Integrative care includes interprofessional collaboration and interdependent considerations such as genetics, social determinants of health, and community support and resources.
In a recently published report, Northwestern Health Sciences University (NWHSU) has identified seven domains of knowledge, skills, and behaviors that clinicians need to provide the best integrative care.
Integrative care has many elements. At NWHSU, the concept of integrative care extends beyond multi-disciplinary care, including team-based and holistic care, interprofessional collaboration, and partnerships between patients and communities. Integrative care also includes interdependent considerations such as genetics, social determinants of health, community support and resources, and beliefs and habits that influence health.
Domain 1, values, ethics, culture, and diversity: In integrative care, clinicians work with colleagues in other professions in a climate of mutual respect and shared values, with the recognition that there is diversity in and between disciplines as well as diversity in patient populations.
Values, ethics, culture, and diversity are the connective tissue of integrative care and a transdisciplinary approach to healthcare, says Michele Renee, DC, director of integrative care at NWHSU. "It is the shared mindset that unifies diverse paradigms of healing, creating a dynamic approach in which each point of view is honored and yet not sufficient in and of itself. We are also acknowledging the importance of social factors, from socio-economic status to religion to cultural norms, and professional diversity, from indigenous healing to mainstream medicine to complementary and integrative healthcare approaches. All these differences are important considerations in providing robust, multifaceted, and individualized approaches to care."
Domain 2, patient-centered care: Clinicians should seek out, integrate, and value contributions and engagement of the patient, family, and community in designing and providing care.
Patient-centered care acknowledges the pivotal role of patients in their care, Renee says. "Patient-centered care calls out the importance of acknowledging the bio-psycho-social-spiritual nature of whole person care. It is vital that healthcare providers are not doing to the patient, but rather with the patient. Our patients are active participants in care and the most important person in a healthcare team."
Domain 3, roles and responsibilities: Clinicians should use knowledge of their role and the role of other professions to identify and address the healthcare needs of patients, families, and communities.
"For team-based care to work, we must each understand the part we play, the unique skills others bring, and how we all fit into the larger picture. This is a dynamic process, created uniquely for each person we serve. These skills are essential to ensure care is complete and wraps around our patients and communities," Renee says.
Domain 4, interprofessional communication: Clinicians should be responsive and responsible in their communication with patients, families, communities, and other healthcare professionals, which helps establishing a team approach to health and the treatment of disease.
Communication is often where healthcare fails, so shared communication competencies are essential, Renee says. "This includes understanding ourselves, acknowledging biases, identifying and resolving conflict when it arises, and documenting care in a way that is universally understood. Multilayered communication is key to building trusting relationships."
Domain 5, team and teamwork: Clinicians should practice relationship-building values and embrace team dynamics to perform effectively in different team roles to plan, deliver, and evaluate patient-centered care that is safe, timely, efficient, effective, and equitable.
Patients and communities rely upon their healthcare teams knowing how to evaluate, plan, and deliver care, Renee says. "This involves designing and implementing evidence-informed systems that support effective teamwork, and creating accountability for each care team member to focus on all aspects of patient and population focused problem solving. Team-based care goes beyond what happens in the treatment room or hospital to include social determinants of health and health equity."
Domain 6, collaborative leadership: Clinicians should foster shared leadership and collaborative practice of care.
Healthcare professionals need to cultivate the skill of passing the baton as needed, Renee says. "One provider may be providing the primary intervention at one moment in time and complementary care at another. The needs of the patient change over time and the care team needs to be prepared to collaborate and share leadership accordingly, leaning on one another's unique insights and expertise as needed."
Domain 7, well-being and resilience: Clinicians need to recognize that the health of an individual has positive and negative effects on their ability to make change around them and adopt sustainable strategies to address challenges, while remaining committed to their sense of purpose.
Building a resilient healthcare system starts with the well-being of healthcare professionals, Renee says. "Health creation begins with prioritizing self-care, which in turn reduces burnout and improves job performance and satisfaction. Learning the skills to identify one's circle of influence, develop a growth mindset, and cultivate grit prepare providers to better support patients in their own health creation by putting the focus on well-being and resilience instead of disease management."
The cancer center has patient navigators who specialize in particular cancers, and they are permanently assigned to specific patients.
Specialized patient navigators are making a difference for patients and care teams at Detroit-based Karmanos Cancer Institute.
At health systems and hospitals, patient navigators are deployed to play a key patient engagement role in the organization. Patient navigators can be involved in the patient journey in several ways, including helping patients communicate with care teams, setting appointments for doctor visits, and securing financial, legal, and social support.
At Karmanos, specialized patient navigators are trained to work with patients who have specific kinds of cancer. "Patient navigators are better equipped to assist their patients when they understand the way the cancer affects the patient. At Karmanos, our physicians are specialists, and our patient navigators are specialists. What we decided to do was embed our navigators into a multidisciplinary team, where they specialize in a particular kind of cancer such as breast cancer or head and neck cancer," says April Brown, director of concierge services at Karmanos.
Having specialized patient navigators drives several benefits for patients and the cancer institute, she says.
