Two federal payment programs that give financial support to rural hospitals are set to expire on Oct. 1.
The Federation of American Hospitals (FAH) is urging Congress to reauthorize two federal programs that provide financial assistance to rural hospitals.
Rural hospitals face multiple financial challenges, including low patient volumes and relatively high numbers of Medicare, Medicaid, and uninsured individuals in their patient populations. Over the past decade, more than 130 rural hospitals have closed and more than 30% of rural hospitals are at risk of closing, according to the Center for Healthcare Quality and Payment Reform.
Two Medicare payment programs that provide financial support to rural hospitals—the Medicare-Dependent Hospital (MDH) program and the Low-Volume Hospital (LVH) program—are set to expire on Oct. 1. Last week, FAH President and CEO Charles N. Kahn III sent a letter to Congressional leaders imploring them to reauthorize the MDH and LVH programs.
"Rural hospitals traditionally serve patient populations that are older, lower income, uninsured and more likely to rely on Medicare and Medicaid when compared to the national average and to their urban counterparts. This challenging patient demographic means rural hospitals have a high volume of Medicare-dependent patients, and a lower volume of total patients overall. The MDH and LVH Medicare payment programs provide eligible rural hospitals with the financial stability and support they need to prevent closures and ensure continued access to care in rural communities," Kahn wrote.
Citing rising inflation and supply chain challenges, he wrote that rural hospitals are facing "unprecedented times" and financial pressure. "The nation's healthcare workforce shortage, in particular, is having a devastating, disproportionate impact on rural hospitals. Long-documented recruitment challenges have been exacerbated by an aging healthcare workforce, burnout, price gouging by traveling nurse staffing agencies, competing higher wages in larger cities, and a slowing of visas granted to foreign healthcare workers—all factors that are contributing to higher average payrolls and strained resources."
Dire consequences
Many rural hospitals are desperate for federal assistance, Jonathan Jagoda, MPP, senior vice president of legislative affairs at FAH, told HealthLeaders. "When you look at the role that rural hospitals play in their communities, you are often talking about the sole comprehensive provider for patients within many miles—sometimes hundreds of miles. It is critical that those facilities remain open and that services remain available to their patients. Even before the coronavirus pandemic, we saw the struggles that rural hospitals faced across the nation. They were cutting services lines, and many were being forced into closure. It is the community that suffers when service lines are cut or hospitals close."
If the MDH and LVH programs are not reauthorized, the consequences for rural hospital would be severe, he said. "If these programs are not reauthorized, the risk of rural hospitals closing is significant. Obviously, it depends on the hospital and the extent to which they utilize these programs to offset costs. Every rural hospital would not close, but you would see difficult decisions having to be made, whether that is eliminating services or hospital closures in the worst-case scenario. These programs help keep the doors open at rural hospitals. I would be very worried if the MDH and LVH programs were not renewed."
Congressional support
The MDH and LVH programs have bipartisan support in Congress. Last month, U.S. Rep. Terri Sewell (D-Alabama) and U.S. Rep. Carol Miller (R-West Virginia) introduced H.R. 8747, the Assistance for Rural Community Hospitals (ARCH) Act. The bill would reauthorize the MDH and LVH programs for five years.
The FAH, which represents more than 1,000 for-profit health systems and hospitals across the country, supports the ARCH Act.
Federal lawmakers know the stakes for reauthorization are high, Jagoda said. "They know they have to do it on a bipartisan basis. Leadership and the committees of jurisdiction have indicated support for these programs. They want to ensure that rural hospitals have the resources they need. So, we are fighting tooth and nail to ensure reauthorization comes by October 1 to make sure there is no gap in funding for rural hospitals."
Hospital patients experience hundreds of thousands of falls annually, with increased length of stay and care costs, according to The Joint Commission.
A smart sock system significantly reduced patient falls at The Ohio State University Wexner Medical Center's Neurological Institute, according to a recent research article.
Hospital patients experience hundreds of thousands of falls annually, according to The Joint Commission. About one-third of those falls result in an injury, which lead to an average increase in length of stay of 6.3 days and an average care cost of $14,000.
The recent research article, which was published by the Journal of Nursing Care Quality, features data collected from 569 patients over a 13-month period. The patients were equipped with Palarum's PUP (patient is up) smart socks, which alert nurses when a patient attempts to stand up in their hospital room.
The study includes two key data points:
For patients enrolled in the study, there were no falls over 2,211.6 patient days
There were 5,010 alarms generated by the PUP socks, with only 11 false alarms (99.8% of alarms were generated by patient stands)
The smart socks system includes socks with pressure sensors that can detect when a patient tries to stand up. The system also includes a tablet for patient rooms, a local server, a monitoring device at the nurse station, and notification badges that are worn by nurses.
