The health system is experiencing staff shortages in all areas, including certified nursing assistants, registration, pharmacy, respiratory therapy, and registered nurses.
Workforce shortages are the biggest challenge at Clive, Iowa—based MercyOne, the health system's chief medical executive says.
Hijinio Carreon, DO, MBA, was named chief medical executive of MercyOne in May 2021. At the time he was elevated to the chief medical executive role, Carreon had been with the organization for more than 13 years, starting as an emergency medicine physician. Before being named chief medical executive, he had served as chief medical officer and vice president of medical affairs for MercyOne Central Iowa.
HealthLeaders spoke with Carreon recently about a range of issues, including physician burnout, clinical challenges now that the crisis phase of the coronavirus pandemic has passed, workforce shortages, and patient safety. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the primary challenges of serving as the chief medical executive of MercyOne?
Hijinio Carreon: Similar to other hospitals across the country, we are experiencing critical staffing shortages. We are also seeing seasonal conditions such as RSV, influenza, and COVID that are compounding our capacity challenges.
There are challenges in attempting to stay focused on our strategy and not just the day-to-day operational challenges. The other overwhelming challenge and heightened concern is around moral injury and where our providers are in terms of their distress.
HL: How are you rising to these challenges?
Carreon: We are doing a lot around recruitment and retention. So, we are constantly reevaluating our benefit packages and determining how we can attract people into healthcare services. We are looking at our labor pool and partnering with schools—high schools and colleges. Our human resources staff has been going into high schools to highlight opportunities and increase our pipeline of individuals who might be interested in pursuing a healthcare career.
We are looking at statewide internal nursing traveler programs. We are advancing and redesigning our care models—we were the first in the state to start a virtual nursing program, and we are looking to expand that program. We have looked at our current care models to see how we can reinforce our nurses with care technicians, and we have looked at nursing ratios closely.
We are also focused on employee wellness and engagement—that is always going to be in the forefront. We continue to ensure that we have services in place to provide our healthcare workers with the support that they need.
Hijinio Carreon, DO, MBA, chief medical executive of MercyOne. Photo courtesy of MercyOne.
HL: What is the status of physician burnout at MercyOne?
Carreon: Burnout was pervasive before the coronavirus pandemic. Certain specialties such as the emergency department were reporting burnout levels of 50% of the staff. Now, you add the global pandemic, workforce shortages, and healthcare disruptors that have entered the arena, and it is difficult to suggest that yoga or symposiums are going to be sufficient tools to address burnout. We know all of these factors have had a significant impact on our colleagues, so the prevalence of burnout is extremely concerning to us. The extent has yet to be fully assessed and determined, but we have significant concerns in light of all the challenges we have faced over the past couple of years.
HL: What are the primary initiatives you have in place to address physician burnout?
Carreon: We are integrating with Trinity Health, and Trinity has embraced MercyOne into their culture. We have been leveraging some of their tools and expertise such as their Advancing Together webinars, which focus on a compassionate approach to healthcare.
We have a Colleague Care Circle program that features a peer group of behavioral health professionals and others who connect with our team members in high-volume and high-stress areas to provide high-touch comfort and support for them during real-time situations. The goal of this initiative is to reach all of our colleagues who are working shifts and provide active listening and empathy around concerns that may have arisen during a specific event.
We have been creating social events now that in-person meetings have become more acceptable. We are creating environments where we can build relationships and reestablish trust that may have been lost during the pandemic.
We partner with our employee assistance program. They have done a tremendous amount of work on physician burnout with us, and we have used some of their strategies and tactics in getting the message out about resources that are available to help staff through these difficult times.
HL: What are your primary clinical challenges now that the crisis phase of the pandemic has passed?
Carreon: Staffing is the biggest challenge. We have an aging workforce and some individuals have accelerated decisions to retire or leave healthcare. There are healthcare disruptors that are offering more flexible hours and remote work—those are challenges to our hospitals, and we need to become nimble and flexible and try to compete in this landscape, which has challenged us to be more innovative.
HL: What kind of workforce shortages are you experiencing at MercyOne?
Carreon: All areas are being impacted. It is extensive from certified nursing assistants to registration to pharmacy to respiratory therapy to registered nurses and many other positions. At the national level, there may be a belief that this is just a nursing shortage, but it is not. The shortages that we are seeing at MercyOne are in all areas.
HL: What are the main efforts you have in place to address workforce shortages?
Carreon: A main effort is increasing the pipeline—the individuals who are pursuing careers in healthcare. We are trying to attract staff and determine how we promote education within our organization; so, if they want a career path or higher level of education, we can allow them to do that in their journey as they become employed within the MercyOne organization.
We are trying to reach individuals as early as we can who may be interested in healthcare. Engaging these individuals is important to us. We are strengthening our relationships with universities. We have our Mercy College of Health Sciences in Des Moines, and we have been strengthening that relationship to ensure the offerings they have are consistent with the needs of the organization. We want to ensure that we can support clinical rotations and make them as robust as possible so that the students are getting not only a great education but also a great experience when they are at MercyOne that makes them want to remain a part of the organization.
