Migraine can be safely diagnosed in the primary care setting and advanced medications are available.
There is a shortage of neurologists nationwide, and primary care physicians can help fill the gap in migraine care, a headache expert says.
Migraine is one of the most common disabling medical conditions, according to the American Migraine Foundation. In the United States, 1 in 4 households has a family member who suffers from migraine, and migraine affects 1 out of 7 people globally, the foundation says.
Recent advancements in migraine care and research make treating migraine in the primary care setting easier, says Loretta Mueller, OD, a headache specialist and family physician at Cooper University Health Care, which is based in Camden, New Jersey. "There has been a boom of new therapies in recent years and a lot more research going on. It is a good time to be treating headache and researching headache. The newer medications that are out generally are tolerated better than the older medications, and many of them work much quicker than the older medications."
Primary care physicians have several medication options for migraine that have become available over the past four years, she says. "The newer ones that have come out since 2018 include injected monoclonal antibodies that target the calcitonin gene-related peptide, which is migraine specific. We also have new oral medications called gepants that also target the calcitonin gene-related peptide. Two of the oral treatments are for as-needed use once a headache starts—rimegepant, which is Nurtec ODT, and ubrogepant, which is Ubrelvy. We also have a new medication that is only for headache prevention—atogepant, which is Qulipta. Nurtec ODT can also be used for prevention, when taken every other day."
Detecting migraine in the primary care setting
Diagnosing migraine is appropriate for the primary care setting, Mueller says. "It is not a procedural field, so every primary care physician who has an interest in headache should be able to treat migraine. It is just a matter of having the time to sit down and provide the care as well as having the education about what to look for. The reality is that most of what you are going to see in a primary care practice is migraine. So, if primary care physicians were taught to start with the diagnosis of migraine and work backwards from there, we would have a lot more patients who could be easily treated for migraine."
To diagnose migraine, primary care physicians should review the patient's medical history and schedule a visit to focus on the patient's headaches, she says.
"The medical history is key as well as dedicating an office visit specifically for headaches rather than just having a by-the-way complaint when a patient is in the office for high blood pressure or another condition. The primary care physician should focus only on headache during a visit. I see nothing but headache patients on a hospital's neurology floor, and it takes me an hour with a new patient, but we do have migraine identifiers such as ID Migraine, which is only three questions: Have you not been able to function at least one day out of the past three months because of your headaches? Do you ever get nauseous with your headaches? Do you ever get light sensitivity with your headache? If two out of those three are positive, there is about a 93% chance that the condition is migraine. If all three are positive, there is a 98% chance that the condition is migraine."
Primary care physicians can use tools to rule out more serious causes of headache such as SNOOP, Mueller says.
'S' is for systemic symptoms such as cancer.
'N' is for neurologic abnormalities.
The first 'O' is onset of rapid escalation of pain within seconds or the so-called thunderclap headache that can be a marker for aneurysm or brain bleed.
The second 'O' is for onset of new headache over the age of 50.
'P' is for prior headache history, where a change in headache history such as increased severity or frequency could be signs of a serious condition.
Treating migraine in the primary care setting
The treatment of migraine requires a holistic approach to care, Mueller says. "It comes down to a clinical judgment call. There is no single algorithm as is the case for other conditions such as a diagnosis of Lyme disease calling for a specific antibiotic. There is some art in the treatment of migraine because many of these patients have other comorbidities such as depression and anxiety. You look at the whole picture."
Migraine treatment can be complicated, she says. "There are many treatment options. For example, how many medications do you go through or how many classes of medications do you go through with the patient in shared decision-making. A lot of migraine care requires shared decision-making. Some patients definitely have a preference as to what they are looking for or side effects that they do not want. Some migraine medications have weight gain associated with them."
Compared to other hospitalized patients, patients with diabetes have longer lengths of stay and higher readmission rates.
Hospitals could save millions of dollars with better glycemic control of patients with diabetes.
In 2017, per capita healthcare expenditures for hospital care were estimated at $4,966 for patients with diabetes and $1,202 for patients without diabetes, according to the American Diabetes Association. Riverside Healthcare found that better management of hypoglycemic patients at their facility led to an estimated savings of $544,756 annually, and that by reducing length of stay in critical care units due to the implementation of a computer-guided insulin protocol they achieved a $2.1 million in savings in a year.
"There are high healthcare costs with the poor management of blood sugar. Costs associated with diabetes in hospitals include length of stay—these patients tend to stay in the hospital longer than other patients. They need more treatments—insulin management is a major cost for these patients. They need more interventions. They also have more readmissions than other patients," says Betsy Kubacka, MSN, an endocrinology advanced practice registered nurse at The Hospital of Central Connecticut in New Britain, Connecticut.