"The benefit of having specialized patient navigators is understanding a particular kind of cancer and the needs that those patients have. For example, for a breast cancer patient versus a head and neck cancer patient, they are going to have different needs in areas such as medical records, treatments, and psychosocial issues. Our patient navigators also address financial toxicity. We do a lot of research on cancer-specific endowments and patient assistance programs. There can be a set of money available for lung cancer patients or a set of money for lymphoma patients. With patient navigators focused on specific cancers, they know what financial assistance is available for specific patient populations."
The specialized patient navigators received extensive training, Brown says. "Our patient navigators undergo online training with George Washington University and online training with the American Cancer Society. Our clinical staff also mentors the patient navigators. They work with our physicians to understand a particular type of cancer. We also utilize our pharmaceutical companies—they come in as new drugs are developed for various types of cancer. They educate us about these new drugs. We also have an education office that works with our patient navigators."
Best practices
There are several best practices for running a specialized patient navigator program, Brown says.
At Karmanos, a patient is assigned to a particular specialized patient navigator. "When a patient navigator starts working with a patient, they are often the first point of contact. The patient navigator begins to build a relationship with the patient. Then, that patient knows that when they run up against an issue or a concern, they can feel comfortable seeking out their particular patient navigator. The patient knows the patient navigator is always there for them," she says.
After a clinic visit, the patient navigators have a follow-up phone call with their patients and have a conversation, Brown says. "We have found that those calls are like peeling back an onion because there are multiple layers to our patients. Listening to our patients is another best practice. Sometimes, our patients just want the patient navigators to listen to them."
Specialized patient navigators have multiple points of contact with patients throughout the patient journey, she says. "It makes the patients feel comfortable reaching out to our navigators. If a patient misses an appointment, the patient navigator will call and ask, 'What is going on?' It does not have to be a long conversation—just the fact that you called and checked on the patient makes them feel more comfortable."
Generating positive results
Having specialized patient navigators has resulted in positive results for patients and the cancer institute, Brown says. "Our no-show rates decreased because patient navigators were following up with patients. We have improved dealing with financial toxicity, and we have improved our bottom line. Patients are adhering better to their chemotherapy appointments because patient navigators address barriers such as transportation difficulties. Patient satisfaction has also improved. It helps to have one person the patient speaks to when they have a problem."
The work specialized patient navigators conduct to connect patients with financial resources is a financial benefit for patients and Karmanos, she says. "We found that we were writing off bills because patients were not able to pay for deductibles and co-pays. By getting our patient navigators to find financial assistance such as payments from the pharmaceutical companies, that affected our bottom line."
Part of the care team
Specialized patient navigators are a vital part of the Karmanos care teams, Brown says. "Patient navigators are in constant contact with our physicians, sometimes three times a day depending on the situation. The patient could have a new issue that is going on. Patient navigators are also in constant contact with our nursing staff and social workers. Patient navigators are a central point of contact for everyone. They go between the patient and all of the resources that we have at Karmanos."
Although specialized patient navigators are not clinical specialists, they often facilitate clinical care, she says. "After a clinical visit, patients may have questions about their treatment and contact their patient navigator. That will prompt a call to a physician or a nurse, who will be asked to call the patient. Sometimes, the patient is not feeling well, and they reach out to their patient navigator. They know that we will take the call and connect them with a clinical team member who can assist them quickly."
The specialized patient navigators also get involved in care coordination, Brown says.
Students in the community medicine medical degree track will learn at one of the top community medical centers in Ohio during their third and fourth years of medical school.
Physicians tend to practice in urban and suburban areas of the country. About 20% of Americans live in rural areas but only about 11% of physicians practice in rural communities, according to Kristina Johnson, PhD, president of The Ohio State University.
The community medicine medical degree track is set to begin enrolling medical students in 2024. The program was spawned by the Healthy State Alliance, an initiative between The Ohio State University Wexner Medical Center and Bon Secours Mercy Health to address thorny healthcare issues in Ohio.
An important facet of the new medical degree track will be to encourage students to be leaders in their communities, says Carol Bradford, MD, MS, dean of The Ohio State University College of Medicine.
"Working as engaged leaders in the community will enable our students to become more empathetic and compassionate caregivers and help them to quickly build relationships within the community where they serve. As leaders within these communities, they will be uniquely positioned to bring teams together who can effectively address the challenges their patients face and to work collaboratively to eliminate local inequities in care. In addition, our students will become the physician leaders of the future who will transform care and impact the health of the communities. They will help innovate solutions to solve our most pressing healthcare needs," she says.
The curriculum will be geared toward practicing medicine in less densely populated areas, Bradford says. "During the first and second years of medical school, students will begin their clinical experiences in a longitudinal preceptorship with a practicing physician in a community setting. During their third and fourth years of medical school, students will learn at Mercy Health—St. Rita's Medical Center in Lima, Ohio, one of the top community medical centers in Ohio. Students will get hands-on experience with patients from less densely populated areas with a multitude of health issues that affect these populations. Faculty who practice at St. Rita's will provide them with the education they need to learn how to better serve these populations."
Interprofessional education
Medical students will be taught about team-based collaborative care with pharmacy, nursing, social work, and behavioral health professionals help prepare them to practice medicine in less densely populated areas, she says.