When the system detects that a patient is trying to stand up, an alert is sent to the notification badges of the three closest nurses. When one of the nurses enters the room, the alert is deactivated. If none of the three closest nurses responds within 60 seconds, an alert is sent to the next closest three nurses. If none of the nurses respond within 90 seconds, an alert is sent to all of the nurses wearing the notification badges.
Patients were enrolled in the study after a fall risk assessment, Tammy Moore, PhD, RN, associate chief nurse at the Neurological Institute, told HealthLeaders. "We base our fall risk assessment tool on known evidence of what creates a potential fall risk in hospitalized patients. We look at history of falling, altered mobility and/or gait, altered mental status, secondary diagnoses, medications, attachment to any equipment, and altered sensory or communication deficits. This assessment is done on admission and every eight hours or as needed."
Over time, nurses shed any hesitation they had over wearing the notification badges, she said. "While I am sure there may be staff that found the wearable badge a 'nuisance' in the beginning, I believe they began to realize the worth of wearing them and the ability to react sooner to their patient with this wearable device. Response times to respond to an alarm from a patient with the socks was an amazing feature of the product."
The cost of the PUP system is about $10 per day per licensed hospital bed, Chris Baker, co-founder and vice president of business development and marketing at Palarum, told HealthLeaders. The bed license is an all-inclusive price that covers all components of the system, including hardware, software, installation, training, and 24/7 support, he said.
"Our goal is to reduce hospital falls by a minimum of 20% to 25%, which would offset the cost of our system. Additional fall rate reductions would save the hospital significant costs as well improve the patient's hospital experience and outcomes," he said.
McKinsey & Company experts say health systems should focus on three areas to boost the performance of their supply chains.
A recent article produced by McKinsey & Company provides advice on how health systems can improve their supply chains.
The coronavirus pandemic has heightened interest among healthcare executives in revamping their supply chains. For many health systems and hospitals, the pandemic served as a reminder of the key role of supply chains, with many organizations struggling to secure personal protective equipment such as respirators in the early months of the crisis.
The McKinsey article identifies three areas where health systems can bolster their supply chains.
1. Clinician engagement
Including clinicians in formal and informal supply chain roles is essential, the McKinsey article says. "In high-performing organizations, clinicians play an integral role in supply chain initiatives: They provide input on supplier selection and contracting strategies, including their financial impact; they support compliance with contract terms (for example, by committing to give a supplier a negotiated share of business); they manage the use of supplies; and they otherwise contribute to achieving financial, quality, or other goals," the article says.
The McKinsey article says health systems can take three approaches to maximizing clinician engagement in the supply chain.
Involvement of senior clinical leaders: The chief medical officer, chief clinical officer, chief nursing officer, and service line leaders should be fully engaged in the supply chain. "Leaders can accelerate progress and enable best-in-class performance by offering clinical guidance, building clinician confidence in supply chain efforts, making tough decisions, and holding other clinicians accountable for changes in behavior," the article says.
Formal teams assessing category strategies: Formal teams drawn from clinicians and supply chain leaders should play pivotal roles in contracting and utilization. "Optimally, one accountable and influential physician—for example, a service line chair or high-volume surgeon—will chair each committee. The absence of such leadership can result in extended delays, fewer savings, or stalled initiatives," the article says.
Establish a frontline supply chain team: Top executives cannot lead supply chain initiatives on their own—pairing supply chain managers with clinicians can guide supply chain functions such as product choices and compliance with contracts. " Supply organizations may consider filling this role with supply chain professionals who have clinical backgrounds and a threefold mission: support supply chain initiative implementation, identify local opportunities for improvement, and develop relationships with physician and facility leadership to better understand and meet their needs over time," the article says.
2. Establish goals across facilities and functions
Supply chains should set annual goals in conjunction with other clinical and non-clinical departments, a process that is often not achieved, the article says. "This lack of goal sharing can lead to misaligned incentives between the supply chain function and other stakeholders, siloed decision making, resistance to supply chain initiatives, and the perception that the supply chain function is focused solely on cost savings rather than broader organizational goals."
Three approaches can be taken to attain effective goal setting, the article says.
Establish mutual savings targets: "Shared savings targets between the supply chain function and its partners—specific functions, service lines, and facilities—help ensure that the organization is unified in its mission to find and implement savings opportunities. Such targets also reinforce the notion that all stakeholders are accountable," the article says.
Goal incentives: Supply chain actions are often associated with change for some clinicians such as dropping a preferred supplier, so enticements can be useful tools. "To assist this change, systems may consider providing incentives for reaching targets. These incentives can be financial or nonfinancial and may include a commitment to reinvest a percentage of savings in things prioritized by physicians, such as equipment, conference attendance, or publications," the article says.
Report goal progress: "Once targets are established, tracking performance and ensuring that stakeholders have access to up-to-date information on their progress is critical to fostering a sense of accountability. Ensure that dashboards display the high-level metrics that matter most (for example, savings and contract compliance for medical implants)," the article says.