One of the pieces is reconnecting individuals to professional purpose. That has been a big initiative for us. We want staff to get back to the mission of why they went into healthcare. We lost some of that during the height of the pandemic.
HL: What are the primary elements of patient safety at MercyOne?
Carreon: There are several main areas, and I will name a few. We are looking at preventable hospitalizations, and our 30-day readmissions. We are looking at our OSHA reportable injury rates, and at falls with injury rates.
HL: What are some of the metrics you follow to measure your performance in patient safety?
Carreon: There are the measures that I just mentioned. They are all tied to a specific numerical value. We establish our internal goals based off our historical performance. We are striving to get to zero harm. So, we are trying to improve these numbers with the objective of continuing on the path of high reliability.
HL: What kind of initiatives have you launched to become a high reliability organization?
Carreon: We are still early in our journey. We have been focused on serious safety event reporting. We want to establish a foundation of a just culture—we want individuals to feel comfortable bringing forward concerns and near misses, so that we can continue to refine our processes and try to mitigate any risk of harm to patients.
A 12-week telehealth patient navigator pilot program increased patient visit attendance and generated $11,387 in return on investment.
Patient navigators are a cost-effective way to increase video telehealth visit appointment attendance, according to a new research article.
Since the beginning of the coronavirus pandemic, telehealth visits have increased dramatically. One concern is patients having technological challenges that make it difficult to keep their video telehealth visits.
The new research article, which was published by JAMA Network Open, features data collected from 4,000 video telehealth patients. A patient navigator attempted to reach 1,000 of the patients by phone before their video telehealth visit—the intervention group—and 3,000 of the patients had usual communication including reminders by phone and text—the comparator group.
The 12-week study period was from April to July 2021. The patients were served by a primary care clinic and a gerontology clinic affiliated with an academic medical center. A patient navigator was hired for the pilot program.
The patient navigator contacted patients by phone the day before their video telehealth visit, offering technical assistance and answering questions about accessing the visit. A script was given to the navigator that included the steps for patients to connect to their visits and frequently asked questions.
The study generated three key data points:
91.6% of patients in the intervention group attended their appointment compared to 82.8% of patients in the comparator group
5.8% of patients in the intervention group canceled their appointment compared to 9.2% of patients in the comparator group
The pilot program's return on investment was $11,387
The study's data indicate the telehealth patient navigators can be effective, the research article's co-authors wrote. "The findings of this study suggest that adding a patient navigator to episodic telehealth visits may increase visit attendance and provide a net financial return."
Telehealth patient navigators can improve video telehealth visit attendance with a return on investment, the study's co-authors wrote. "At our institution, the Telehealth Patient Navigator program proved to be an effective, cost-effective, and high-value intervention associated with improving telehealth visit attendance and fewer patient no-shows and cancellations and increased successful video visits over the course of a 12-week pilot. Implementing a Telehealth Patient Navigator may be a high-value proposition for healthcare systems, as it uniquely benefits patients and clinicians while being cost-effective and yielding a positive net return on investment."
The former administrator of the Centers for Medicare & Medicaid Services wants the agency to make more progress in addressing health equity.
A group including health systems, a health plan, a healthcare analytics company, and the association representing Illinois community health centers has launched the Midwest Health Equity Coalition.
Health equity has emerged as a pressing issue in U.S. healthcare during the coronavirus pandemic. In particular, there have been COVID-19 healthcare disparities for many racial and ethnic groups that have been at higher risk of getting sick and experiencing relatively high mortality rates.
Two of the prime organizers of the Midwest Health Equity Coalition are Andy Slavitt, former administrator of the Centers for Medicare & Medicaid Services (CMS), and Eric Whitaker, MD, MPH, founder and executive chairman of Zing Health, a payer that features a Medicare Advantage health plan.
Slavitt has expressed frustration about the inability of CMS to address health equity when he was leading the agency, Whitaker says. "While they had a deep interest in addressing health equity under the Obama administration, there were few clinical models for addressing health equity and the ability of CMS to impact health equity was sorely lacking. That included clinical models that CMS could get behind for high-impact diseases and that included data collection."
The coalition is committed to reducing racial health disparities among underserved seniors in Illinois, Indiana, and Michigan.
The primary goal of the coalition is to do foundational work on health equity that leads to policy recommendations, Whitaker says. "By coming together with health systems, federally qualified health centers, payers, and healthcare associations, we wanted to put together the best thinking about health equity, so that we could make policy recommendations to CMS as well as demonstrate and recommend clinical models. We want to see what works."
The coalition held its first meeting last week and features six work groups: clinical, payment, data support, policy coordination, benefit design, and marketing and outreach.
