COVID-19 during the omicron surge than in earlier phases of the pandemic, Kurt Newman, MD, president and CEO of the hospital, told The Washington Post.
"Through the beginning parts of the pandemic with the original variants, we would see routinely at a peak maybe 20 patients in the hospital … and about a third of them would go to the ICU. And people were thinking, well, maybe it didn't have that much impact on children. … Now with this omicron variant, we've seen what a false kind of set of conclusions that was. This variant is hitting children hard. It's hitting them differently. And it's really impacting our hospital. … With the other variants, our peak would be about 20 kids in the hospital at a time. Lately, it's been about 60 or 70," he said.
The omicron variant poses a particular danger to younger children, Newman said.
"The science that we're seeing is that the kids are coming in with a little bit different presentation. Instead of deep in the lungs, … this omicron variant seems to hit the upper airway a little harder. And the real problem for children with that, particularly the smaller children and the babies—and we're seeing increased numbers of babies and smaller children—is that their airway is smaller. So, they can't take a lot of inflammation or infection," he said.
The omicron variant has strained the hospital's staff, but the Washington, D.C.-based facility has been able to maintain operations, Newman said. "They're stressed. But I am so proud of how our hospital has stepped up. We have not turned a patient away. We haven't closed a clinic."
Coronavirus vaccination for children
Children's National Hospital staff are anxious for coronavirus vaccination to be available for children under 5, he said. "We can't wait for the vaccine that will be approved, hopefully this spring, for children under 5, because they're unvaccinated and they are at risk."
Coronavirus vaccination rates for children aged 5 to 11 have been significantly lower than vaccination rates for adults, which is a concerning, Newman said. "I'm very disappointed because I did expect a much higher uptake among parents and children … to get that rate up where it needs to be."
For children who are eligible for vaccination, he said there are two priority groups who should get vaccines. The first priority is to vaccinate children who have underlying conditions such as cancer, sickle cell disease, and obesity. The second priority is to vaccinate children who struggle with access to vaccines such as children living in poverty. "We want to get those kids vaccinated," Newman said.
For parents who know children face lower risk from COVID-19 than adults and may want to take a cautious approach to vaccination, he said vaccination should still be encouraged. "Doing the right thing for your child may mean doing what's right for the public good as well. And your child may be impacted by what goes on with other children and families. … We've had enough experience now with these vaccines that they're safe. They're protecting your own children. … Maybe most importantly of all, they're protecting all of our children."
Parents with vaccination hesitancy for their children should also consider that new variants of coronavirus may arise that will have a greater impact on children, Newman said. "Having huge amounts of circulating virus … creates the opportunity for new variants and things that we don't know that could impact [children] in different ways. So, I would say study it all, talk to your pediatrician, talk to the public health authorities, and make that decision for your child."
About 30,000 to 40,000 opioid use disorder patients are hospitalized with sepsis each year.
The Sepsis Alliance is highlighting the intersection of sepsis and opioid use disorders.
Sepsis develops in response to infection, and 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.
On Jan. 27, the Sepsis Alliance Institute is hosting a webinar on the intersection of sepsis and opioid use disorder. The webinar features Chanu Rhee, MD, MPH, associate hospital epidemiologist at Brigham and Women's Hospital and assistant professor of population medicine at Harvard Medical School, and Simeon Kimmel, MD, MA, attending physician at Boston Medical Center and assistant professor of medicine at Boston University School of Medicine.
Rhee and Kimmel were interviewed recently by HealthLeaders. The following transcript of that conversation has been edited for brevity and clarity.
HealthLeaders: How prevalent are sepsis cases among people afflicted with opioid use disorder?
Chanu Rhee: You need to have the denominator—how many people have opioid use disorders. In 2018, the Centers for Disease Control and Prevention (CDC) estimated that about 2 million people in the United States had opioid use disorders. We also know how many adults are hospitalized with sepsis each year, which is about 1.7 million adults. In a paper that Dr. Kimmel and I published recently in Critical Care Medicine, we found that about 2% of hospitalized sepsis patients had opioid use disorder.
With those numbers, we can do some math. There are 1.7 million adults with sepsis each year, and 2% of those patients have opioid use disorder, so we are talking about 30,000 to 40,000 opioid use disorder patients who are hospitalized with sepsis each year.
HL: What are the primary elements of the intersection of sepsis and opioid use disorder?