3. Data and analytics
While data and analytics can play a pivotal role in supply chain performance, many health systems struggle to develop accurate and actionable information, the article says. "Organizations outside the hospital's walls—such as those that supply medical devices, pharmaceuticals, and services—often have better visibility into a health system's spending and utilization than the system itself does. As a result, the health system may be unable to effectively negotiate or identify savings."
Health systems should consider four kinds of investment to improve data and analytics, the article says.
Data management: "Having clean, categorized supplies data enables proactive identification of opportunities through granular product comparisons. This is especially important for systems that have gone through M&A activity because systems and data nomenclature must be reconciled across the system before savings opportunities can be identified," the article says.
Practical and applicable tools: "Analytical tools are only useful if they provide relevant insights to their users, which may require individual customization and, for convenience, accessibility on multiple devices. For example, a supplies cost-per-case tool, which shows the cost of all supplies for a given operating-room procedure, should provide the relevant views for physicians so that they can see the supplies they used; the cost compared to supplies used by peers; alternative supply options; and, where possible, quality outcomes," the article says.
Effective dashboards: "Organizations need to ensure that supply chain tools and reports are being used not only to review results but also to enable decisions. Organizations should ensure ample visibility into key supply chain metrics across all levels of the organization and ensure that conversations focus not just on what has happened but also on what actions can be taken to influence future performance," the article says.
Staffing: "Building a robust analytics engine requires an integrated team comprising analysts, data translators, visualization experts, and data engineers, among other roles. Recruitment that focuses on these skills, regardless of previous industry experience, can expand the talent pool and ensure that leading practices are brought into the organization, including from industries such as tech that have invested substantially in developing data and analytics as part of their core businesses," the article says.
HealthLeaders talked with Winters recently in a conversation that included how healthcare leaders should work with colleagues during a crisis, delegating decision-making during a crisis, and being realistic during a crisis. The following transcript of the conversation has been edited for brevity and clarity.
HealthLeaders: How can a leader liberate colleagues' time for deliberate focus so that they can adapt to a crisis and triage what is most important to address?
Richard Winters: First of all, it means that there is an understanding that it takes time to process and think through complex problems. As you are meeting with groups of colleagues, it starts out with whether people are just making decisions or are they thinking about the decisions that they are making. Even as we are structuring meetings and group decision-making, are we allotting time for individuals to process what is occurring, to understand different perspectives, then to make decisions? Generally, that tends not to be the case. Generally in a crisis, a few people who are opinionated speak up and a decision is made, with those who did not speak up not being able to reflect or not feeling safe to evolve their thinking.
Leaders need to role model taking the time to consider complex, thorny issues.
Leaders can also block out time. They need to understand that they are there to act but also to gain perspective. I use the metaphor of the balcony and the dance floor. Leaders need to get off the dance floor and get up to the balcony, then gain perspectives on what they might do about a situation before they react, so they can act with deliberate intent. That means as leaders are scheduling meetings and putting things on their schedule, they are leaving some space to take time for deep thinking. That can be role modeled by senior leaders so others can feel free to move deliberately.
HL: How can you use your leadership team to clarify perspectives as well as align thinking and actions?
Winters: The thing that is great about Mayo Clinic is triad leadership. You have a physician leader, a nursing leader, and an administrative leader who work together to run the departments and divisions. With triad leadership, each individual has a perspective that the others may not have. The nurse has a different perspective than the administrator and the physician. If you just have a physician alone looking at a difficult issue, they proceed forward with their own perspective, which includes their blind spots.
With triad leadership, you have multiple perspectives that help address blind spots. You can see different ways to move forward and different possibilities. You can benefit from multiple perspectives.
HL: What about aligning thinking and actions?
Winters: Aligning thinking and actions means understanding the thinking at play. You are not aligning individuals with your thinking and blind spots. You are aligning thinking by understanding the perspectives that are within the environment in which you are making decisions. To align thinking, we must first understand the perspectives of others and bring them together. Within those perspectives, you will find disagreements, but those thoughts represent a range of understanding. By understanding the disagreements and agreements and what individuals see as the opportunities and the threats, then you can start to think about the options.
First, you develop a shared reality and shared perspectives, then you develop options for what you might do given the shared reality and perspectives. From there, you can move forward. So, first you are understanding perspectives and aligning perspectives, then you are choosing the options for how you can move forward.
HL: How can a leader delegate decision-making to experts in a crisis?
Winters: As leaders step up—as a cardiologist becomes a leader or an emergency physician becomes a leader—we have our expertise but there are things that we do not know. Leadership requires other individuals who have a broader knowledge or understanding to make sense of specific areas. So, it makes sense to delegate decisions to individuals who have the necessary areas of expertise.