"Interprofessional education brings students from two or more professions together during their training to learn about, from, and with one another to improve health outcomes, cultivate collaboration, and provide patient-centered care. It connects students and caregivers with people where they spend most of their time—in the community—and helps them to develop skills to effectively lead and be part of teams solving pressing healthcare challenges, such as those imposed by social and other determinants of health and advancing the social and humanistic missions shared across the health professions. This is particularly important for physicians who will be working in less densely populated areas, where resources are often scarce and reaching across sectors and professions is essential to serve patients."
Interprofessional education will equip medical students with the ability to provide comprehensive care to their patients, Bradford says. "Using this educational approach will prepare our students to enter the workforce ready to provide the best care for their patients in the future. Establishing a framework for team-based care will ensure that those patients who do not always have easy access to all members of their healthcare team will still receive comprehensive care."
Community focus
The new program is designed to attract students who want to make an impact in less densely populated areas, she says. "These students are looking for the innovative, top-tier education from The Ohio State University College of Medicine combined with the community care expertise of Bon Secours Mercy Health. This program will produce some of the most sought-after physicians in community medicine but more importantly produce physicians with the knowledge and heart to serve such an important population of patients."
Training medical students at Mercy Health—St. Rita's Medical Center will hopefully encourage them to work in mid-sized and rural areas, Bradford says. "It is our hope that physicians trained in less densely populated areas will be drawn to stay in those communities, to work as residents, and ultimately as physicians who are passionate and uniquely prepared to improve health and health outcomes."
In 2015, homebound seniors accounted for about 11% of total Medicare fee-for-service spending but they were only 5.7% of the Medicare fee-for-service patient population.
Homebound seniors are more frequent users of hospital-based care and have higher Medicare spending than non-homebound seniors, a new research article says.
In the study, homebound was defined as leaving home once per week or less. There are an estimated two million homebound seniors in the country. Homebound adultsare often medically complex, with high levels of dementia and chronic disease.
The new research article, which was published by the Journal of General Internal Medicine, features data collected from nearly 6,500 adults aged 70 years and older with Medicare fee-for-service coverage. A primary source of data for the study was the National Health and Aging Trends Study (NHATS), which conducts annual in-person interviews of Medicare beneficiaries or proxy respondents for information such as living arrangements, health conditions, and functional status.
The research article, which examined data from 2011 to 2017, has several key data points.
About 40% of homebound seniors had a hospitalization annually compared to about 20% of non-homebound seniors
Total annual Medicare spending is more than $11,000 higher for homebound seniors compared to non-homebound seniors
In 2015, homebound seniors accounted for about 11% of total Medicare fee-for-service spending but were only 5.7% of the Medicare fee-for-service patient population
Homebound seniors account for nearly 14% of Medicare beneficiaries in the 95% percentile of Medicare fee-for-service spending
In the year following the NHATS interview, homebound seniors compared to non-homebound seniors were more likely to have a potentially preventable hospitalization (14.8% versus 4.5%) and more likely to have an emergency room visit (54.0% versus 32.6%)
After adjusting the data for demographic, clinical and geographic characteristics, homebound seniors were less likely to have an annual primary care visit or specialist visit compared to non-homebound seniors
"Homebound older adults use more hospital-based care and less outpatient care than the non-homebound, contributing to higher levels of overall Medicare spending," the study's co-authors wrote.
Interpreting the data
Homebound seniors are not receiving home health services that could offset the lack of outpatient services, the lead author of the study said in a prepared statement. "When we adjusted for demographic, clinical, and geographic differences, we found the homebound have a negligible increase in the probability of having a home health visit compared to the non-homebound, suggesting that the gap in outpatient care is not being addressed by a home-based care model within Medicare. It's concerning but not surprising; the finding is consistent with well-known barriers in Medicare to accessing home health services," said Benjamin Oseroff, a third-year medical student at Icahn School of Medicine at Mount Sinai.
Home-based primary care would likely benefit homebound seniors, the study's co-authors wrote. "The lower rate of primary care utilization we observe may partially explain our finding that the homebound experience more potentially preventable hospitalizations than the non-homebound and higher spending. Previous research suggests increasing access to home-based primary care may lower hospitalizations and overall spending for the homebound, depending on the intervention type."
Targeting homebound seniors for enhanced care would decrease Medicare spending, the study's co-authors wrote. "We find that homebound older adults in 2015 accounted for 11.0% of Medicare spending among those over 70 despite making up only 5.7% of this population. The homebound are even more concentrated among the top spenders, making up 13.6% of those in the 95th percentile or above of Medicare spending. Our findings suggest that the homebound, a group often invisible to the healthcare system, may be an important population to target for quality improvement and to reduce Medicare spending."
Telehealth could improve care for homebound seniors, but it has limitations for this population of patients, the study's co-authors wrote. "Telemedicine provides another alternative to in-person visits, though recent experiences during the COVID-19 pandemic highlight the challenges of virtually reaching homebound older adults."