Simeon Kimmel: Many people with opioid use disorder are using injection opioids. When somebody injects an opioid, there is penetration of the skin barrier with a needle, which introduces the risk of infection. That can be the result of bacteria that are living on the skin, bacteria on the injection equipment such as the syringe, or the substance that is being injected can be contaminated with bacteria. Especially in the era of fentanyl, which has contaminated the injection opioid supply, fentanyl is a shorter-acting opioid that requires more frequent injections. What we are seeing is that people are injecting very frequently, which leads to an increased risk of skin and soft tissue infection. We see blood stream infections, where bacteria get into the blood and infect the heart valves, bones, and joints—we see septic arthritis. We also see lung infections and other kinds of infections related to this dynamic.
Opioid use can lead to overdose, which can lead to the risk of developing aspiration and pneumonias. There is some evidence that suggests that opioid use itself may have some effects on the immune system that can predispose people to developing infections such as lung infections.
Rhee: Even with oral opioid use, overdose can lead to pneumonia, and pneumonia is a common cause of sepsis.
HL: What are the primary signs that someone afflicted with opioid use disorder is also developing sepsis?
Rhee: The signs of sepsis are generally the same for people with opioid use disorder as for people in the general public. There can be confusion, disorientation, shortness of breath, high heart rates, fever, shivering, extreme discomfort, and clammy or sweaty skin. A lot of these signs can overlap with the signs of opioid withdrawal, which can make it very hard to tell an individual is developing sepsis versus having withdrawal. This can be a challenge for patients and healthcare providers.
For healthcare providers trying to identify sepsis in opioid disorder patients, you need to look for signs that might localize specific infections such as cough and shortness of breath. If a chest X-ray is taken, providers should look for pneumonia. Providers should look for redness and signs of infection at injection sites to be on the lookout for skin and soft tissue infections. Providers should look at vital signs for low blood pressure, high heart rates, and low oxygen saturation. Providers should look at laboratory data such as white blood cell counts.
It is always a challenge looking for the warning signs of sepsis. There is no one perfect or sensitive sign. You have to put things together in a constellation of symptoms and signs to get a diagnosis. It can be particularly challenging in patients with opioid use disorder.
HL: What are the key data points that demonstrate the epidemiology of sepsis in opioid-related hospitalizations?
Rhee: In a recent paper, we sought to describe the epidemiology of hospitalized patients with sepsis and opioid use disorders. We looked at a couple million patients who were hospitalized at 373 hospitals between 2009 and 2015. We identified sepsis using CDC surveillance criteria. We identified patients with opioid-related hospitalizations using previously validated diagnosis codes as well as inpatient prescriptions for buprenorphine. The bottom line is we found sepsis was present in about 6% of opioid-related hospitalizations. Conversely, opioid use disorders were present in about 2% of sepsis hospitalizations.
In terms of the burden and the mortality, we found that patients with opioid use disorders who had sepsis had lower short-term mortality rates compared to sepsis patients without opioid use disorders. This was a trend that persisted even after risk adjustment.
Over half of patients who had opioid-related hospitalizations who ended up dying during their hospitalization had sepsis. That was higher than the mortality rate for non-opioid-related hospitalizations—about a third of those patients had sepsis. This data suggests that sepsis is a major contributor to death in patients with opioid-related hospitalizations.
Finally, the prevalence of opioid use disorders among hospitalized patients, and especially among patients with sepsis, rose during the study period from 2009 to 2015. It increased 41% among all hospitalizations, and when we looked at sepsis hospitalizations, it increased by 77%. It became a bigger and bigger problem over time.
HL: How can sepsis be prevented in people afflicted by opioid use disorder?
Kimmel: There are several important steps. The first is that people with opioid use disorder need to have access to supplies to inject substances as safely as possible. That means access to alcohol swabs to be able to clean their skin and access to sterile injection equipment.
Second, there needs to be education for people with opioid use disorder to understand that they should seek care early for their infections.
Third, we need to improve the care of people in the hospital, so people feel comfortable coming to the hospital when they are sick. I take care of a lot of people with opioid use disorder in a drop-in clinic, and I spend a lot of time helping people understand the risks and benefits from their perspective of coming to the hospital because there is fear of being in the hospital such as fear of experiencing withdrawal symptoms.
Fourth, we need to improve access for treatment of opioid use disorders. There has been a lot of progress over the past few years around increasing low-barrier access to buprenorphine and improving access to methadone, which are evidence-based medications that reduce the risk of developing sepsis.
HL: Can you offer other insights about the intersection of sepsis and opioid use disorder?
Kimmel: There is a growing recognition of the importance of training clinicians to be able to treat opioid use disorder. Increasingly, there are systems in place to improve the treatment of opioid use disorder in the hospital. There has been development of addiction consult services. There are a growing number of infectious disease doctors who also are dually trained in addiction medicine. These are encouraging developments in terms of normalizing and improving the treatment of opioid use disorder.