For example, when the coronavirus pandemic started, we did not know anything about the virus. We did not know what was going to happen. We did not know the morbidity and mortality associated with the virus. But the CEOs needed to make decisions, and they did not have the benefit of bringing together task forces and having committees over several months. They had to make difficult decisions. So, some decisions were delegated to the infectious disease specialists, who certainly knew more about virus transmission.
HL: Why is it important for a leader to be open, humble, and realistic during a crisis?
Winters: During a crisis, there are many unknowns. You are in a world of unknowns. If a leader is operating without an openness to the unknown, they are at a disadvantage.
During a crisis, there may be a sense that we make decisions and if a decision works out, then it was a good decision. If it doesn't work out, then it was a bad decision. However, that is not the correct way to make decisions in times of crisis. The best way to make decisions in times of crisis is to acknowledge that the leader has some expertise, the leader sees the situation, the leader senses what is occurring, then the leader simulates in their mind what might happen if different options are pursued. The leader makes decisions to poke at the crisis and see how the situation responds. It is not about failing in a decision. The leader makes decisions of discovery.
So, being open and humble about what might occur is essential. You need to be open to how the situation responds and the new data that arises. You need to be open about what information the leadership team can come together around to make better decisions as we move forward and continue to understand the situation. A leader needs to be humble because they may make a decision that does not generate the desired effect.
HL: Why is being realistic important?
Winters: There are constraints that we all face. There are limitations. We do not have infinite budgets. We have groups of individuals who have different perspectives. There are politics. There are regulations. Within these sorts of constraints, we need to be understanding and realistic about them. We need to face them head-on. We need to make decisions based on realistic constraints about where we do have efficacy and where we can affect change.
A survey of 1,000 healthcare workers finds mental health concerns as well as significant levels of alcohol and substance abuse.
About half of healthcare workers are either at their breaking point or seeking new jobs because of the stress and trauma they are experiencing at work, according to new survey data.
The coronavirus pandemic has severely strained healthcare workers. A healthcare worker well-being expert has told HealthLeaders that burnout rates ranged from 30% to 50% before the pandemic and now range from 40% to 70%.
The new survey, which was conducted by All Points North (APN), features data collected from 1,000 healthcare workers between July 19 and July 25. Based in Edwards, Colorado, APN is a whole person health company that specializes in the care of healthcare workers, veterans, and athletes. Services provided by APN include group and individual therapy, medical detox, hyperbaric oxygen therapy, trauma-based therapy, medication management, and small-group fitness.
The survey generated several key data points:
49% of survey respondents said they are either at their breaking point or seeking new jobs because of the stress and trauma they are experiencing at work
40% of survey respondents said they feel anxiety or dread about going to work
64% of survey respondents said that the scrapping of Roe v. Wade either boosted their stress or made them feel betrayed
14% of physicians said they were using alcohol or controlled substances at work
21% of physicians said they were using alcohol or controlled substances multiple times per day
About 20% of healthcare workers said they had checked into rehab or a detox facility in the previous three months, but 14% said they did not want to admit they have a problem
Survey respondents cited several reasons for not seeking help: 32% said they were overworked and did not have time to seek help, 23% said they were concerned that colleagues or family would judge them, 23% said they feared license revocation, and 20% said they did not know where to begin and that the system was broken or too hard to navigate
Male healthcare workers were more likely to struggle with alcohol or substance abuse compared to their female counterparts: 21% of men versus 4% of women were more likely to use their work position to acquire controlled substances, 18% of men compared to 4% of women were likely to use alcohol or controlled substances while at work, 44% of men versus 17% of women were likely to use alcohol or controlled substances up to 12 hours before their shift
The survey report says the findings are troubling. "Our 2022 State of Mental Health: American Healthcare Workers Report indicates high levels of substance abuse, an acute mental health crisis, and stigma within the healthcare industry. This report also highlights the brokenness of the healthcare system, proving it is difficult to navigate, even for people who work within the system."
Interpreting the data
The founder and CEO of APN, Noah Nordheimer, told HealthLeaders that there are several ways to encourage healthcare workers to get help for mental health issues. "We have to keep chipping away at the stigma of mental health in healthcare from all angles—raising awareness around burnout, normalizing mental health days, encouraging organizational initiatives for work-life balance, and providing clear pathways for non-judgmental help. While we advocate for systemic progress, friends and family of healthcare workers can care for their loved ones by creating a safe space for honest conversations. Heroes are humans, too."
The challenges are similar in encouraging healthcare workers to seek help for alcohol and substance abuse, he said. "There is still so much progress we want to see in the stigma around substance use disorders in healthcare fields, much of which echoes our sentiments about mental health stigma. Still, it's important to remember that there are loads of healthcare leaders who want to help their employees to reach providers like APN to get them back to well-being and back to work. Healthcare workers and their families can also look into trusted, confidential resources like physician health programs through the Federation of State Physician Health Programs to help them navigate issues and options."