There are two primary elements of caring for patients with diabetes in the hospital setting, she says. "When a diabetic patient is admitted to the hospital, they are primarily treated with insulin, which is the safest modality and has the least amount of side effects. We can get blood sugar control of the patient and maintain it throughout the hospitalization. When they are under control, patients can recover quicker and have less of a risk for infection. For most patients, we want to keep their blood sugar between 100 and 180 milligrams per deciliter throughout the hospitalization. We also want to ensure that our diabetic patients have adequate diabetes education to manage their diabetes when they are back home. We provide chronic disease management education."
Diabetes management is a challenge in the inpatient setting, Kubacka says. "Resources such as endocrinology are often limited at hospitals, so it is often a challenge getting our patients under control within the hospital setting. With insulin, you must give the right amount. If we don't give the right amount, you either have blood sugar that is too high or too low, both of which can lead to adverse outcomes."
In the hospital setting, there are adverse outcomes for patients with diabetes who have low blood sugar and high blood sugar, she says. "The adverse outcomes of low blood sugar include hypoglycemia, which can make the patient feel shaky and dizzy. In severe cases where the patient's blood sugar goes below 40, they can have altered mental status or hypoglycemic coma. Those patients have a longer length of stay at the hospital. Low blood sugar is the biggest concern for hospital staff. The adverse outcomes of high blood sugar—above 180 during hospitalization—include bacterial infections. Among COVID-19 patients, those who had uncontrolled high blood sugar while hospitalized have had higher mortality rates."
Managing hospitalized diabetic patients
Expert resources for patients with diabetes are often lacking in many hospitals across the country, and technology can fill the gap, Kubacka says. "We have a shortage of endocrinologists. We have a shortage of nurses who specialize in diabetes to help support team members in managing diabetic patients in hospitals. With a shortage of expert resources, we must look at things like technology to improve glycemic care. That is something that we implemented within Hartford HealthCare to assist our staff in calculating insulin doses by using Food and Drug Administration-cleared computerized algorithms."
The Hospital of Central Connecticut has launched three primary initiatives to improve glycemic care, she says.
"There has been a lot of work in order set design. Within the electronic health record, we provide guidance to our physicians, nurse practitioners, and physician assistants in how to prescribe insulin. So, although endocrinology may not be their specialty, information on how to prescribe for a patient is at their fingertips."
"We have ensured through our nutrition services that diabetic patients are getting the correct diet. We ensure that we have a process, so the nurse knows when a meal is delivered, and the nurse can check the patient's blood sugar before the meal and administer insulin in a timely manner. We have put processes in place and support the staff as best as we can."
"We have an endocrine council that meets monthly, and I serve on that council. We look at any adverse event that occurs in the hospital and do root cause analysis on those events to see if there is anything within our processes that we can do differently to prevent adverse outcomes in the future."
Researchers found that completion of the primary series of COVID vaccination before acute COVID-19 illness was associated with a lower risk of long COVID.
A new research article gauges the prevalence of long COVID symptoms among U.S. adults and examines the effectiveness of vaccination for averting long COVID.
The World Health Organization has definedlong COVID as a syndrome that occurs three months after a COVID-19 infection, with symptoms that last for at least two months. Long COVID symptoms include cough, shortness of breath, anxiety, depression, cardiac issues, and fatigue.
The new research article, which was published by JAMA Network Open, features survey data collected from more than 16,000 adults who experienced a test-confirmed COVID-19 illness. The study includes several key data points:
Among the 16,091 survey respondents, 2,359 people (14.7%) reported long COVID symptoms. When this data was reweighted for national sociodemographic distributions, these long COVID patients represented 13.9% of patients who had tested positive for COVID-19.
Completion of the primary series of COVID vaccination before acute COVID-19 illness was associated with a lower risk of long COVID (odds ratio 0.72).
Older age per decade above 40 years was associated with higher risk of persistence of long COVID (adjusted odds ratio 1.15).
Female gender was associated with higher risk of persistence of long COVID (adjusted odds ratio 1.91).
People with a graduate education versus high school or less were associated with a lower risk of persistence of long COVID (adjusted odds ratio 0.67).
People who lived in urban versus rural areas were associated with a lower risk of persistence of long COVID (adjusted odds ratio 0.74).
Among long COVID patients, fatigue was the most common symptom (52.2% of patients), followed by loss of smell (43.7%), brain fog (40.4%), and shortness of breath (39.7%).
"This study suggests that long COVID is prevalent and associated with female gender and older age, while risk may be diminished by completion of primary vaccination series prior to infection," the study's co-authors wrote.