One of the study's co-authors who helped write a journal article on telehealth barriers for homebound seniors said in a prepared statement that there are several telehealth difficulties to overcome. "The types of barriers we uncovered ran the gamut from lack of broadband access to lack of support help to use the technology, and cognitive and sensory impairments. In this population, older age may compound some of the inequalities that this population is already facing. A high-tech solution will not always work for this high-need, medically and socially complex population," said Katherine Ornstein, PhD, MPH, an adjunct associate professor of geriatrics and palliative medicine at Icahn School of Medicine at Mount Sinai.
Researchers find that cigarette smoking is a leading cause of cancer-related death, with a significant economic burden.
In 2019, cancer deaths attributable to cigarette smoking resulted in more than 2.1 million person-years of life lost (PYLL) and $20.9 billion in lost earnings, a new research article says.
About 600,000 Americans succumb to cancer annually, making the disease the second leading cause of death in the country and generating a significant economic burden. Cigarette smoking is the most preventable cause of cancer death.
The new research article, which was published by International Journal of Cancer, estimates the proportions and numbers of cigarette smoking-attributable cancer deaths and associated PYLL and lost earnings among Americans between the ages of 25 and 79. The study generated several key data points.
In 2019, there were 418,563 cancer deaths among Americans aged 25 to 79 years. An estimated 122,951 of the deaths were linked to cigarette smoking, with 2,188,195 PYLL.
In 2019, the total lost earnings linked to cigarette smoking-attributable cancer deaths were estimated at $20.9 billion.
The estimated number of cancer deaths linked to cigarette smoking were higher among men than women (74,508 versus 48,425).
Lost earnings linked to cigarette smoking-attributable cancer deaths were higher among men than women (15.2 billion versus $5.6 billion). The study's co-authors said this difference was caused by higher employment rates and wages among men.
Lung cancer accounted for the most smoking-attributable lost earnings ($12.9 billion), followed by esophageal cancer ($1.5 billion), colorectal cancer ($1.2 billion), and liver cancer ($1.1 billion).
Utah had the lowest estimated proportion of cancer deaths linked to cigarette smoking (16.5%), and Kentucky had the highest estimated proportion of cancer deaths linked to cigarette smoking (37.8%).
Wyoming had the lowest estimated total lost earnings linked to cigarette smoking-attributable cancer deaths ($32.2 million), and California had the highest estimated total lost earnings linked to cigarette smoking-attributable cancer deaths ($1.6 billion).
If the PYLL and lost earnings rate of Utah had been achieved nationwide in 2019, more than half of the estimated total PYLL and lost earnings nationally would have been avoided.
In a prepared statement, the lead author of the study said the research shows the terrible toll that smoking takes on the country. "Our study provides further evidence that smoking continues to be a leading cause of cancer-related death and to have a huge impact on the economy across the U.S. We must continue to help individuals to quit using tobacco, prevent anyone from starting, and work with elected officials at all levels of government for broad and equitable implementation of proven tobacco control interventions," said Farhad Islami, MD, PhD, senior scientific director for cancer disparity research at the American Cancer Society.
Interpreting the data
There are 13 states in the South and Midwest—the "Tobacco Nation" states—that have generally weaker tobacco control policies and higher cigarette smoking prevalence than the rest of the country. Those states are Alabama, Arkansas, Indiana, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Ohio, Oklahoma, South Carolina, Tennessee, and West Virginia.
Death rates were highest in the Tobacco Nation states. In addition, the annual PYLL rate for the Tobacco Nation states was 46.8% higher than in other states and the District of Columbia, and the lost earnings rate for these states was 44% higher than in other states and the District of Columbia.
Relatively low tobacco excise taxes in the Tobacco Nation states likely contribute to their worse outcomes, the study's co-authors wrote. "The highest state tobacco excise tax rate per pack of cigarettes in the 13 'Tobacco Nation' states as of March 2021 was in Oklahoma ($2.03), Michigan ($2.00), and Ohio ($1.60), while it was ≤$1.20 in the other 10 states, as low as $0.17 in Missouri. In contrast, the state excise tax rate per pack of cigarettes in the Northeast region was ≥$1.78 in all 9 states, and >$3.00 in 5 states. Increasing the price of cigarettes through excise taxes is the single most effective policy for reducing cigarette smoking prevalence."
Smoking restriction laws also play a role in smoking prevalence at the state level, the study's co-authors wrote. "States with the highest smoking-attributable PYLL and lost earnings rates also generally lack statewide comprehensive smoke-free policies that completely prohibit smoking in workplaces, restaurants, and bars."
Lung cancer screening is critical to address smoking-attributable mortality and lost earnings, the study's co-authors wrote. "In addition to reinforcing tobacco control policies and expanding access to care, strategies and efforts to increase uptake of lung cancer screening can substantially reduce PYLL and lost earnings due to lung cancer, which accounts for about two-thirds of the total PYLL and lost earning due to smoking-attributable cancer deaths."
At the national level, stronger tobacco control policies are needed to reduce smoking-attributable mortality and lost earnings, the study's co-authors wrote. "PYLL and lost earnings due to cigarette attributable cancer deaths are substantial in all states, although they are largest in states with weaker tobacco control policies. Broad and equitable implementation and enforcement of proven tobacco control interventions across all states could substantially reduce cancer deaths and the associated economic burden."