There are several reasons why male healthcare workers are struggling more than their female counterparts with stress, burnout, trauma, and alcohol and substance abuse, Nordheimer said. "As the data in APN's 2022 State of Mental Health: American Healthcare Workers Report shows, male healthcare workers struggle more because of the stigma attached with seeking help. They are often afraid their colleagues and family will judge them, afraid their license will get revoked, and some even think the system is broken and too hard to navigate, even though they work within the healthcare system."
Actions must be taken to reduce the stigma of behavioral health issues among healthcare workers, he said. "Every person in healthcare, especially those in policy, licensing, and management, needs to begin looking at healthcare as inclusive of mental health. Then operate from there. We need a fundamental shift in our philosophy of what health is. A person who is physically healthy but mentally struggling is not 'well' in the way that they can be. Healthcare providers, companies, and organizations can set the tone for a shift by educating and equipping the systems and people who may be affected."
Medical and pharmacy students learn about body language and visual cues that musicians use to communicate during performances.
Medical and pharmacy students at Wayne State University have learned about nonverbal communication from a string quartet.
Communication is a critical skill in medicine. Communication is crucial in interprofessional interactions as well as in encounters between healthcare providers and patients.
Recently, The Viano Quartet came to Wayne State University School of Medicine's Margherio Family Conference Center to hold a rehearsal and provide an educational session for 65 third-year medical students and 50 pharmacy students. This is the third year in a row that musicians have schooled Wayne State healthcare students about nonverbal communication.
The string quartet modeled valuable communication skills, says Aline Saad, PharmD, director of interprofessional education at Wayne State's Applebaum College of Pharmacy and Health Sciences. "We want to show our students how musicians communicate with each other—they give cues to each other to decide who is going to lead utilizing intonations and body movements to send messages to their colleagues. As healthcare providers, we can communicate amongst each other similarly and emphasize the importance of working as a team."
The musicians show that communication takes practice, she says. "When a quartet goes on stage, they have practiced many times before. We want to give our students the message that communication is a skill that does not always come intuitively and that we must practice it. With the string quartet, we can learn from a group that is cohesive, coherent, and capable of producing a piece of music that an audience can enjoy. They prepare themselves to communicate. We want our students to prepare to communicate effectively and cohesively with patients."
Members of the string quartet engage in several forms of nonverbal communication, says Georgina Marusca, MD, a resident in internal medicine at Detroit Medical Center and a graduate of Wayne State University School of Medicine who has attended all three of the musician sessions. "From an audience standpoint, you can see mostly nonverbal communication such as body language. Sometimes, there are subtle cues with head motions. There are also breathing cues—if they have a rest in the music, they take a breath."
The exercise helps prepare healthcare providers to work with patients, she says. "When it comes to communication between clinicians and patients, from a quartet we can learn facial expressions and visual cues that can help guide us in our treatments and how we make diagnoses. You also learn that it is helpful to practice communication beforehand. For example, if you are going to give a patient a diagnosis that is unfavorable, then you can practice what and how you are going to say with another medical professional before you talk with the patient."
Learning about nonverbal communication generates several benefits for healthcare providers, Marusca says.
"It is tied into the sensitivity that you need in this profession. It also helps strengthen the patient-physician relationship because if you are attuned to nonverbal communication, it is less likely that you will dismiss the patient or not pick up on things that the patient is reluctant to talk about. Mastering nonverbal communication can also reduce medical mistakes in terms of what is prescribed and what can work with a patient because nonverbal communication can be applied not only with the patient but also family members who come to a visit. Among medical professionals, nonverbal communication can help with verbal communication by giving you cues on what to say or giving you feedback from a colleague," she says.
More than two dozen CMOs from across the country gathered in Coeur d'Alene, Idaho, to discuss the top issues facing their health systems, hospitals, and physician practices.
Executives at the HealthLeaders Chief Medical Officer Exchange this week discussed a range of high-priority topics impacting their health systems, hospitals, and physician practices.
The HealthLeaders Exchange program features peer-to-peer interactions to address industry challenges. The intimate conference format of small-group breakout sessions encourages open conversation and deep networking.
This year's CMO Exchange included vibrant discussions on four topics.
1. Post-COVID environment
Tracy Breen, MD, chief medical officer of Mount Sinai West in New York, New York, said health systems and hospitals are emerging from the emergency phase of the coronavirus pandemic.
"Our challenge is moving past just surviving and into thriving. The first year and a half of the pandemic, it was about survival. Now, we have to find ways to thrive even with The Great Resignation. We need to bring joy back to work. We need to bring purpose back to work. Our staff and our teams really need to understand why they are there and to get joy from their work in the setting of massive disruption," she said.
The healthcare sector is experiencing the "post pandemic hangover," said Anil Keswani, MD, corporate senior vice president and CMO for ambulatory and accountable care at San Diego-based Scripps Health.