Rhee: The intersection of sepsis and opioid use disorder highlights an important message around sepsis in general. There is so much focus on early recognition and treatment of sepsis in the hospital, which is perfectly important and makes a lot of sense. However, we are not focusing on what causes sepsis to develop in healthy people or people without underlying issues. Opioid use disorder is the perfect example of an issue that leads relatively healthy people to develop sepsis. There is only so much we can do to address sepsis once someone is in the hospital—we need to get upstream on the factors that predispose people to sepsis.
With massive turnover in the healthcare workforce, hiring high-quality candidates and retaining staff is essential for physician practices.
MGMA has suggestions and resources to help physician practices hire and retain employees.
Workforce shortages have become one of the biggest challenges in U.S. healthcare. About one in five of healthcare workers have left their job during the coronavirus pandemic.
In the current healthcare employment market, it is crucial to have a multifaceted approach to hiring, says Andrew Hajde, director of consulting and assistant director of association content at MGMA.
"It is extremely challenging now, with so many practices having job turnover. You need to use as many channels as possible to find candidates—online job sites, social media, local job postings, and the local chamber of commerce. Some of the best sources of candidates are personal referrals and word of mouth—that can be critical to attracting high-quality candidates. When you have excellent employees, they often know many other people who work in the same industry. You need to leverage as many channels as possible to get the word out that you have openings and tie that into your wages, benefits, and culture," he says.
Utilizing compensation benchmarking data should be part of a physician practice's hiring strategy, Hajde says. "It is more important than ever to use compensation benchmarking data such as that available from MGMA. Many people are leaving healthcare because they can find better compensation and perks outside of healthcare settings, so it is critical for practice leaders to look for ways to attract those people back into the healthcare workforce."
Practices should also have remote career opportunities, he says.
"There are many positions in medical practices that work well in a remote setting. Offering remote positions can broaden your applicant pool. You can have remote positions in scheduling work such as a call center, where remote workers can take calls and make appointments—these are positions where an employee does not need to interact directly with patients at the front desk. Billing and authorization positions can be done remotely. There are even clinical positions such as nurse navigators that can work in a remote setting. Having remote workers can reduce your office's footprint and increase employee engagement and satisfaction."
Offering long-term growth opportunities can help practices draw job candidates, Hajde says.
"When you think about the different positions where practices are struggling the most such as medical assistants, practices should think about long-term growth opportunities that can be offered to attract candidates. For example, you can have tuition reimbursement or programs where you are encouraging your medical assistants to become registered nurses. Eventually, a medical assistant may move on to a nursing role—even if you do not offer that role at your practice—but it gives employees growth opportunities and keeps them engaged in your practice through their education process. So, you might have an excellent medical assistant for several years even if they eventually move on to a hospital setting or another practice."
Employee retention at physician practices
Compensation levels and good benefits are essential for employee retention, but there are other key considerations, Hajde says.
"Having competitive wages and benefits is always going to be important to employees. However, most people who leave their jobs do so because of a couple of different factors, which can include a lack of appreciation for the job they are doing or not liking their supervisor or work environment. Some staff members view their work environment as a toxic situation. So, executives and medical practice leaders need to make sure that they have strong leadership skills and that they work on having an attractive culture for their organization."
It is important that an organization's culture is employee-centric and takes into consideration employee feedback on the way the practice functions, he says. "You need to provide feedback and appreciation for employees who are doing things well. Practice leaders need to take employee thoughts into consideration when they use quality improvement techniques to improve their operations. You need to go to employees to find ways to optimize their workflows and make sure they are engaged in the overall goals and mission of the practice."
"It provides resources; best practices recommendations in the areas of hiring, recruitment, operational efficiency, culture, and retention; and staffing benchmarks. Those areas are critical to not only helping an organization find and hire new talent but also to retain employees once they have been hired. It is also critical to improve practice efficiencies to make the staff you have more efficient and to make them more effective in their roles. We also have great information on staff compensation, benefits, and many other practice data points that can be useful by geographic area, practice type, and other metrics to help practice leaders make decisions."
For MGMA members, the organization offers an online community focused on workforce issues. "Our Staffing Member Community is a place where medical practice leaders can post questions or comments for their peers across the country. Typically, when MGMA members post questions or comments, they are getting expert responses and guidance not only from MGMA staff but also from peers nationwide, generally that same day. It helps practice leaders make decisions based on what is going on across the country, and other leaders can make recommendations for their particular situation," he says.
MGMA also has a Career Center, where practices can post open positions.
During the coronavirus pandemic, Intuitive Health has experienced strong patient volume growth and has retained clinical staff.
A Plano, Texas-based healthcare provider that is operating an emergency room and urgent care model under one roof has been experiencing success during the coronavirus pandemic.