The coalition will be focusing on health equity for one syndrome, Whitaker says. "After consulting with our clinical work group, we decided to focus on metabolic syndrome, which is hypertension, diabetes, and hypercholesterolemia. When you look at seniors—particularly seniors of color—an overwhelming percentage of this population have those conditions. The thought is that if we can make some progress in this area, we would do a great service for the country."
The coalition will be gathering best practices for health equity, he says. "At our first meeting last week, we put together the first draft of a compendium of best practices from the coalition partners that is a living document that will be expanded over time as we identify work that is being done by coalition partners. As part of the compendium, we have done a literature review of best practices related to health equity. One of the things that is true about medicine in the United States is it can take almost two decades before something that is discovered in the lab or the community is rolled out for general consumption by populations that can benefit. We want to accelerate that process for health equity."
A potential health equity best practice that the coalition is looking at is continuous glucose monitoring for diabetic patients, Whitaker says. "At Zing Health, we are making these sensors available to our diabetic members at no cost. Right now, there are no other healthcare payers doing this, and it is not something that CMS is mandating. We are getting this out to our members, who are by and large in low-income communities of color. We are monitoring the impact it has on glucose control."
Collection of data is pivotal in Zing Health's continuous glucose monitoring initiative, he says. "We are going to end up having a data set of the impact of continuous glucose monitoring on blood sugar levels and be able to assess health outcomes. Then we will be able to recommend to CMS criteria if you were to have continuous glucose monitoring as one of the options for measuring blood sugar. We can do on-the-ground work with the institutions we are working with. We can have outcomes, and we can recommend policy as a result of the findings."
The coalition is hoping to have several positive impacts, Whitaker says. "I would be excited if the coalition can point to clinical models that have a good effect on the vulnerable populations we are targeting. I would be excited if we could be able to make policy recommendations to CMS that matter around health equity. I would also be happy if we shine a light on the existing work that is being done at our partner institutions. It would be ideal to find great models that are successful then replicate them across the country."
Institute for Healthcare Improvement president emeritus and co-founder calls for single-payer system in United States.
The focus on profits in U.S. healthcare is "damaging," Institute for Healthcare Improvement President Emeritus and Senior Fellow Donald Berwick, MD, said during this week's IHI Forum in Orlando, Florida.
U.S. health systems, hospitals, and physician practices are committed to addressing the health needs of their patients. But making sure bottom lines are in the black and securing return on investment are also top goals at these healthcare organizations.
Berwick is one of the country's leading authorities on healthcare quality and improvement. The co-founder of IHI served as administrator of the Centers for Medicare & Medicaid Services during the Obama administration. He began his medical career as a pediatrician, serving on the staffs of Boston Children's Hospital, Massachusetts General Hospital, and Brigham and Women's Hospital.
In a meeting with journalists during the IHI Forum, Berwick criticized the financial model of U.S. healthcare. "One of the problems in healthcare is greed. We must address the degree to which the pursuit of profit and the acquisition of money and high valuations and investor-oriented business models has taken over healthcare. It is damaging. It is wrong."
The problem is systemic, he said. "I am not taking the position of people being bad people—it is not for me to judge. But the behaviors are bad on both the payer and provider sides. The pursuit of money is overwhelming the well-being of populations and patients."
Individual patients are being harmed, Berwick said. "At the individual level, this is leading to higher and higher out-of-pocket costs, more and more insurance benefit structures where people have to pay more, and disadvantages to people with lower incomes."
The emphasis on profits limits the ability of healthcare organizations to improve quality, he said. "This is affecting the context in which quality plays out. Our work on improvement depends on a basic foundational structure that can invest in improvement. The distortion in behaviors and the demoralization that results from profit-driven excess is hurting our ability to improve."
Berwick acknowledged that many healthcare organizations have been financially challenged during the coronavirus pandemic, but he said the need for reform remains. "The context is difficult. With COVID, the hospitals are currently in a stressed position, with high labor costs and workforce shortages. They are in the red this year—they are losing money. I understand that, but I don't want to back down on stopping the acquisitiveness in healthcare."
Other countries have established a better business model for healthcare, Berwick said. "I work in many systems around the world, which include single-payer systems in which there is a much stronger sense of collective duty. In many countries, the ministry of health feels responsible for making sure that resources are allocated in a way that will help the population. There is no minister of health in the United States. There is nobody thinking about whether the healthcare system is making sense for people. I remain an advocate of a globally budgeted, single-payer system."
El Camino's CMO says the health system uses artificial intelligence that creates a deterioration index, which alerts physicians when a patient is deteriorating clinically.
Innovative health systems anticipate change, then apply changes in a way that benefits patients, says Mark Adams, MD, chief medical officer of El Camino Health.
Adams has been the CMO of the Mountain View, California–based health system since 2018. Prior to joining El Camino Health, he was interim system chief clinical officer of SSM Health and CMO of PeaceHealth. He earned his MD degree from University of Pennsylvania.
HealthLeaders recently talked with Adams about a range of issues, including CMO leadership, innovation, physician burnout, and workforce shortages. The following transcript of that conversation has been edited for brevity and clarity.