The data estimates the prevalence of long COVID among adults who test positive for COVID-19, they wrote. "In this cross-sectional study of a cohort of 16,091 adults surveyed between February 2021 and July 2022 in all 50 states in the U.S. and the District of Columbia, we estimated that 14.7% of those who reported a positive COVID-19 test result more than 2 months previously continued to describe symptoms that they associated with acute infection, or 13.9% after reweighting to reflect the U.S. adult population."
To help address healthcare workforce shortages in western Kentucky, Owensboro Health has led an effort to open a staff development innovation center in Owensboro, Kentucky.
Many healthcare executives say workforce shortages are their top challenge as the country emerges from the crisis phase of the coronavirus pandemic. Health systems, hospitals, and physician practices nationwide are struggling with workforce shortages in clinical and nonclinical roles.
Mark Marsh, president and CEO of Owensboro Health, says workforce shortages have affected the entire organization. "Throughout the country, workforce shortages are impacting our ability to provide care. It is affecting clinical roles such as nursing, respiratory therapy, and physical therapy, but we are seeing shortages throughout our organization including the support staff, dietary staff, and housekeeping. With COVID, we had a lot of retirements. We are seeing shortages on the inpatient and the outpatient sides."
Owensboro Health has launched the Commonwealth West Healthcare Workforce Innovation Center (CWHWIC), which was formed in collaboration with nine regional colleges and universities. The Kentucky General Assembly approved $38 million to establish the innovation center and develop a curriculum.
Owensboro Health got involved to spearhead the CWHWIC to meet a critical need, Marsh says. "We knew we were facing workforce hardships, including burnout from COVID. I am on a collaborative with the other nine big health systems in Kentucky, including Norton Healthcare. We were all facing workforce hardships. With traveling nurses, we have just been swapping nurses. So, we have been trying to put a plug in the problem, but even with the travelers, it has not been enough."
Working in collaboration with the colleges and universities is a critical component of the CWHWIC, he says. "We are blessed—we have nine colleges and universities in the western part of the state. When I first got here—I have been at Owensboro Health for about 16 months—I pulled those nine colleges and universities together and said, 'Here is what we are confronting.' I said, 'How can we put our collective resources together to address workforce shortages?' I came to the conclusion that we are going to be a lot better off trying to solve for this problem ourselves rather than rely on state or national resources. CWHWIC is an attempt to grow our own staff."
Owensboro Health worked with state legislators to establish the CWHWIC, Marsh says. "That was the exciting part. … Lawmakers love collaborative efforts. They saw nine public and private institutions come together with a solution. Lawmakers had been hearing about workforce shortages from the health systems in Kentucky. It made it easy for me to work with some of our local politicians. One was state Rep. Suzanne Miles. We had the chance to put our story together, and we went to the capital to meet with politicians. What was initially designed just to present the concept and how the innovation center would help moved so quickly that it went up for a vote in the appropriations committee."
Owensboro Health has invested heavily in the CWHWIC, says Bart Darrell, vice president of the innovation center. "Owensboro Health did not just go to the legislature and make a request for money. It has made a significant investment in everything from personnel to auxiliary services and the human resources piece. Owensboro Health is all in. This would not have moved forward if the state legislature and the governor did not believe that Owensboro Health was going all in. There is a significant $10 million–$12 million investment from Owensboro Health, which makes a great point to everybody that this is not just an idea. This has been researched and we have the right people involved."
How the CWHWIC will work
Owensboro Health has made a facility available to house the innovation center, Marsh says. "We have a facility that serves as our business office in the heart of Owensboro. It is about 48,000 square feet. We needed space to create the simulation labs and the innovation center. We were able to have some people work from home, and we have some other facilities throughout the area where we can relocate some of our personnel. It gave us the freedom to go ahead and convert and retrofit our business office into this new innovation center. That was a great speed to market for us and we are investing those resources."
The contribution of space for the innovation center was crucial for the initiative, Darrell says. "If Owensboro Health was not willing to contribute this building, you could not build a similar facility with the money that is coming from the legislature. Without that facility, this initiative would not be happening. It is going to be a state-of-the-art facility. It will have the cutting edge in technology as it relates to simulation."
Simulation labs are the key component of the CWHWIC, he says. "Anything that we do here is going to be done with excellence. So, we are making sure that we are being smart on how we start down the road. We anticipate offering simulation lab training in nursing, respiratory therapy, radiology, and lab techs initially."
The simulation labs will provide essential training at the innovation center, Marsh says. "We are putting together 13 simulation labs—those simulation labs are going to provide real-life scenarios where participants can see what an operating room nurse is or an ER nurse is. We are trying to role-play and provide real-life scenarios, so when participants get into the workplace setting, it will reduce the orientation and allow them an easier transition. It will give innovation center participants a better understanding of what their jobs entail."