The Progressive Care Unit at Tampa General Hospital has generated impressive results, including an 83% ventilator weaning rate and 75% reduction in readmissions.
A unique partnership at Tampa General Hospital is generating positive results for patients on ventilators.
Ventilator-dependent patients are medically complex and often have multiple morbidities. Providing care for these patients is costly, and they have extended lengths of stay compared to many hospitalized patients.
In a partnership with Boca Raton, Florida-based Special Care Unit, Tampa General Hospital operates a Progressive Care Unit to wean patients off ventilators. "It is separate from an ICU. It is a step-down level of care from an ICU. It has its own dedicated area in the hospital," says Sam Nimah, CEO of Special Care Unit.
The Progressive Care Unit has staff members from Tampa General Hospital and Special Care Unit, he says. "It is a jointly staffed unit, with staff from Tampa General as well as Special Care Unit to provide a unique opportunity for ventilator-dependent patients to wean off the ventilator at a rate of greater than 80%. It is staffed with dedicated nurses, respiratory therapists, physical therapists, occupational therapists, speech-language pathologists, and case managers. All of the staff are dedicated to the unit."
The Progressive Care Unit provides an exceptional patient experience, with daily intensive rehabilitation efforts, Nimah says.
"Most hospitals have a rehabilitation department that is responsible for rehabilitation opportunities and consults throughout the hospital. They may have to go to dozens of patients on a given day across the hospital. But hospitals are controlled chaos—there are multiple activities going on at any given moment. So, a physical therapist may show up in a patient's room, and they may be off getting a CT scan, or they may have had a rough night and they are sleeping. In those circumstances, the physical therapist has to move on to the next patient. In the Progressive Care Unit, we have a dedicated team, so if a patient is not ready for their rehab it is no problem—we will be there when the patient is ready."
The consistency of staffing is a crucial part of the patient experience at the Progressive Care Unit, he says.
"On average, our patients are with us for about three weeks. We become their family, and they become our family. The average length of stay in a hospital is only a few days. If you have nurses working three shifts in a row—one at day and one at night—a patient will rarely see more than one set of nurses during their stay. But when a patient is in a hospital for three weeks, the patient can rotate through multiple nurses' shifts. Our respiratory therapists, our physical therapists, our occupational therapists, and our nurses are all on the unit six days a week. They see the family. The patient sees the team working together every day."
The patient experience at the Progressive Care Unit includes an intensive level of rehabilitation that is not common at acute-care hospitals, Nimah says. "The key part of this is that every patient interaction can become a rehabilitation opportunity. With a team that is dedicated to this unit, we go far beyond what payers will pay for. For example, one physical therapy session per day is reimbursable by Medicare. We go far beyond that—turning every patient interaction into a potential rehabilitation opportunity."
The rehabilitation activities in the Progressive Care Unit include activities of daily living, range of motion, and walking, he says. "We just had an example where we had a physical therapist, occupational therapist, respiratory therapist, and a nurse all walking with a patient who was on the ventilator and had multiple intravenous connections. They were walking with the patient to get rehabilitation accomplished. There are a lot of rehabilitation hindrances when a patient is on a ventilator with IV drips—it can get very complicated. But we have a whole team that is dedicated to working with the patient together. It's a rare opportunity in any hospital."
Playing an important role during the coronavirus pandemic
The Progressive Care Unit has helped Tampa General Hospital post impressive clinical outcomes for COVID-19 patients, says John Couris, president and CEO of the hospital. "During the height of the pandemic, our resources were stretched. We were able to transition the medically complex, ventilator-dependent patients to breathing independently smoothly and safely with the support of the Progressive Care Unit. When you look at the outcomes for patients with COVID-19 at Tampa General Hospital, we have been in the top quartile for clinical outcomes, and we have been in the top decile for length of stay. I attribute part of that success to having the relationship with Special Care Unit."
The Progressive Care Unit is well-suited to weaning COVID-19 patients off ventilators, he says. "Specific to COVID-19, the Progressive Care Unit contributed in a significant way to better results with a lower length of stay for our COVID patients who were being weaned off ventilators. With the Progressive Care Unit, we had quality, better outcomes, better safety, and better efficiency and effectiveness for our patients."
Delivering good results
Reducing length of stay is a primary benefit of the Progressive Care Unit, Nimah says. "You do not typically have a respiratory therapist 24/7. You do not typically have physical therapists, occupational therapists, and speech-language pathologists all converging on one unit. For the patients we serve, we reduce length of stay by up to 12 days. That is how our service is paid for—it is paid for through efficiency and effectiveness of care."
The Progressive Care Unit generates several positive results, he says.
The unit has weaned patients off ventilators at a rate of 83% over the past three years.
The unit has reduced length of stay by six and 12 days, respectively, for DRG 003 and DRG 004. DRG 003 is a patient with a tracheostomy who is on a ventilator for more than 96 hours, with additional complications such as extracorporeal membrane oxygenation. DRG 004 is a patient with a tracheostomy who is on a ventilator for more than 96 hours.
The unit has reduced hospital readmissions by more than 75%.