In 2021, Intuitive Health saw explosive growth in patient volume—patient facility usage across all locations increased by 52% over 2020. In 2020, patient volume was up 35% over the level in 2019.
Intuitive Health is also expanding its locations, with new facilities opened in 2021 in Ohio and Florida. The organization is now operating 14 facilities in Florida, Indiana, Ohio, New Mexico, and Texas. Intuitive Health plans to operate 28 facilities in 13 states by the end of 2022.
Intuitive Health's emergency room and urgent care model addresses a longstanding problem in healthcare, says CEO Thom Herrmann, MBA. "The problem is if a patient shows up in a hospital emergency department, and they only need urgent care-level services, they are going to spend $2,000 or more when it could have cost them or their payer only $200 if they went to an urgent care center. On the flip side, if a patient ends up going to an urgent care center and they are having a life-threatening emergency, they are putting their health at risk."
Intuitive Health has taken the uncertainty out of a patient's decision to seek care in an ER or an urgent care center, he says. "The uniqueness of our model is we have decided to simplify things for patients. Every one of our locations is a free-standing, 24-hour, seven-day-a-week emergency department that also treats urgent care conditions. If a patient is not sure whether they should go to an ER or an urgent care center, they can come to our facility at any time of day. They are going to be evaluated by an ER physician. We have all of the same services as a hospital emergency department; but if it turns out that the patient does not need ER care, they are going to get a much lower-cost urgent care bill."
Resource utilization determines whether a patient is charged for an ER visit or an urgent care visit, Herrmann says. "We use resource-based criteria to determine whether someone receives ER-level care or urgent care-level care. There are certain services that are only available in an emergency department such as a CT scan or a complex lab service. Depending on what our physician needs to order or do to diagnose and treat the patient determines whether a visit is going to be billed as an ER visit or an urgent care visit. Most of our patients walk out with an urgent care bill because most situations do not require a high, ER-level of care."
Intuitive Health has six facilities in the Dallas market that the organization owns and operates independent of health systems and hospitals. However, its other facilities and future facilities will be operated as joint ventures with regional health systems, he says. "When we come into a new market with a health system, each one of the locations that we open is going to be branded under the health system's brand, but we are operating that facility for our health system partner."
Drivers of patient volume growth
Pandemic-related factors have driven patient volume growth at Intuitive Health facilities over the past two years, Herrmann says. "Some of the growth is testing related—over the past twelve months, patients have been looking for COVID testing. But there is a much bigger underlying trend unrelated to COVID testing."
Since the pandemic began, patients have been trying to avoid hospital emergency rooms, he says. "In 2020, there was a lot of fear and attention focused on the chances of contracting a communicable disease such as COVID inside a hospital emergency department. Most people have an experience of going to a crowded, somewhat disorganized emergency department, and it is not a pleasant experience. It is inconvenient. There are usually a lot of sick people waiting in the lobby. Most patients have to wait a long time in the lobby. So, in 2020, patients did everything they could to try to stay away from hospital emergency departments."
Intuitive Health facilities are an attractive alternative to hospital emergency rooms, Herrmann says.
"If you walk into one of our typical centers, patients generally wait in the waiting room for less than 10 minutes before they are taken to a room. Our design is focused on rapid throughput for the patient. Our sites are also clean and sanitary. So, when patients have the opportunity to experience service in one of our facilities, they realize that we offer all of the same emergency services that they would get in a hospital emergency department. They also understand the value proposition that if they do not need ER services, they are going to get a lower-cost bill," he says.
Staff retention
During the pandemic, Intuitive Health has been able to buck the trend of clinical staff shortages. Early in the pandemic, childcare was a prime motivator for clinical staff to leave healthcare organizations, Herrmann says. "You had people who expected their kids to be in school, then the schools or their childcare center were closed. They faced dropping shifts to care for their child at home. The first step was working collaboratively with our staff to identify employees who had childcare challenges and have them change shifts with other employees who did not have those same kinds of challenges."
Intuitive Health also offered retention bonuses to encourage staff to remain with the organization, he says. "As market conditions changed and workloads changed, we introduced retention bonuses as a way to compensate employees for sticking through the challenging time of increased COVID patient volumes."
The organization also focused on safety, Herrmann says. "We made sure that clinical staff had all of the personal protective equipment that they needed, that they were working in a sanitary environment, and that we had screening protocols for patients who we thought were symptomatic or at high risk for transmission of coronavirus."
Burnout has been a top concern, he says. "We made sure staff were getting relief from long shifts. We made sure there was adequate staff support within all of our clinics—whether that was scribes or administrative support—to try to make life as easy as possible."
The multipronged effort to retain staff has been successful, Herrmann says. "All of these things in a cumulative sense allowed us to retain staff at a high rate and maintain high employee satisfaction scores."