HealthLeaders: What are the primary challenges of serving as CMO of El Camino Health?
Mark Adams: I need to make sure that we have the right resources to provide the best clinical care that we can. The role of the chief medical officer is to oversee all of the clinical care that we provide, so that is my number one responsibility. I need to make sure we have the resources, personnel, and the latest and the greatest equipment to provide the best care that we can.
There are three things that can be challenging given my responsibilities. First, I need to make sure that I stay in touch with our frontline workers to understand their needs. I need to make sure that we can meet those needs. Second, I need to anticipate changes. Healthcare is dynamic—it is changing all the time. Third, depending on how we adapt to change, I must be a strong voice for patients.
HL: How do you keep up with change?
Adams: There are a couple of ways. There is a lot of medical information in literature that is constantly being published. So, I must keep abreast of medical publications. The other way to keep pace with change is through organizations such as the Institute for Healthcare Improvement, which is important for quality and safety issues. There are also organizations that facilitate gathering chief medical officers—it is an opportunity for us to communicate with each other, which is a good source of getting information about what is ahead and how people are adapting to change.
Mark Adams, MD, chief medical officer of El Camino Health. Photo courtesy of El Camino Health.
HL: El Camino Health has a reputation for pursuing innovation. What are the keys to being an innovative health system?
Adams: First, we need to stay abreast of potential changes, then we learn how to adapt those changes in a way that benefits our patients.
We were the first medical organization in the United States to have an electronic health record in the 1970s. It was a primitive contraption compared to what we have today. We have always tried to be on the frontline of innovation. We are a showcase site for Varian, which has advanced radiotherapy systems.
We have many robots throughout our organization. We have da Vinci robots, we have robots for joint replacements, and those that look down windpipes and do surgical procedures on the lungs that avoid making incisions. So, we have been active in areas where either technology or changing practices are applied.
We have taken our electronic health record and added some artificial intelligence that creates a deterioration index. By using AI, we can tell when a patient may be deteriorating clinically, and the EHR alerts us so we can intervene before the patient gets worse.
While pursuing innovation, we want to make sure that we maintain the best quality and safety. We have a high ranking by Leapfrog.
HL: How do you balance pushing the boundaries of innovation and maintaining patient safety?
Adams: We do research, which may be surprising to people because most research is conducted at academic medical centers. We have a robust research institute—the Taft Center for Clinical Research. We participate in rigorous research to make sure that innovations have benefits to the patients that we serve.
We also have an institutional research board, which is an independent board that looks at what we are doing and makes assessments. This board oversees what we do in the innovation space.
HL: What is the status of clinician burnout at El Camino Health?
Adams: Physician burnout is a big issue throughout healthcare, and the past couple of years of dealing with COVID has made the problem worse. The coronavirus pandemic has accelerated burnout for all healthcare workers and physicians in particular. Burnout is something that we always keep top of mind, and we have several ways to try to address it. For extreme cases, we do provide our employee assistance program—physicians can get help from that program.
For most physicians, addressing burnout is a matter of making the work they do easier and more streamlined. We are also trying to reduce bureaucracy, reduce redundancy, and simplify workflows when possible, so physicians do not get burned out doing things that do not add value to taking care of patients. We want our physicians to be able to focus on the work they are trained to do, which is to be diagnosticians and to apply therapies.
HL: Are there other initiatives in place at El Camino Health to address clinician burnout?
Adams: We stay close to our physician leadership, and we have physician leadership embedded in a lot of the activities of the organization—particularly around quality and safety. That is important because it is easy for physicians to become alienated and to feel that things are being done to them instead of with them. We make sure physicians have a strong voice in the organization and they are involved in the decisions we make.
We are also looking at ways to decrease physician workload and to improve our processes. Part of this effort is paying attention to their work-life balance because it is easy for a physician to become overwhelmed on the work side, which then impacts their personal life. We also have programs that target physician stress.
HL: What kind of workforce shortages are you experiencing at El Camino Health?
Adams: We have the same problem that other healthcare organizations have—there is higher demand for healthcare workers. One of the outcomes of the pandemic is that many healthcare workers who were looking at retirement took early retirement, or even changed careers.
We are trying to make sure we keep a steady influx of healthcare workers. We have training programs. For example, nurses who graduate from nursing school—particularly in specialty areas such as operating room, intensive care, and emergency department—can take advantage of our training programs that are like residencies for nurses. We can help them train in specialty areas.
We also have a transition program. For example, we can have nurses who are already in the organization who have specialty experience, but they may want to try something more challenging or more complex such as intensive care. We will transition those nurses over to higher level of care areas and help them grow. The transition program is a way that we can maximize our workforce internally.
We are located in an area with a high cost of living, so we make sure that we stay competitive in terms of compensation.
