The benefits of Cleveland Clinic's internal coaching programs include professional development, employee retention, and reduction of burnout.
Cleveland Clinic has robust coaching programs for the Cleveland-based health system's physicians.
Coaching programs can help health systems address physician wellbeing and retention. The coaching programs at Cleveland Clinic are credited with helping the health system avoid $84 million in physician turnover costs over the past decade.
Cleveland Clinic has two programs that provide coaching services to physicians. The Center for Excellence in Coaching and Mentoring provides physician peer-based coaching. The Mandel Global Leadership and Learning Institute (GLLI) provides non-physician coaches for physicians.
"We have two core components. The Center for Excellence in Coaching and Mentoring is physician-led peer physician coaching. The Mandel Global Leadership and Learning Institute features coaches who are not physicians; however, 60% to 70% of the people we coach are physicians," says Ashley Villani, MBA, senior organization development consultant at GLLI.
The programs work in concert, she says. "The intentionality around it is that the programs collaborate with one another. I collaborate with the Center for Excellence in Coaching and Mentoring to complement and align our coaching initiatives. We align our training for both our physician coaches and non-physician coaches, with the idea to not compete with one another because we are here for the same reason—to provide coaching for all caregivers and physicians."
Villani says GLLI has 42 non-physician coaches, which are drawn from two sources. About half of the coaches are leaders in the institute or organization development consultants at the institute. The other half of the coaches are "enterprise coaches," she says. "Those are formal or informal leaders in the enterprise who went through the same training as all of our other coaches. Examples are chief nursing officers, executive directors, chief operating officers, and human resources senior directors."
Coaching benefits
Physicians and physician coaches generate several benefits from being involved in the coaching programs, Villani says.
"Physicians benefit from coaching by having dedicated time to pause and focus on their own development with a confidential thought-partner. An example of a benefit is increased resilience during times of change. Additionally, participants have reported increased leadership role consideration and attainment as a result of their participation, as well as increased academic output, including grants, publications, and presentations," she says.
The coaching programs also reduce physician burnout, Villani says. "Our coaching programing drives fulfillment and satisfaction as well as increasing resilience and a sense of relationship for participants. These are components of wellbeing that can mitigate burnout."
The coaching has been linked to increased physician engagement, which helps address burnout, she says. "When engagement increases, wellbeing often increases, and burnout likely decreases."
Physician coaches benefit from their coaching, Villani says.
"It's been found that the physicians who coach other physicians get as much value from the experience as those they are coaching. Additionally, they report using the skills across contexts outside of the formal coaching with colleagues, patients, and at home. Coach training surveys in 2019 showed a 62% increase from pre-to-post training in their ability to apply coaching skills in daily interactions with colleagues, a 58% increase with patients, and a 55% increase in their personal lives," she says.
Physicians have cited the coaching programs as part of the reasons why they decided to stay at Cleveland Clinic, which helped the health system avoid millions of dollars in turnover costs over the past decade, Villani says. The avoided costs include recruitment costs, onboarding costs, and training costs, she says.
Boosting physician retention also avoids the opportunity costs associated with filling a physician position, Villani says. "It takes time to recruit a new physician. Especially with the nature of our academic medical center, there are unique medical specialties, and it can take a long time to replace a physician."
Advice for establishing internal coaching programs at health systems
Establishing internal coaching programs at health systems requires an intentional effort, Villani says. "Implementing an internal coaching program and a coaching culture is a journey. It is important to understand the organization's perception of coaching prior to implementing a formal coaching program, to identify what you want the coaching program to be known for, and to use this information to inform the creation of a realistic implementation plan unique to the organization."
She says health systems should be mindful of several other considerations when establishing internal coaching programs.
Obtain support from the highest levels of leadership that coaching is valuable
Provide recognition for those who serve as coaches to maintain engagement of the coaches and to drive acknowledgment from the organization that coaching is a valuable offering
Understand the needs of your employees with a needs assessment and recognize that needs may vary based on roles within the organization
Promote a coaching culture where coaching is seen as a positive way to support personal and professional development
Make sure employees know that coaching is available and know how to request a coach
Ensure that employees know the difference between coaching and mentoring—coaching includes focusing on reflection and building upon an employee's personal assets, whereas mentors can offer employees advice
Telediagnosis on the grand scale experienced since the beginning of the coronavirus pandemic is an evolving science, researchers find.
More research is necessary to ensure diagnostic quality and safety in telemedicine, a new report published by the Society to Improve Diagnosis in Medicine (SIDM) says.
Telemedicine utilization has expanded exponentially since the beginning of the coronavirus pandemic. As noted in the new report, most research on telemedicine has focused on the maintenance health, but the use of telemedicine for telediagnosis at a grand scale is not as well understood.
The new report, which is based on information collected from healthcare organizations, clinicians, vendors, and patients, includes several key findings.
Remote patient monitoring is "an important enabler of continuity of care and patient support" in telemedicine that can facilitate diagnostic quality and safety.
Many clinicians interviewed for the report said that the skillset necessary for a good diagnosis in an in-person visit is similar to the skillset necessary to make a good telediagnosis.
Clinicians reported that a primary barrier in telediagnosis is the inability to perform a physical exam.
A crucial area for more research is in determining when a virtual visit is appropriate and when an in-person visit is necessary.