"Over the last few years, our minds were focused on the waves of COVID-19. We focused on new treatments, changing guidance, and the repeated surges that we faced. COVID still exists but we are in a new phase of this health crisis that we think of as the post pandemic hangover. Many of us are experiencing the after effects of what happened over the last few years—financial challenges, deferred care that is driving additional demand, patients with long COVID, workplace fatigue, labor shortages, and clinician burnout. This is all built upon increasing costs. The unanswered question is how long this hangover will last and if there is a cure for this hangover," he said.
2. Medical errors and transparency
Breen said the recent criminally negligent homicide and gross neglect of an impaired adult conviction of RaDonda Vaught, a former nurse who made a fatal medication error at Vanderbilt University Medical Center in Nashville, has impacted how healthcare providers address medical errors.
"After the nurse in Tennessee was convicted criminally of a medical error, it is chilling for all of us. In New York, which can be a litigious environment—we have always talked about protecting the record and protecting our staff. Now, it takes on a whole other view. We not only have to educate our staff but also build quality and peer review systems that are better protected. We need to go into our departments and talk about quality assurance. Then, you have to get the staff to disclose errors—they happen every day. Staff may be worried that anything they say could affect their job, their license, and even bring criminal charges," she said.
3. Workforce vitality
Efforts to promote workforce well-being and engagement generated vigorous discussions at the CMO Exchange.
"We are facing multiple challenges in the hospital setting presently. For example, we have many patients coming to the emergency department requiring hospitalization but are challenged by staffing shortages. On top of that, we have seen a sharp increase in workplace violence. The staff need support and do not like it when they are on an island dealing with these challenges on their own. They want to see leadership—they want to see you on the floor commiserating, collaborating, and listening. You need to be visible to the staff and to offer solutions. Staff have options today. If they don't feel supported, they will leave, be it locum tenens or otherwise. We have worked to have leadership on the frontlines, and it has made a difference," said Erik Summers, MD, CMO and vice chair of internal medicine at Wake Forest Baptist Medical Center in Winston-Salem, North Carolina.
Mount Sinai is encouraging leaders to return to face-to-face interactions with staff rather than virtual engagement, Breen said.
"We have been intentional in re-wiring the human component whether it's on formal leadership rounds or what I call my walkabouts—I walk the units and whenever I do that I run into people and talk with them about what is going on. The leadership team has made a commitment to go around to every unit to thank them for their work. It has become a structured, weekly effort, where we go in and visit one or two units. They know we are coming—it is not a surprise. We take note of what the staff's issues are and have a structured way of going back to the unit within a few weeks to tell them what we have done and what we cannot do. This process has been helpful, and the follow-up is important," she said.
Rounding is important, but it is just a modest piece of employee engagement, said Richard Morel, MD, CMO of Optum Tri-State, which employs healthcare providers in Connecticut, New Jersey, and New York.
"I heard a term recently, it is not The Great Resignation—it is The Great Upgrade. Staff is feeling more mobile, and they are looking to improve their situation. We hear it all the time—a competitor group has offered $10,000 signing bonuses for ultrasound techs. There are three things you need to compete on because you want to be The Great Upgrade. First is what staff get for doing their work—their income, their benefits, and their work-life balance. Second is the staff's purpose at work. In healthcare, this is a relatively easy factor because there is a high purpose in work, but you have to continually promote that in the organization. Third is who is the boss. People will quit over bosses. You have to look at your management team and leadership structure," he said.
4. Workplace violence
Health systems and hospitals have to work closely with law enforcement to address workplace violence, said Peter Arnold, MD, PhD, associate CMO of hospital operations at University of Mississippi Medical Center in Jackson, Mississippi.
"I have always been an advocate that if someone hits one of my nurses, I would seek to have charges brough against the perpetrator. If somebody says, 'I am going to come back and shoot the place up,' and they come back and shoot the place up, I would argue that in addition to the front line providers, the administration is at high risk. I advocate to have law enforcement involved under those circumstances to attempt to de-escalate the situation," he said.
Reducing workplace violence requires a multipronged approach, Breen said. "There are multiple layers to addressing workplace violence. There is no single solution. You have to layer your response. For example, you have to have de-escalation techniques, good administrative policies, and a low threshold for taking a threat seriously."
Health systems and hospitals need to be willing and ready to confront patients about workplace violence, Summers said.
"In the inpatient setting, we have developed a process. If a patient can make their medical decisions and engages in verbal or physical abuse with staff, we will go to the floor and talk with the staff to make sure they are OK. Then we talk to the patient to let them know that behavior was not acceptable. We let them know that a behavior contract may be required if their behavior does not change. And, if necessary, we discuss removing the patient from the hospital. While a patient would need to be medically stable to remove, it is imperative to support our staff and keep them safe just as we keep our patients safe. Any patient who engages in workplace violence gets a behavior alert in the electronic medical record, so when they come in again, our staff is aware and prepared for any concerning behavior," he said.