Generally, El Camino Health has been an attractive workplace. We do better than many other organizations in terms of attracting healthcare workers. In the end, the work environment is critical to recruitment and retention. We make sure our healthcare workers get the resources they need. Healthcare is a people business—it's people taking care of people. Healthcare workers have decided they want to take care of people. It is our job to make sure that we can make that career as successful as we can.
So, maintaining a workforce is about the culture, the work environment, and the camaraderie among the healthcare workers. That is what keeps us all going.
Efforts to start joy in work initiatives at healthcare organizations require a commitment from leadership.
Health system and hospital leaders have a crucial role to play in advancing joy in work initiatives at their organizations, an Institute for Healthcare Improvement executive said yesterday at the IHI Forum.
The IHI Framework for Improving Joy in Work is designed to reduce healthcare worker burnout and increase healthcare worker well-being. Healthcare worker burnout has spiked dramatically during the coronavirus pandemic, with a recent research article finding that 62.8% of physicians reported at least one symptom of burnout in 2021 compared with 38.2% in 2020.
Healthcare organization leadership is foundational in implementing the IHI Framework for Improving Joy in Work, Jesse McCall, MBA, director and improvement advisor at the Institute for Healthcare Improvement, told HealthLeaders at the IHI Forum.
"There must be commitment from individual leaders and leadership teams—that is the first step. Even having a leader ask the question about what matters to you at work is a signal that the leadership team cares—they are interested. However, leaders must go beyond asking about what matters to staff to doing something about it. Leaders can put a team together to surface issues, amplify strengths, or address barriers. Leaders can deputize other leaders across the organization to do this work in individual units or services lines," he said.
Beyond commitment to joy in work, healthcare organization leaders need make joy in work a high-level concern, McCall said. "The first step is to commit to this work as a leader—to say staff satisfaction, staff engagement, wellness, and well-being is important. The next step is to get joy in work in the strategic plan and the organizational dashboard. In addition to asking staff what matters, leaders need to feed back the data that is collected, whether it is qualitative from conversations or quantitative from staff experience surveys. Leadership needs to be transparent about what they are seeing and what they are doing based on the data."
There are four phases to implementing the IHI Framework for Improving Joy in Work, he said.
The first phase is asking staff what matters to them. "We have a lot of resources in how to engage people in these conversations and how to theme that data and turn it into actionable changes for your organization," McCall said.
The second phase is to identify unique impediments to joy in your organization. "What gets in the way of joy? What is frustrating day after day? What are the pebbles in your shoe—the small annoyances? What are the boulders—what are the things that management really needs to get involved in and what needs to change to enable you to do your best work?" he said.
The third phase is for an organization to make joy in work a shared responsibility. "Leadership must set the context to make joy a priority. Then there are specific roles in each organization to create and reinforce systems that foster joy in work," McCall said.
The fourth phase is focused on taking actions. "You use improvement science to test ways to remove impediments and test ways to improve your processes," he said.
Successful adoption of joy in work framework
There are three primary elements to adopting the IHI Framework for Improving Joy in Work, McCall said.
"The first key is making the case for the framework in your organization. You need to understand what problem you are trying to solve—whether it is burnout in a specific unit or whether it is burnout among the entire staff. Then you need to dive deeper and understand what matters to people such as larger things like scheduling, pay, or benefits. It also can be relatively small things such as supply availability. You need to understand the problem you are trying to solve first," he said.
"The second key is leadership support. You need to find the right leaders—finding an executive leader and a clinical champion. These leaders are someone who can say, 'Here is what I am doing. Here are the changes that I am making,'" McCall said.
"The third key is having a methodology. You need to have a model for improvement. It makes joy in work more than a fluffy concept. Having a model for improvement brings some rigor to the process—you are using a scientific method to test process changes and to bring about better outcomes for the staff," he said.
Primary barriers to joy in work initiatives
Healthcare organizations face a daunting hurdle in promoting joy in work, McCall said. "The biggest barrier is time and resources, which go hand in hand. When you think of resources, human capital comes to mind. You also need the time to engage in this work because it does take considerable effort to engage leadership and frontline staff. You must have conversations, develop a theory, and coach people. This takes time."
Organizational perspectives on devoting time and resources to boosting joy in work can also be problematic, he said. "In a progressive organization, you can realize the return on investment from devoting time and resources. But if you are looking at this work from a strictly bottom-line standpoint, it becomes more difficult to make the connections between expending resources and dedicating staff time and affecting the bottom line."
The Boston-based hospital is gaining ground on a racial hypertension disparity.
Community health workers are playing a leading role in addressing health equity among primary care patients at Massachusetts General Hospital, according to a presentation yesterday at the Institute for Healthcare Improvement Forum in Orlando, Florida.
Health equity has emerged as a pressing issue in U.S. healthcare during the coronavirus pandemic. In particular, there have been COVID-19 healthcare disparities for many racial and ethnic groups that have been at higher risk of getting sick and experiencing relatively high mortality rates.