Collaboration with the colleges and universities is also crucial, Darrell says. "Another piece is when we collaborate with the colleges and universities. Each one of them has their own niche or specialty. We know where we are going for the first three to five years, but we are also ready for whatever the healthcare environment presents to us and whatever technological advances arise. We believe we will be well-positioned to take advantage of change."
Researchers examined 1,193 major surgeries involving 992 community-living older adults from 2011 to 2017.
Among nearly 1,000 Medicare beneficiaries over age 65, the overall 1-year mortality rate after major surgery was 13.4%, according to a new research article.
Earlier research has found that the 5-year cumulative risk of major surgery for older U.S. adults is 13.8%, which amounts to nearly 5 million people. Given this relatively high number, major surgery for older adults is a consequential public health concern in the United States.
The new research article, which was published by JAMA Surgery, features data collected from 1,193 major surgeries involving 992 community-living older adults from 2011 to 2017. The data was drawn from Centers for Medicare & Medicaid Services fee-for-service Medicare claims and the National Health and Aging Trends Study. The definition of major surgery included any procedure performed in an operating room with general anesthesia.
The study includes several key data points:
The 1-year mortality rate was highest for patients over the age of 90
The 1-year mortality rate for elective surgeries was 7.4%, and the mortality rate for nonelective (unplanned) surgeries was 22.3%
Older adults who had elective surgery tended to have a more favorable risk profile than older adults who had nonelective surgery, including younger age, higher educational attainment, and lower incidence of frailty as well as possible or probable dementia
The 1-year mortality rate for older adults who were not frail was 6.0% and 27.8% for older adults who were frail
The 1-year mortality rate for older adults without dementia was 11.6% and 32.7% for older adults with probable dementia
The median time to death was 96 days for all major surgeries, 169 days for elective surgeries, and 62 days for nonelective surgeries
"In this study, the population-based estimate of 1-year mortality after major surgery among community-living older adults in the U.S. was 13.4% but was 3-fold higher for nonelective than elective procedures. Mortality was considerably elevated among older persons who were frail or who had probable dementia, highlighting the potential prognostic value of geriatric conditions after major surgery," the research article's co-authors wrote.
Interpreting the data
The data shows there are significant differences in 1-year mortality after major surgery for older adults across subcategories, the study's co-authors wrote.
"We found that nearly 1 of every 7 community-living older U.S. adults died in the year after major surgery, including more than 1 of 4 who were frail and nearly 1 of 3 who had probable dementia. Mortality was 3-fold higher for nonelective than elective surgery and was especially elevated for persons who were 90 years or older. Our findings suggest substantial differences in 1-year mortality after major surgery across distinct subgroups of older persons and highlight the potential prognostic value of geriatric conditions such as frailty and dementia," they wrote.
The data suggests there are ways to improve outcomes for older adults who undergo major surgery, the study's co-authors wrote. "Our findings are notable because they define the scope and scale of mortality after major geriatric surgery in the U.S. and because they suggest a mix of surgical quality and safety among older persons. With improved preoperative optimization and recognition as well as enhanced perioperative management strategies, it is possible that mortality after major surgery could be reduced among older persons, especially those in high-risk subgroups."
Researchers examined data from 9.5 million deliveries in hospitals between 2007 and 2018.
Compared to White women, Black women had a 53% increased risk of dying in the hospital during childbirth, according to new research set to be presented at the ANESTHESIOLOGY 2022 conference.
Earlier research has found racial healthcare disparities in maternal mortality. For example, a 2019 study by researchers at the Centers for Disease Control and Prevention found that pregnancy-related deaths per 100,000 live births for Black, American Indian, and Alaska Native women older than 30 were four to five times as high as they were for White women.
The new research is based on data collected from 9.5 million deliveries in hospitals between 2007 and 2018. The data was drawn from inpatient databases in California, Florida, Kentucky, Maryland, New York, and Washington.
The finding that Black mothers had a 53% increased risk of dying in hospitals compared to White women was regardless of income level, type of insurance, or other social determinants of health. The research includes another key finding. Of the 49,472 mothers who died in the hospital or experienced harm to the heart, eyes, kidney, or other organ, there were 0.8% of all Black women, 0.5% of all Hispanic women, and 0.4% of all White women.
"This study is the most up-to-date and extensive study—factoring in various states, insurance types, hospital types, and income levels—to determine that the much higher maternal mortality rate among Black women often cannot be attributed to differences in health, income or access to care alone," Robert White, MD, MS, lead author of the study and assistant professor of anesthesiology at Weill Cornell Medicine in New York, said in a prepared statement.