Recent research found that home caregiver engagement during care transitions reduced hospital readmissions by 17%.
For adult patients living with chronic illness, home caregiver engagement plays a significant role in patient outcomes during the transition of care from hospital to home, a recent research article found.
The recent research article, which was published by Medical Care, examines the findings of more than 50 studies of transitional care interventions. The study includes two key data points:
In studies that involved home caregiver engagement in transitional care interventions, the overall likelihood of hospital readmissions was reduced by 17%
Transitional care interventions that did not have caregiver engagement in the components of the interventions did not have significant impacts on hospital readmissions
"Whether in research or clinical practice, transitional care should not be conducted without careful consideration of where and how caregivers will be incorporated and supported as active partners in optimizing patient care across healthcare transitions," the study's co-authors wrote.
Forms of home caregiver engagement
Healthcare providers can engage home caregivers, who include family members and friends, in several ways, the lead author of the recent research article says.
"When we think about engaging home caregivers, we need to adequately support them beyond just information provision. Caregiver engagement truly involves not just giving them information but also understanding what their preferences and needs are. We also need to collaborate with them to develop the plan of care. That is the way that care gets personalized. Engagement can take the form of understanding what caregivers' needs are in terms of anticipatory guidance for symptoms that might be experienced at home and how to navigate those symptoms at home with medication management. You can discuss red flags and signals that may indicate a need for calling a physician," says Kristin Levoy, PhD, MSN, RN, a Regenstrief Institute research scientist and an assistant professor at Indiana University School of Nursing.
Health systems and hospitals also need to have an infrastructure in place to support care transitions and home caregivers, she says. "Having a common healthcare provider or spokesperson who can advocate for communicating the plan of care to the scope of practitioners who are involved with the patient's care should incorporate the family caregiver in that process. You also need to coordinate services—make sure that home health shows up, make sure any change in medication is adequately communicated to the primary care provider, and make sure that routine follow-up phone calls are happening in the home to maintain health and prevent hospitalizations."
Preventing hospitalizations
Home caregivers can help avoid hospitalizations and hospital readmissions, Levoy says. "To the extent that home caregivers are equipped and engaged in things like anticipatory guidance for symptoms, caregivers can contribute to reducing hospitalizations."
Active engagement of home caregivers is critical, she says. "What we found was that when home caregivers were actively engaged in the transitional care process—actively receiving education, actively being asked about the needs in the home, and receiving help in care coordination—caregiver engagement with the various components of interventions influenced overall reduction in the probability of hospital readmissions. Those interventions that had caregiver engagement in their intervention design yielded better outcomes. We all anecdotally recognize the contribution that home caregivers are making to patient outcomes, and we have provided some empirical evidence to support that perception."
Impacts beyond hospitalizations
Home caregiver engagement has positive effects beyond limiting hospitalizations, Levoy says. "Home caregiver engagement broadly helps to ensure a common understanding between the patient, provider, and caregiver about the patient's condition and their treatment plan. That common understanding helps inform healthcare decision-making. That can be in decisions about selecting treatment options, decisions about self-care in the home, and managing disease with medications. It can also impact decisions about whether to seek emergency care, to go back to the hospital, or to call a provider. All of these things impact patient outcomes."
Home caregiver engagement also has a positive impact on the caregivers, she says. "Home caregiver engagement not only helps patients—it also helps to improve caregiver outcomes. Other studies have looked at home caregiver engagement and noted improvements in caregiver depression, reduced caregiver burden and distress, and improved quality of life. When we are actively engaging home caregivers as partners in care delivery, we are not only influencing the patient's outcomes and helping them make better-informed decisions on their own behalf, but also helping caregivers achieve better outcomes for themselves."
Part of the care team
Home caregivers can play an active role in a patient's care team, Levoy says. "The home caregiver can serve in a variety of functions. They might be the information broker, where they are soliciting information on the patient's behalf from the healthcare provider on how to navigate symptoms or deal with issues that come up with the condition between visits. They can advocate for the patient's preferences when they feel their preferences are not being honored or incorporated into the plan of care."
Home caregivers can be involved in a patient's care decision-making, she says. "Oftentimes, patients defer decisions to their caregivers, and they function as the primary healthcare decision-makers for patients. To the extent that they are not tangentially involved in clinical interactions, caregivers are active partners. They can make informed decisions on the patient's behalf or provide guidance to patients. Home caregivers and patients often move forward together."
Genetic testing identifies coronary artery disease patients who are at highest risk for sudden cardiac death.
A new research article shows a precision medicine technique is promising for identifying patients at highest risk for developing sudden cardiac death—an electrical malfunction of the heart that causes the organ to stop beating.