Community health workers can be pivotal in efforts to address health equity, Sarah Matathia, MD, MPH, associate medical director of primary care equity at Massachusetts General Hospital said at the IHI forum. "One of the potential solutions for having diverse representation in the workforce is to include community health workers in your workforce and integrate them as part of the care team."
Community health workers are well-suited to help health systems and hospitals tackle health equity issues, she said. "Community health workers are public health workers with shared life experience, who apply that unique experience such as language or culture or specific issues such as substance use disorder. They try to provide culturally appropriate health education, and they serve as a bridge. They are able to bridge between individuals, families, and the community that they are a part of and the healthcare system."
At Boston-based Massachusetts General Hospital, community health workers are well established, Matathia said. "We are lucky to have a group of community health workers that has grown over the past 25 years. They are working in several key domains. The community health workers help find health-related social needs resources for patients, so they develop expertise in areas such as healthy food and job-finding programs. They are working on system navigation—community health workers help patients get to their appointments by calling patients and giving reminders. They provide care coordination—they help patients make appointments. And increasingly, we have been working with community health workers on models for chronic disease management."
Addressing racial hypertension disparity
Community health workers are an essential element of an effort to address a racial hypertension disparity among Massachusetts General Hospital primary care patients, she said. "We felt it was important for the program to be led by community health workers. We did not just want the community health workers to be helping with medications because we felt this was an opportunity to get to the root causes of hypertension. We incorporated more education around lifestyle, and we built modules such as why high blood pressure matters, what is too high and too low for blood pressure, how do you take blood pressure, medication adherence, nutrition, physical activity, stress management, and sleep."
The community health workers lead patient engagement in the blood pressure program, Matathia said. "We helped the community health workers in facilitating conversations by building them motivational interviewing guides and trying to put everything on one page so they could use the guidance as they were working with patients. For every patient who entered the program, they got a blood pressure cuff, the community health workers met with the patients and taught them how to use the cuff, and the community health workers helped to collect the readings. For each patient doing blood pressure monitoring, community health workers distilled those numbers down to a single value, and they could escalate to the primary care provider and the care team if there was a need for medication changes."
The blood pressure program was launched seven months ago, and so far, the results are promising, she said. "As we have been following our blood pressure control month-to-month, we have seen a 4.8% improvement in blood pressure control in our Black patient population, a 6.4% improvement in our Hispanic patient population, and 4.2% improvement in our non-English speaking population."
While there are challenges in the program such as carving out time for primary care providers to participate in the effort, progress is being made, Matathia said. "These types of initiatives can move the needle in real time, and community health workers are uniquely poised to help bridge the gaps for patients who are not as well served by traditional population health strategies."
About 233 million Americans are enrolled in health plans that cover preventive services without cost-sharing because of the Affordable Care Act.
The American Medical Association (AMA) and seven other physician groups have filed a friend-of-the-court brief defending no-cost access to preventive services under the Affordable Care Act (ACA).
The ACA, which Congress passed in 2010, requires insurers to cover preventive services without cost sharing such as deductibles for services that have "A" or 'B" ratings from the United States Preventive Services Task Force. "A" or "B" ratings indicate that a preventive service has moderate to substantial net benefits, with moderate to high certainty.
On Nov. 30, the friend-of-the-court brief was filed for Braidwood Management v. Xavier Becerra, an ACA case in the U.S. District Court for the Northern District of Texas Fort Worth Division. Braidwood and other plaintiffs in the case want U.S. District Judge Reed O'Connor to rule that insurers can impose cost sharing for preventive services.
The friend-of-the-court brief calls on Judge O'Connor to maintain the ACA's no-cost provision for preventive services. "The Court should refrain from ordering any remedy that would allow insurers to reimpose cost-sharing requirements on the millions of Americans who currently have access to no-cost preventive care. Make no mistake—that is what Plaintiffs seek," the friend-of-the-court brief says.
The physician groups that filed the friend-of-the-court brief with the AMA—known collectively as amici—are the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American Medical Women's Association, the Infectious Diseases Society of America, the National Medical Association, and the Society for Maternal-Fetal Medicine.
The amici say there are several benefits from the ACA's preventive services provision. "The research is clear: no-cost preventive care saves lives, saves money, improves health outcomes, and enables healthier lifestyles. As medical professionals, amici know that preventive care can mean the difference between kicking a smoking habit or living with a heightened risk of dozens of illnesses; between taking a statin or suffering a life-changing heart attack; between providing essential prenatal care and screening or leaving children behind; and between catching a patient's cancer early or catching it after it's too late. Identifying and treating conditions before they worsen, or before they present at all, yields better outcomes for patients and saves money for the health system overall."
Improving health outcomes and bolstering the healthcare system
The AMA and the other amici argue that no-cost preventive services boost public health and the healthcare system. "An extensive body of evidence demonstrates how preventive care can help patients live long, healthy lives. Preventive services include both services aimed at the early detection and treatment of potentially fatal medical conditions and chronic diseases as well as services aimed at encouraging people to adopt healthy lifestyles," the friend-of-the-court brief says.