The unit increased hospital margin by about $2.3 million in fiscal year 2021.
The partnership between Tampa General Hospital and Special Care Unit has been beneficial for patients and the hospital, Couris says. "It is a contractual relationship that is predicated on volume and quality. It is fair market value. It is commercially reasonable. It is driven by the activity that Special Care Unit does, the volume that they handle, plus the quality and clinical outcomes that they are responsible for achieving in collaboration with us."
Special Care Unit has a ventilator-weaning partnership with one other hospital—University of Alabama at Birmingham Hospital.
Emergency department screening is an opportunity to boost individual and population health.
Health systems and hospitals should follow seven principles to conduct screening for disease or health risk factors in emergency departments, according to a new journal article.
Particularly for patients with limited resources, the emergency department is a key access point for care. Screening for disease and health risk factors in the emergency department can boost individual and population health.
There is a tremendous opportunity to conduct screening in emergency departments. Research has shown that about half of U.S. adults over age 35 have not received screening for common health risk factors such as tobacco use and depression.
The new journal article, which was published by Annals of Emergency Medicine, identifies seven principles for conducting disease and health risk screening in emergency departments.
1. Screening should be conducted with evidence-based practices from established sources such as the United States Preventive Services Task Force (USPSTF) and the Centers for Disease Control and Prevention. For example, the USPSTF has made several screening recommendations for substance use disorders, HIV, suicide, and other conditions in the emergency department setting.
2. Emergency department screening should account for local disease and health risk factor epidemiology.
"The epidemiology of a disease can vary substantially by geography. Furthermore, risk factors, including social determinants of health, are highly variable depending on community resources. Screening is most efficient when the prevalence of a disease or risk factor meets a clinically significant threshold in the screened population. However, epidemiology must be considered in conjunction with the potential morbidity and mortality associated with the disease or risk factor, test characteristics (including material and staff costs), and feasibility of the intervention," the journal article's co-authors wrote.
3. Screening should only be conducted in the emergency department as long as primary ED functions and quality metrics are not disrupted. "Although population health initiatives encourage a broader perspective on ED visits, screening should not detract from the primary purpose of the ED: management of acute illness and injury. Furthermore, an increased length of stay in the ED is associated with decreased patient satisfaction and increased morbidity and mortality," the journal article's co-authors wrote.
4. Screening should be designed to limit the burden on ED clinical staff. "Clinical staff in the ED often faces mismatched patient/staff ratios, boarding of admitted patients, and crowding. Adding numerous screening questions can detract from their care of emergency conditions. Shifting screening and referral roles to dedicated patient navigators or other nonclinical staff can focus clinician time on evaluation and treatment," the journal article's co-authors wrote.
5. Screening should be based on transparency and communication with patients and the community. "Many screening topics involve stigmatizing conditions, and those developing screening initiatives should attempt to educate patients and the broader community about the rationale behind the screening. Public awareness campaigns in the community, signage around the ED, and patient handouts can help patients anticipate the screening. Upfront discussions with the patient also help avoid surprise results, especially because a proportion of screening test results will be falsely positive. This is especially crucial for tests such as HIV or syphilis screening," the journal article's co-authors wrote.
Establishing community trust is crucial to avoid the perception that the ED clinical staff is "experimenting" on patients.
6. Screening should only be conducted when follow-up resources are available.
"Patients who screen positive for disease or risk factors should have support in addressing the identified concerns. First, health systems should develop processes to ensure that patients receive their screening results, including test results that return after discharge. Second, screening initiatives should develop mechanisms for patients to access further resources, regardless of their insurance status. Third, those developing screening programs should ensure that they have institutional support, including departmental and hospital leadership, as well as appropriate community partnerships to provide follow-up care or referral to social services," the journal article's co-authors wrote.
7. Screening should be financially sustainable for patients and the healthcare system. "Incorporating the ED as a screening location into national guidelines, such as those provided by the USPSTF or Centers for Disease Control and Prevention (CDC), can help ensure that costs are reimbursed by insurers. Continuing grants and community funding can also offset costs to promote sustainability," the journal article's co-authors wrote.
The partnership between Elevance Health and Aledade features a shared risk model, with a budget for the total cost of care for a population of patients.
A new partnership between Elevance Health and Aledade is designed to foster the transition to value-based care at independent primary care practices.
Elevance Health features several health plans, with independent primary care practices participating in Elevance Health's networks serving 47 million health plan members. Aledade is a Bethesda, Maryland-based primary care physician enablement company.
The partnership between Elevance Health and Aledade centers on a value-based payment model, says Farzad Mostashari, MD, co-founder and CEO of Aledade. "It is shared risk. We have a budget for the total cost of care for a population of patients. If we can reduce hospitalizations and healthcare costs come in less than the budget, Aledade and the practices share the savings with the health plans."
The value-based payment model in the partnership between Elevance Health and Aledade has several advantages over the fee-for-service payment model, he says. "Value-based payment arrangements can pay primary care doctors more for their services if they provide superior experience and outcomes for the patients. It means we have much more of an ability to do same-day appointments. If a patient has a need, instead of sending them to the ER our practices tell patients, 'Call us first.' In addition, when patients show up, the primary care doctors know more about the patient's needs than in a traditional system because one of the things the payer does as part of these agreements is give us access to their full claims history for the patient. So, the primary care doctor knows more about what is going on with a patient."