White called for interventions to address the healthcare disparity. "Clearly there's a need for legislation to improve access to healthcare throughout pregnancy and improve funding among safety-net hospitals. But it's also essential that hospitals train their employees to provide culturally appropriate care, offer translation services, and conduct implicit bias association testing."
Anesthesiologists are well-positioned to impact maternal mortality, White said. "Physician anesthesiologists are leaders in quality, safety, and perioperative medicine and are working very hard to help decrease racial differences through science and implementation of protocols that treat everyone the same—with a focus on those who are worse off to achieve health equity. We not only provide pain management during childbirth, but our training in critical and emergency care help us to proactively handle complications, prevent death, and ensure the health and safety of the mother and baby."
Healthcare organizations must create an environment where it is unambiguous that racist behavior will not be tolerated, ECRI's top leader says.
A new report published by ECRI includes data on racist incidents at health systems and hospitals.
The majority of the racist incidents involved patients and family members making inappropriate comments related to race or ethnicity. These comments can have a negative impact on the mental health of healthcare providers—leading them to consider leaving their jobs at a time when workforce shortages are a significant problem at healthcare organizations.
The new report features data collected between July 1, 2019, and June 30, 2020. The data on racist incidents was drawn from more than 500 patient safety incident reports collected from health systems and hospitals nationwide.
The patient safety incident reports were broken into seven categories:
Patients or family members making inappropriate comments about race or ethnicity (56%)
Patients saying that others are racist or engaged in racist behavior (22%)
Patients or family members saying that they received substandard care because of the patient or family's race or ethnicity (9%)
Staff members making inappropriate comments about race or ethnicity (7%)
Staff members saying management or a supervisor discriminated against them (4%)
Patients requesting a healthcare provider based on race or ethnicity (1%)
Patients or family members complaining that interpretation or translation services were not provided (less than 1%)
Addressing racist incidents at healthcare organizations
Racist incidents are not just a matter of bad behavior, Marcus Schabacker, MD, PhD, president and CEO of ECRI, told HealthLeaders.
"These incidents have negative consequences for patient safety directly and indirectly. If a staff member is exposed to racist comments, then they are going to be impacted in their emotional well-being. If they are not emotionally well—if they are frustrated or angry—they may not be able to provide the best care and they might not be as attentive to potential health issues of the patient as they could be. That is a direct impact on patient safety. If a staff member has racially motivated issues, they might not provide appropriate care to a patient," he said.
There are two primary ways healthcare organizations can detect racist incidents in the workplace, Schabacker said. "First of all, the leadership, administration, and management team must provide an environment in which employees and patients feel comfortable that they can report these issues, that they are going to be taken seriously, and that there are mechanisms in place for incidents to be reported. Secondly, it is helpful to have a dedicated member of the senior management team who is the advocate for reporting and is trained in dealing with these issues both on the staff side and the patient side."
Although healthcare organizations cannot single-handedly change racist societal constructs, they can create an environment where it is unambiguous that racist behavior will not be tolerated, he said. "Leadership at the top must be clear that racism is an unacceptable behavior, then they must train their staff on being able to deal with racism in the appropriate manner. There also must be training for conscious and unconscious biases among staff. Unconscious bias is a big source of racially tainted comments. Leadership can't do much about unconscious bias among patients, but they can certainly address it among staff."
Healthcare organizations can address racist comments by patients, Schabacker said. "Among patients, they may not be aware that they are making racially tainted comments, but someone in an appropriate way can address the patient and say, 'I'm not sure you meant to say that, but it was very offensive, and we ask you not to do that anymore.' That signals to the staff that they are taken seriously, which can prevent their frustration or even leaving their job."
Staff members should be able to turn to specific people in the organization when a patient or family member makes racist comments, he said.
"As difficult as it is, they should not engage with the patient. The organization should have people to notify under these circumstances, so the staff member can say, 'I was exposed to this behavior. I feel uncomfortable addressing that person. Can you speak to them?' There needs to be a safety net for staff. They need to know that they will be taken seriously. They need to know they have somebody to go to. There must be a mechanism in place to support them. The leadership and the administration must take action."
To address racist behavior by staff members, healthcare organizations should have a clear culture and rules for what is acceptable and what is not acceptable, Schabacker said.
"You need to provide training to everybody—particularly around unconscious bias. When incidents occur, they should be tackled up front. It should not be allowed to fester. A typical reaction is to say, 'They really didn't mean that.' But if there is a racist comment, it needs to be dealt with and it needs to be addressed. There should be a clear code of conduct and a rulebook that says if there is racist behavior, here is what this organization is going to do. If something happens, there is a warning, there is training, then if something happens again, there is an escalation and there are disciplinary consequences."