No-cost preventive services also reduce healthcare costs such as catching cancer in an early phase, the friend-of-the-court brief says. "Put simply, cancer is cheaper to treat at the outset than after it has metastasized."
The ACA has increased utilization of preventive services, the friend-of-the-court brief says. "Prior to the enactment of the Affordable Care Act, the majority of Americans either lacked health insurance or were enrolled in insurance plans that did not cover preventive care without cost-sharing—creating a substantial barrier to widespread use of preventive care."
ACA expanded access to preventive services
The ACA has expanded access to preventive services, the friend-of-the-court brief says. "The ACA's preventive-care requirements have generally been successful in expanding access to preventive care, and for that reason, have proven to be one of the most popular parts of the statute."
Millions of Americans have gained access to preventive services because of the ACA, the friend-of-the-court brief says. "In 2014, the Office of the Assistant Secretary for Planning and Evaluation (ASPE) of the U.S. Department of Health and Human Services estimated that 76 million individuals gained access to preventive care without cost-sharing as a result of the ACA, either by newly enrolling in private insurance or by having already enrolled in insurance plans that shifted to covering preventive care after the ACA's enactment."
The AMA and the other amici say there are now about 233 million Americans who are enrolled in health plans that cover preventive services without cost-sharing because of the ACA.
The ACA is not perfect, but the no-cost preventive services requirement is essential, the friend-of-the-court brief says. "To be sure, the ACA's preventive care requirements are not a panacea; substantial additional work needs to be done to encourage patients to use the means provided to them to obtain these vital services. But gutting the ACA's requirements would impose further barriers, making it even harder for amici to ensure that their patients receive the requisite care."
As part of the new partnership, Bryan Health and Medline will work together to identify new strategies for enhancing patient outcomes and streamlining supply chain operations at the health system. Medline will be the exclusive provider of medical supplies for every Bryan Health hospital. Prior to the new partnership, Medline was already the provider of medical supplies for Kearney Regional Medical Center.
Medline is an ideal partner for Bryan Health, Heather Seeba, director of supply chain for the not-for-profit health system, said in a prepared statement. "Medline's proactive approach facilitated a smooth implementation, and the customer support has been incredibly responsive. We look forward to partnering with the Medline experts to optimize our operational processes and improve our supply consistency."
As part of the partnership, Medline will provide resources to help Bryan Health address clinician needs and boost operational efficiencies. Medline also will provide advanced analytics to track key metrics such as item utilization, contract compliance, price accuracy, and spending by product categories.
Medline will help Bryan Health achieve supply chain success, Megan Schwellenbach, vice president of corporate accounts at the company, said in a prepared statement. "Medline is committed to providing Bryan Health with continuously reliable, superior service. We are excited to enter into this prime vendor partnership and together develop solutions to help provide consistency and stability to its supply chain."
Westchester Medical Center Health Network's CMO says staff members ''understand the forces behind decisions if they are a part of the process.''
Renee Garrick, MD, executive vice president and chief medical officer of Westchester Medical Center Health Network (WMCHealth), says managing the health system's quaternary care hospital and balancing resources are her top challenges.
Garrick is the clinical leader for the Valhalla, New York–based health system, which features 1,700 inpatient beds at nine hospitals in the Hudson Valley. She recently talked with HealthLeaders about a range of topics, including leadership, physician burnout, clinical challenges now that the crisis phase of the coronavirus pandemic has passed, and workforce shortages. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: What are the main challenges of serving as CMO of WMCHealth?
Renee Garrick: There are two major issues in being the CMO of our network.
First, we are the only quaternary care hospital for this region, which spans several thousand square miles. As the major quaternary care hospital, it means we accept patients at the main hub who need high-end care that cannot be offered at the other facilities in the Hudson Valley. We are a referral hospital not just for our patients but also all hospitals in the region.
From the CMO perspective, that means there is a lot of juggling in terms of having our staff at the ready to accept patients and to be able to juggle inpatients and transfers 24/7. We must be able to do that while taking great care of the patients in our hospitals and the patients who transfer to our medical center. I spend a fair amount of my time making sure we have the best possible staff on the medical side, the nursing side, housekeeping, social work, and dietary to be able to care for a broad range of patients. I also need to make sure that the staff has the time to take care of themselves as well as patients, so their lives are balanced, and they can give the best care possible.
The other challenge is we have a lot of busy practitioners, and they have valid and important resource needs. It takes a lot to balance those needs and know that people understand that you are doing everything you can for everyone to the extent possible. That means there is some sharing that must go on. So, if surgery needs A and B, and neurosurgery needs C and D, and medicine needs E and F, they all must understand everyone's needs as a group. I expend a lot of energy making sure that people understand we are balancing resources and making sure that everyone has access to the best that is available. There's nobody who gets more than another. In the end, it all balances out.