The partnership also promotes more engaged primary care for the patient, Mostashari says. "When my mom went to the emergency room, her primary care doctor was not told about it and the primary care practice did not have a workflow for calling patients who had been to the ER. Our practices call the patient if they have gone to the emergency room within 48 hours, and they find out whether the patient is OK or feeling better. Our practices have the incentives, the data, and the workflows to provide better care."
Independent primary care practices can benefit financially from value-based care, he says. "Hospitalizations are very costly. If we can prevent hospitalizations by doing better primary care, that can generate a lot of money for a primary care practice. With better primary care and prevention, we reduce hospitalizations and the primary care practices get a piece of the savings by keeping patients out of the hospital. For our average primary care practice in 2021, the average payment from the Medicare Shared Savings Program was $200,000. That is a lot of money for a primary care practice."
Improving finances is essential to sustaining independent primary care practices, Mostashari says. "At the end of the day, if we want to maintain independent primary care, we have to pay for it. Instead of squeezing practices out of existence or having them join a health system, which reduces choice and competition, primary care practices can make more money keeping patients healthy and out of the hospital. That is what doctors went to medical school to do."
The partnership between Elevance Health and Aledade also eases frictions between health plans and primary care practices, he says. "The practices are now on the same side with the payer. There are the same incentives—the payer is no longer concerned that the practices are going to drive up costs or provide unnecessary services because the doctors now have the same incentives on total cost of care. The payers can ease up on some of the administrative burdens that make doctors miserable. For example, there is less prior authorization. The payers do prior authorizations because they want to limit unnecessary procedures and medications; but doctors who are in our program have an expedited prior authorization process for hundreds of services."
Aledade gives independent primary care practices tools, support, and resources to make the shift to value-based care, Mostashari says. "That is what we were founded to do. That is how we serve independent primary care practices. We strive to be the 'easy button' for the practices so that they do not have to figure out how to get data out of the electronic medical record, they do not have to figure out how to connect with the health information exchange, and they do not have to understand the various options in government programs. They do not pay us a dime. We get paid when there are shared savings. There is no upfront cost."
One of the primary purposes the ER on Demand telehealth service is to direct patients to the most appropriate site of care.
Northwell Health's ER on Demand telehealth service has reduced utilization of emergency rooms and urgent care clinics, according to the New Hyde Park, New York-based health system.
Emergency departments are one of the most expensive sites of care. If patients can be treated via telehealth, services can be delivered with higher value.
ER on Demand, which is available to all residents of New York State, was developed in response to the coronavirus pandemic. The telehealth service was piloted with Northwell Health employees in November 2020, then it was offered to the public from 8 p.m. to 8 a.m. Now, ER on Demand is available to the public 24 hours a day, seven days a week.
One of the primary goals of ER on Demand is to determine whether a patient needs to go to an emergency room. To access the service, patients can call 833-556-6784 or download the Northwell Health app. The first point of contact is a certified paramedic, who determines the appropriate level of care. If the patient does not require a trip to the emergency room for life-threatening symptoms such as heart attack or stroke but needs care, the patient is connected within an hour to an emergency medicine physician via video on a smartphone, tablet, or computer.
"Our aim is to meet patients where they are at—help them get the right level of care as easily and affordably as possible," Jonathan Berkowitz, MD, medical director of emergency medical services at Northwell Health, said in a prepared statement. "We get patients of all ages—parents of infants to senior citizens—calling our service. If someone feels they need to go to the ER and is not sure, that's where we can help."
The health system has examined more than 3,000 patient visits through ER on Demand from January 2021 to April 2022, finding that 92% of patients did not need to visit an emergency room or urgent care center. "Our emergency medicine physicians are experts in telehealth, and are comfortable guiding patients through self-exams, such as abdominal or neurological exams or muscular skeletal tests. Patients are increasingly trusting of this modality of care, and appreciate spending more time with their doctors and are happy with outcomes," Berkowitz said.
ER on Demand accepts all types of insurance, but there may be a specialist copay depending on the patient's coverage. If a patient is directed to go to an emergency room, the telehealth visit copay is waived.
ER on Demand services
In addition to diagnosis and treatment recommendations, ER on Demand physicians can send prescriptions to pharmacies, order lab tests, and schedule imaging such as X-rays.
Many conditions and symptoms can be addressed by ER on Demand physicians.
All issues related to COVID-19
Gastrointestinal symptoms such as heartburn, constipation, diarrhea, minor abdominal pain, and vomiting
General symptoms such as fever, chills, body aches, and fatigue
Urine-related symptoms
Head, eyes, ears, nose, and throat symptoms such as eye irritation, earache, sore throat, sinus pain, and congestion
Musculoskeletal conditions such as minor sprains, bruises, joint pain, and minor back and neck pain
Neurological symptoms such as headache and dizziness
Respiratory concerns such as asthma and cough
Skin conditions such as dermatitis, eczema, cellulitis, rash, bug bites, minor burns, and cuts
If an ER on Demand physician refers a patient to an emergency department, the doctor calls the emergency room to alert the facility's staff. In some cases, ER on Demand physicians will refer patients to follow-up visits with a primary care practice or specialist. The day after an ER on Demand visit, a team member will call the patient to make sure their condition is improving and to answer questions.