One chief physician executive says the primary COVID-19 challenge now is "getting everyone to think about it as an endemic versus a pandemic."
Now that COVID-19 has reached an endemic phase, one of the biggest challenges facing healthcare organizations is to "recharge batteries" for healthcare workers who have been on the frontline of the pandemic, says Jordan Asher, MD, executive vice president and chief physician executive at Sentara Healthcare.
Asher is one of more than a dozen healthcare executives set to participate in The Way Forward, a HealthLeaders leadership summit being held this week at the Loews Atlanta Hotel in Georgia. Asher will serve on a clinical care panel, and there will be panels for CEOs, chief financial officers, and chief information officers.
The focus of The Way Forward will be on sharing plans, thoughts, strategies, and impressions of the future of the healthcare industry. HealthLeaders' coverage of the leadership summit includes a Q&A interview of each panelist. The transcript of Asher's interview below has been edited for clarity and brevity.
HealthLeaders: Now that the crisis phase of the coronavirus pandemic has passed, what are the primary clinical challenges that you are facing?
Jordan Asher: We are facing three clinical challenges. The first is continuing the great work that we did during the pandemic. We were innovative and creative, and we want to continue that work.
The second challenge is finding ways to recharge batteries for clinicians and other frontline staff who worked during the pandemic. Everyone needs to recharge and get relaxation. We need to figure out how to do that even though we still have work to do as COVID-19 continues.
Third is dealing with staffing issues that have occurred, including workforce shortages related to the pandemic. There are staffing issues that we are all dealing with in healthcare. Across the country, it is just hard to fill positions across the board in every market. There is a labor shortage today.
HL: What are you doing to address workforce shortages?
Asher: We are doing several creative things. Number one is meeting workforce demands within the needs and desires of the workforce. So, we are getting creative around scheduling. We are thinking about automation to enhance what we do every day, and we are redesigning workflows to make jobs easier to do.
We are also trying to create our own internal staffing services such as traveling nurses. So, we are coming at this from multiple directions at the same time. At Sentara, we have multiple locations, and we can set up traveling staff services internally. It is like a match.com model—we find the people who want to do that type of work, identify the needs, and bring those factors together.
HL: Now that we are in a new phase of the pandemic, what are your primary COVID-19 challenges?
Asher: Our COVID-19 challenges now are getting everyone to think about it as an endemic versus a pandemic. Now that we have vaccines, now that we have treatments, now that there is much more immunity in the community, we need to shift from how we were thinking during the crisis and transfer our response to a new phase of the virus. We need to think about coronavirus as one of the things we are dealing with just like we do with the flu.
A challenge now is that everybody was thinking in a certain way for two years, but we have progressed in our science, our treatments, and our prevention. Now, we need to think about how we move forward more than we did during the first two years of the pandemic. Now, many people have had COVID, and many people are getting it again. There are COVID long haulers, and we need to learn how to treat that condition. We need to figure out how to think about the COVID boosters in a process model, and we need to think about public health measures and prevention.
HL: In the next year, in what areas would you like to launch clinical initiatives?
Asher: In the next year, we are focused on enhancing clinical initiatives, including how we get the care and services for the community into the community. So, we are focusing on health equity issues and disparities that we saw rise up during the pandemic.
We want to focus on behavioral health. There are two components we want to address. First, there is the psychiatric component or chemical imbalances. Second, there is the behavioral component of human beings in their overall health and wellness.
HL: In what ways are you enhancing existing programs related to behavioral health?
Asher: Behavioral health has been thought of differently than other conditions such as heart disease. It has sort of been disconnected. So, one thing we are doing is saying, "Wait a second. We need to reconnect behavioral health because we see it all the time in multiple situations."
We also need to think about the upstream services that are needed within behavioral health. Behavioral health is a bigger issue than just mental health. We need to address the areas that are rising up in a much more coordinated and longitudinal manner.
From a behavioral health standpoint, we need to figure out what makes patients tick. How do we activate patients? How do we engage patients both for their mental health and their other healthcare issues?
HL: Do you have any other insights on the way forward now that the crisis phase of the coronavirus pandemic has passed?
Asher: What I think we have learned and what we need to remember is that we must be adaptable. We must live with ambiguity, and we must embrace it. We must remember that we are managing multiple things at the same time, and we have to live with that complexity.
HL: How has the business of healthcare changed because of the pandemic?
Asher: We will have to treat the business of healthcare a little bit like we treated the pandemic. Meaning, we must get creative. We must do things differently, and we must think more broadly about what we do versus just taking care of patients when they are sick—and we need to figure out how that approach to care can be funded.