Sometimes, people want to have an enormous amount of add-on resources, and you cannot do that if it is going to hurt a smaller department with equal need. I spend a lot of time speaking to the physicians, the medical staff, and the graduate medical staff so they can all understand how it works. Transferring patients and allocating care—and recruiting and retaining the medical staff—is a big part of what I do. It can be a challenge getting everyone to understand the greater good and the goals of the organization. It takes a lot of listening to make sure you do that well.
HL: How do you persuade colleagues to share resources?
Garrick: I try to be transparent about it. People understand the forces behind decisions if they are a part of the process. You must be aware of the staff you are working with—the medical staff, the nursing staff, and the administrative staff. You must explain your position and how you came to a decision—that is an effective way of building a coalition and having people come to an understanding of why things are being decided the way they are.
I graduated medical school in 1978. My experience has been as long as people are treated respectfully and you are honest about what can and cannot be done, the process resonates with people. A problem is created when facts are not shared, then people make up their own facts. They fill the vacuum with what they might think is the truth. It's hard to rescue the process under those circumstances.
Renee Garrick, MD, executive vice president and chief medical officer of Westchester Medical Center Health Network. Photo courtesy of Westchester Medical Center Health Network.
HL: What is the status of physician burnout at WMCHealth?
Garrick: Over the past year, we have recruited hundreds of providers. In the past three months, we have recruited 100 new nurses. So, we are a resilient organization. Part of that is we are the tertiary care referral center, and we are proud of that.
We are still dealing with COVID. But we have also been dealing with monkeypox—we have given 1,800 monkeypox vaccinations. We are thinking about polio because we are in the Northeast, where polio has had a resurgence. We also are dealing with RSV. So, our staff takes enormous pride in being at the ready and being resilient. We get so much joy out of helping patients on the nursing side and the physician side that our burnout has been less than other organizations.
A big key to physician burnout is the happiness and unanimity of purpose that we share with our nursing colleagues. Our nursing staff just ratified a new five-year contract, with overwhelming support. The core of the contract is to make it clear to our nursing staff that we have an enormous amount of respect for their skill and expertise, and we want to be able to recruit, retain, and reward the best nurses in the country. For doctors to be at their best, they work best when they have nurses who are happy by the bedside. A big part of our resiliency is we partner with an extraordinary nursing staff. That helps with how physicians cope with burnout—having a great nursing staff.
HL: What are your primary clinical challenges now that the crisis phase of the pandemic has passed?
Garrick: For us, the clinical challenges are always being ready for the next stress for the organization. Our staff had to be resilient because in the middle of COVID we had monkeypox, and we were asked by the state to be a referral center for monkeypox. We are also dealing with RSV. So, the clinical challenges are keeping the engine humming while gearing up for the next level because as a quaternary care hospital you must be able to provide basic care and get to the next level.
Right now, we are looking at high-end new radiation oncology equipment and thinking about how to move that part of our service for the region forward. That means recruitment, that means building, and that means growth and development. We are looking at building a new critical care area for the medical center to be able to serve the Hudson Valley with the highest level of care.
The clinical initiatives and clinical challenges are looking ahead to the next things we need to do to always be on the cutting edge. We are asking our people to have their feet in two worlds—the current and the future, where we are thinking about artificial intelligence and outfitting the ICU with bedside ultrasound. It's a big clinical challenge to do the day-to-day care while also planning simultaneously for the next several years to come.
HL: What are the primary efforts you have in place to address workforce shortages?
Garrick: On the medical side, we can attract some of the best physicians in the country because we provide a range of care including quaternary care. We have a good organ transplant program—we do heart, kidney, and liver. We have amazing neurosurgery and pediatric care. We have high-end care, but we are also a large network. So, at our institution, we are lucky because physicians can come to the medical center and ply their trade in complicated cases, then they can go to another hospital and be satisfied taking care of community-level conditions.
One of the advantages that we have in terms of addressing workforce shortages is there is a lot of variation in the kinds of patients that we treat, and physicians like to have the opportunity to see more than one type of patient and tackle more than one type of challenge. Over the past two years, we have credentialled more than 1,000 practitioners in our network, and the wide spectrum of the kind of patients that we see is attractive to young physicians.
We also have a lot of mentoring. When you finish your training, you still want to have somebody near your elbow as a mentor; so, if you have a question or have a complicated case, you have someone to help you. We are proud of the fact that we have a staff here that is stable—the medical staff has little turnover, and we have a lot of opportunities for mentorship. This is important for young physicians, especially the ones who trained during COVID. Our ability to provide mentors makes this network an attractive place to work.
Being an academic medical center also helps us recruit and retain physicians. Having a medical school at our main campus and being able to engage in research is a big part of recruitment and retention. The residents and fellows participate in the research as do the medical students. We love the fact that medical students stay here as residents, and some of them stay on as attending physicians.
Mark Adams, MD, chief medical officer of El Camino Health. Photo courtesy of El Camino Health.
Renee Garrick, MD, executive vice president and chief medical officer of Westchester Medical Center Health Network. Photo courtesy of Westchester Medical Center Health Network.