Health systems and hospitals have an opportunity to open their own standalone infusion centers or to establish joint ventures with standalone infusion center companies.
The CEO of a standalone infusion center business says patient experience and low operating costs are key market differentiators for the facilities.
Standalone infusion centers have been experiencing strong growth, according to the American Society of Health-System Pharmacists. Most standalone infusion centers specialize in providing intravenous medications to patients with chronic or complex conditions such as cancer, Crohn's disease, multiple sclerosis, and rheumatoid arthritis.
"There is no question that infusion is moving in the direction of standalone infusion centers. I can't imagine that five years from today there will still be large numbers of patients going to acute-care hospital systems for monthly IVs," says Shane Reeves, PharmD, CEO of Murfreesboro, Tennessee-based TwelveStone Health Partners.
TwelveStone operates seven standalone infusion centers in Georgia, Tennessee, and Virginia.
The patient experience delivered at most standalone infusion centers is far better than the patient experience at hospital-based infusion programs, Reeves says. "You can't imagine sitting in a dental office with 30 people in one room getting their teeth cleaned. Why would you want to have 30 people sitting in one room at a hospital getting their IVs? We think standalone infusion centers where people have their own private suites is a market differentiator, and we are finding that patients love it. The patient experience is superior, and the five-star Google reviews we get daily prove that."
TwelveStone has tried to look at all aspects of patient experience, he says. "We are not simply trying to be the pharma side of care. From the second when you walk in the door at one of our locations, it feels like a spa. From the sights and the smells, it feels like a spa. When patients are in their individual suites, we offer comfortable massage chairs. We offer places for their family members to sit. We offer WiFi. We offer Netflix. We offer snacks. If people cannot get to us, we have a transportation service to get them in."
TwelveStone addresses the personal side and the clinical side of patients' needs, Reeves says. "We have a full-time chaplain service. For many patients with chronic conditions, they not only have clinical needs but also spiritual needs for comfort and hope. We have a holistic approach to taking care of the patient."
Convenience is a hallmark of standalone infusion centers, which are often closer to where patients live and work than hospitals. Standalone infusion centers are often located in suburban communities to avoid the traffic and parking challenges at downtown hospitals, he says. "We have sited our centers intentionally. If the patient has a two- or three-hour infusion, the family can leave and go to places in the local area such as restaurants and places to shop."
Competitive financial model
Standalone infusion centers are a lower-cost setting than hospital infusion programs, Reeves says. "Acute-care facilities are the most expensive setting to receive any medical service. We do not have nearly the overhead or expenses of hospitals. We can negotiate with payers at a lower price. Standalone infusion centers are more affordable, to the point where we have several payers who are referring patients to us. The payers are pushing patients our way because we are more affordable and have a better patient experience."
TwelveStone's services are reimbursed by Medicare, Medicaid, and commercial payers, he says. "We are contracted with all of them."
TwelveStone provides infusions on a fee-for-service basis and provides patients with price transparency, Reeves says.
"We are transparent with the patient from the very beginning. As soon as a patient gets admitted for our service, we have to go through the process of adjudicating claims and determining what the service is going to cost. We let our patients know about out-of-pocket costs at the very beginning, so they know exactly what they are getting before they walk in the door to get a service. The last thing anyone wants is to come in and get a therapy, then realize they owe thousands of dollars. We are transparent on the front end. We know what your out-of-pocket cost is going to be before you get infused."
Opportunity for health systems and hospitals
Market forces are boosting standalone infusion centers, he says. "There are three significant trends in the healthcare marketplace that have promoted standalone infusion centers. First are the payers—it is just cheaper to get services in our standalone settings than in acute-care settings. Second, the big pharma companies are developing new medications that require IV delivery as opposed to oral medications. Third is the patient experience—people want to get their medications in outpatient settings near where they live and where they work."
Health systems and hospitals should consider seizing on standalone infusion center opportunities, Reeves says.
"Is there an opportunity for health systems and hospitals to open their own standalone infusion centers? The answer is absolutely 'yes.' But I would encourage health systems and hospitals to reach out to companies such as TwelveStone. Let's do something together. As opposed to trying to reinvent the wheel, health systems and hospitals can do joint ventures with companies like TwelveStone. We can establish partnerships to take care of these patients. There is quite a bit of infrastructure that is involved. I would encourage health systems and hospitals to find standalone infusion centers in their markets and establish relationships."
TwelveStone is in joint venture conversations with several large hospital systems including HCA Healthcare and Memorial Hermann in Texas, he says. "We are working with Skyline, which is an HCA Healthcare hospital system in Tennessee. There are a couple of reasons they want to work with a company like ours. First, they are trying to open up hospital beds. So, rather than having a patient in a hospital bed receiving an IV antibiotic, they could come to us. Second, there are revenue-sharing opportunities."