The new reality gets back to the conversation around labor shortages. From a business standpoint, we have inflation, which is driving up costs. So, I have inflation on one side, and even if I wanted to hire people, they are not out there. So, from a business model standpoint, I have got to say, "OK, how do I solve those problems? How do I think about process automation? How do I think about working at the top of licenses? How do I think about the business principles of the demand side of employees and what they are needing?"
Alternative care sites can address several challenges, including boosting access for underserved populations and increasing mental health services.
Alternative sites of care offer several opportunities for healthcare organizations and their patients, according to a new report published by Deloitte.
Alternative sites of care include retail clinics, mobile units, telehealth, community health centers, and care in the home such as hospital at home and outpatient care in the home. Alternative sites of care are not new, but they are a growth area with advantages over traditional doctor's offices such as the ability to improve the consumer experience.
A co-author of the report, Jay Bhatt, DO, MPH, MPA, executive director of the Deloitte Center for Health Solutions and Deloitte Health Equity Institute, told HealthLeaders that alternative sites of care are geared toward serving increasingly empowered healthcare consumers.
"There is a premium on getting closer to patients and providing personalized service as well as meeting patients where they are. By creating more access points, we can support consumer experience, including opportunities to address the drivers of health that directly influence health outcomes. By understanding what consumers need for today and incorporating the range of perspectives that are provided by alternative care sites, organizations can shape better strategies to connect with consumers, build trust, and have a better healthcare experience," he said.
The report is based on survey data collected from a nationally representative sample of more than 4,500 consumers in February and March 2022. The report also includes data collected from online focus groups with more than 400 consumers who identified as Black, Hispanic, Asian, and Native American.
Boosting access for underserved populations
Alternative care sites can improve healthcare access for underserved populations, the report says. "Alternative care sites can help make care more equitable and accessible by providing more patient touch points and expanding the location options for well visits, mental health care services, and so much more. Our survey findings show that retail clinics, virtual health, and community health centers could bridge care delivery gaps for populations that have been historically underserved," the report says.
Alternative care sites have tremendous potential to provide care to underserved populations, Bhatt said. "Alternative care sites can offer more convenient, accessible, and equitable care. We know that there are challenges in getting to traditional care sites. There are issues related to trust, stigma, transportation, and people's lives such as if they are working multiple jobs."
Virtual visits are an emerging area to provide medical services to underserved populations, he said. "At Deloitte, we have seen in our data that many consumers are willing to use virtual health, which would help address gaps in care. Nearly three in four consumers with Medicaid or health insurance exchange plans would use virtual health for mental health visits, for example. More urban consumers would use virtual visits for preventive care. Nearly two-thirds of consumers would use virtual visits for medical care among all races and ethnicities."
Building trust by connecting patients to diverse care teams
Alternative care sites are an opportunity for healthcare organizations to build trust with patients from ethnic and racial groups who feel disaffected with healthcare providers, the report says. "Alternative care sites—if staffed with diverse and empathic care teams—could be opportunities for healthcare organizations to connect with their consumers and rebuild trust. One step to rebuilding trust is employing clinicians and care teams who look like, have shared experiences, and demonstrate empathy toward the communities they serve."
Staffing alternative care sites with diverse care teams is crucial to building trust, Bhatt said. "We have seen in our data in this report that two out of three participants who identify as Black, Asian, or Hispanic descent would like to see healthcare providers who are similar to them—either in race or lived experience. So, consumer and community trust in healthcare providers and organizations is critical for optimal health. Trust influences patients' willingness to get medical care, preventive screenings, and mental health care. We have seen data that shows trust links to improved patient experience, health outcomes, and perception of the care that patients receive."
Improving access to mental health services
Virtual health and other alternative care sites are an opportunity to boost access to mental health services, the report says.
"Virtual visits could be a way for increasing access to mental health care, particularly for individuals in communities where stigma is high. Virtual health could provide access to a clinician who has a shared background or lived experience that an individual may not be able to see during an in-person visit. … Retail clinics, community health centers, or virtual health apps that can feel like a safe and accessible way for individuals to access care could fill a much-needed gap for consumers who want mental health treatment," the report says.
Alternative care sites are part of the solution to increasing much needed mental health services in the country, Bhatt said. "About 50 million adults in the United States experience some type of mental illness, yet more than half of these people do not receive treatment. Access is uneven across the United States, with 37% of Americans living in a mental health provider shortage area. So, we must think about different ways of approaching care delivery, and alternative care sites are an important answer to those challenges."
Meeting consumer demand for convenience and transparency
Alternative care sites are effective in providing convenience and transparency to patients, the report says.