Sudden and/or arrhythmic death (SAD) is a leading cause of death in the United States, causing about 300,000 deaths annually. Internationally, SAD is responsible for 15% to 20% of all deaths. SAD is often associated with coronary artery disease.
The new research article, which was published this week by the Journal of the American College of Cardiology, is based on data collected in the PRE-DETERMINE study of more than 5,500 patients with coronary artery disease. The researchers used a polygenic risk score to identify patients at highest risk for SAD. A precision medicine technique, polygenic risk scores combine the different versions of many genes that an individual has that are related to a specific disease.
The researchers used a polygenic risk score that has been successful in predicting coronary artery disease. They found that coronary artery disease patients who did not have severely impaired heart function had the highest polygenic risk score. These patients had a 77% increased risk for SAD.
The first author of the study says the research is a significant step forward in SAD research. "In order to better predict and prevent sudden cardiac death, we must first understand the genetic connection between it and coronary artery disease. We found incorporating information from this genetic risk score improved our ability to predict sudden death beyond the contributions of other known risk markers. Most exciting, the genetics were able to identify patients where sudden death was more likely to limit their life expectancy," Roopinder Sandhu, MD, MPH, an interventional cardiology and cardiac electrophysiology specialist at Cedars-Sinai, said in a prepared statement.
SAD is different than myocardial infarctions—commonly called heart attacks. In most heart attacks, clogged coronary arteries reduce blood flow to the heart. Typically in SAD, there is the sudden onset of erratic electrical activity in the heart that decreases the pumping function of the organ. There usually is little or no warning of SAD, and death occurs within minutes unless resuscitation is performed.
The senior author of the study says the polygenic risk score could be used in the future to identify patients who could benefit most from lifesaving therapies such as an implantable cardioverter-defibrillator.
"This study indicates there is opportunity to identify patients at highest risk for sudden cardiac death, and then offering meaningful, preventative treatment solutions like a defibrillator. Based on our pivotal research, we now have the foundation to achieve this," Christine Albert, MD, MPH, chair of the Department of Cardiology in the Smidt Heart Institute at Cedars-Sinai, said in a prepared statement.
The assumed annual clinician attrition rate in the prediction of an emergency physician surplus appears to be too low.
A predicted emergency medicine physician surplus by 2030 may not be as large as anticipated, according to a recent research article.
A study published in December 2021 that analyzed Medicare claims data and the American Medical Association Masterfile forecast there would be a surplus of 7,845 emergency physicians by 2030. The study assumed a 3% annual clinician attrition rate.
The recent research article, which was published by Annals of Emergency Medicine, features data collected about more than 82,000 clinicians from 2013 to 2019. In that timeframe, emergency physicians experience a collective annual attrition rate of 5.3% to 5.7%, including 3.8% to 4.9% permanent attrition.
The co-authors of the recent research article say that if the attrition rate for emergency physicians was 1% higher than the assumed 3% rate, the forecast surplus would be only 2,486 clinicians. "The annual rate of emergency physician attrition was collectively more than 5%, well above the 3% assumed in a recently publicized projection, suggesting a potential overestimation of the anticipated future clinician surplus," the co-authors wrote.
The recent research article has four other key findings about the emergency medicine workforce, which consists of emergency physicians, non-emergency medicine physicians, and advanced practice providers.
The proportion of advanced practice providers in the emergency medicine workforce increased from 20.9% in 2013 to 26.1% in 2019, while the proportion of emergency physicians decreased from 68.1% in 2013 to 65.5% in 2019.
Emergency clinician entry to the workforce peaked in 2016 and clinician exit from the workforce was still rising in 2018.
Emergency physicians account for less than half of the rural emergency medicine workforce, with a 51.3% proportion of all clinicians in 2013 and 46.4% proportion in 2019. The proportion of advanced practice providers working in rural areas increased significantly during the study period, rising from 23.0% of rural clinicians in 2013 to 32.7% in 2019.
There was significant state-level variation in emergency clinician densities per 100,000 population. In 2013, the three states with the highest emergency physician densities were Washington, DC (23.0), Michigan (16.5) and Rhode Island (16.4), and the three state with the lowest densities were South Dakota (6.0), Nebraska (6.9), and Montana (7.0). In 2019, the three states with the highest densities were Washington, DC (24.2), Rhode Island (20.6), and Michigan (19.6), and the three states with the lowest densities were Alabama (7.0), Idaho (7.4), and South Dakota (8.3).
The study has troubling findings for the practice of emergency medicine in rural areas, the co-authors wrote. "Rural clinicians providing emergency care in 2019 are now more likely to be nonemergency physicians or advanced practice providers rather than emergency physicians. Our work uniquely identifies a concerning trend regarding the recruitment of rural emergency physicians. From 2013 to 2019, the number of emergency physicians entering the rural workforce never offset the number leaving from the prior year, suggesting that shortages and inequities in access will persist unless substantial efforts are made to address emergency physician recruitment and retention issues."