"Consumers' desire for convenience is well-known, but important—and we need to solve for it because consumers are increasingly expecting a healthcare experience that feels like experiences in retail, banking, and other industries. … Another component of a positive patient experience is transparency. In our 2018, 2020, and 2022 consumer surveys, consumers said 'having clear explanations of costs' was the best indicator of a good patient experience in healthcare. Retail clinics and therapy apps tend to provide fixed and transparent pricing, and most accept insurance/Medicare, which is not necessarily true among more traditional providers," the report says.
Convenience is a primary reason why patients use virtual health, Bhatt said. "Convenience is driving healthcare consumers to virtual health visits. We found convenience is the Number One reason patients use virtual health."
Alternative care sites often provide a higher degree of transparency for patients than traditional doctor's offices, he said. "We know that alternative care sites that offer transparency and a safe space can influence consumers to make better healthcare decisions. For example, we do not have consumers flying blind in grocery stores or other locations shopping for consumer goods without having transparency about price and what they are getting. We should think about transparency in the context of healthcare services and more and more of that is happening at alternative care sites."
For physician practices, potential decreases in telehealth reimbursement and other financial challenges loom on the horizon.
Workforce shortages are the primary challenge facing physician practices as the country emerges from the emergency phase of the coronavirus pandemic, the chief operating officer of the Medical Group Management Association (MGMA) says.
Staffing shortages are impacting the entire healthcare sector. Nurse vacancies are forcing hospitals to close beds and doctors are in high demand at health systems, hospitals, and physician practices.
"Practices are still struggling with staffing—that is issue one, two, and three for practices," MGMA COO Ron Holder, MHA, told HealthLeaders during the organization's conference this week in Boston. "It is hard to find medical assistants, nurses, front-desk staff, and revenue cycle staff. The economy being what it is and inflation being what it is, there are positions that are competing for some entry-level staff in practices that were not competing for that staff before. It is challenging."
Some practices are regretting staff decisions made during the pandemic, he said. "When the pandemic hit, the first thing they did was get rid of medical assistants and other staff. That is hanging around their neck now."
Practices can pursue several strategies to address workforce shortages, Holder said. "They can do some innovative things with regards to working with local programs to support nursing such as students and medical assistants at local colleges. They can help pay off student loans to get medical assistants and nurses to join their practice. They can offer flexible work schedules—flexibility in work schedules is highly desirable now."
Practices can also try job sharing, he said. "There can be two people in the job market who are medical assistants who only want to work 20 hours per week. If you can match up the schedules, you can cover a full-time position, with two bodies instead of one."
Challenges beyond staffing shortages
"There are a couple of challenges that are on the horizon that could be as big of a factor as staffing. The public health emergency for COVID-19 is set to expire this month. Although we believe it will be extended, whenever the public health emergency is lifted, it will present a challenge to physician practices," Holder said.
When the public health emergency is lifted, providing telehealth services could be harder for physician practices, he said. Before the pandemic, telehealth services were reimbursed at a lower rate than in-office visits, but Medicare and other payers established reimbursement parity for telehealth services during the pandemic.
"When the public health emergency ends, there likely will be a period when reimbursement parity for telehealth services will go away," Holder said. "The smart practices have figured out how to adjust their overhead and adjust their cost structures, so that when the payments for telehealth go back down, they will be able to continue telehealth services. If a practice has been doing their telehealth services in an expensive brick-and-mortar site in a nice part of town, when the reimbursement for telehealth drops, they will be losing money. Other practices have figured out how to do telehealth from home, for example."
Practices are also facing financial challenges, he said. "There are also Medicare reimbursement cuts that are set to go into effect at the end of this calendar year, layered with inflation at 9% to 10%. There is no way for practices to make up 9% to 10% in revenue because there is no inflation factor on physician reimbursement like there is in some other aspects of healthcare. So, they are paying for services that have been increased because of inflation, but they have limited ways to increase their revenue."
Opportunity knocks
Value-based care represents an opportunity for physician practices in the new phase of the pandemic, Holder said.
"Practices need to figure out a way to invest in value-based care and make value-based reimbursement work. As the pandemic ends, we are going to see continued progress toward value-based care that took a pause during the pandemic. For example, if you are in primary care, you need to figure out how to put an infrastructure in place such as having a mental health professional on your staff or social workers to address social determinants of health. The goal will be to keep patients out of the hospital, which is often the most expensive part of care."
Payers are likely to step up their value-based care efforts, he said. "Medicare and Medicaid are one part of value-based care, but you are seeing more of the commercial insurers that are moving in that direction. Insurers are going to be pushing more risk on the practices. So, if you can figure out how to manage risk for your patient population, you are going to be OK. If you cannot manage risk, that may be a danger zone for your practice."