Many patients interviewed for the report had developed their own triage framework for determining when a telemedicine visit is appropriate. For example, patients said they would be comfortable with a telemedicine visit to assess familiar symptoms such as a recurring earache.
Insights from the report
Remote patient monitoring has significant potential to improve telediagnosis quality and safety, Suzanne Schrandt, JD, a co-author of the report and senior patient engagement advisor at SIDM, told HealthLeaders.
"We talked with a number of folks involved in remote patient monitoring, including vendors and clinicians who use those services. It seems to have a great deal of promise, particularly for early detection in an otherwise healthy person who has new symptomology or in a person with an underlying health condition who starts to see some worrisome changes," she said.
Remote patient monitoring can also boost patient engagement, Schrandt said. "One of the things that jumped out to me is there seems to be some value from remote patient monitoring in keeping the patient engaged and active in their own care. Patients can be aware of their own symptomology, vital signs, and any other measurements that are captured."
The inability to conduct a physical exam can be problematic in telediagnosis, she said. "What we heard from the 50 listening sessions is that the most important thing is the presenting symptoms. Clearly, there are some symptoms that do not require a physical exam; and in that case, most clinicians and patients felt comfortable with the virtual care. But there are trickier, more amorphous symptoms that require a physical exam such as abdominal pain and swelling that are difficult to perceive over a camera."
Clinicians interviewed for the report said they had found innovative ways to avoid the need to conduct a physical exam, Schrandt said. "We heard many great examples from the clinicians we talked to about things that they figured out in the moment. One was assessing strength over the camera by asking the patient to pick up increasingly heavy objects as opposed to assessing strength in a physical exam by pressing down on limbs. Clinicians can also ask patients to do their own self-exam while the doctor is watching, so they could isolate an area of pain or an area of discomfort."
Equipping patients with simple diagnostic instruments can also obviate the need to conduct a physical exam, she said. "There are some great opportunities to figure out how instruments such as oximeters and blood pressure cuffs can be used by patients to supplement when a clinician cannot do a physical exam."
When asked about the skillsets needed to conduct telediagnosis versus diagnosis in person, clinicians interviewed for the report had two opposing responses, Mark Graber, MD, report co-author and SIDM president emeritus, told HealthLeaders.
"One was that the same skills you use to be effective in person would help you be effective virtually. The opposing view was that telediagnosis was a whole new ballgame, with new rules, new tools, and new everything. Those with the opposing view said that virtual care did not come naturally, that there was a learning curve, and that instruction and practice and feedback were valuable. Someone even mentioned having done simulated sessions to get up to speed, and that this experience was valuable," he said.
Conducting a virtual visit and a physical exam are different in many ways, Graber said.
"A simple example is the ongoing debate on how to evaluate someone who is short of breath. This is a piece of cake in person—you see how fast the patient is walking, whether they are pale or blue, how fast and how heavy they are breathing, and you probably already have a set of vital signs taken that include the respiratory rate, the heart rate, and even a pulse oximeter reading if you are lucky. Contrast that to the virtual encounter, where you may get the same short-of-breath complaint, but there is ongoing debate about how you evaluate this," he said.
In-person visits versus virtual visits
The report found there are five decision factors when deciding whether a patient should have an in-person visit or a telemedicine visit, Schrandt said.
"The first decision factor is the urgency of symptoms. There are some symptoms that warrant immediate, in-person attention such as chest pain. There are some symptoms that are clearly nonurgent such as a rash. However, what about the gray area? A patient could have a symptom that is unusual, but it is hard to determine the urgency. We need more research on methods for making those sorts of determinations. We need to know from the clinical perspective and the patient perspective what constitutes urgency."
"The second decision factor is the underlying health of the patient. Is this a chronic disease patient with very specific risk factors at play, or is this an otherwise healthy person? We need research to determine whether there are conditions that are going to require in-person assessment."
"The third decision factor is the familiarity of the symptoms. Is this the same earache you have had five times or is this a new symptom you have never experienced? We might be able to develop an algorithm tool that could flag when there is a symptom that calls for an in-person visit and when it is probably OK to do virtual care. We need much more research on that."
"The fourth decision factor is the relationship between the patient and the provider. This can get complicated. If there is a well-established relationship, there could be more comfort with virtual care, or at least a virtual-first approach. On the flip side, a patient can be matched with a clinician in telemedicine who the patient does not know, and we need research to know whether there are situations where that model works well or whether there are certain scenarios when that is not the right approach."
"The fifth decision factor is the quality of the virtual care. Is the visit being done over the phone? If the visit is being conducted via video, is the quality of the video clear? The concern over inequity and access to broadband came up repeatedly during the project. You cannot make decisions about whether to have in-person visits or virtual visits unless the virtual is an option."
Spreading coronavirus misinformation could cost physicians their medical licenses and medical board certifications.
The Federation of State Medical Boards (FSMB) and several medical certification organizations are calling for disciplinary action against physicians who spread misinformation about coronavirus vaccines.
The spreading of misinformation about coronavirus vaccines is widely viewed as playing a role in vaccination hesitancy across the country. Joseph Mercola, an osteopathic physician in Cape Coral, Florida, is one of the most influential spreaders of coronavirus vaccine misinformation in the country, according to The New York Times.
The FSMB, which represents medical licensing boards across the country, recently released a statement that seeks to discourage coronavirus vaccines misinformation by physicians.
"Physicians who generate and spread COVID-19 vaccine misinformation or disinformation are risking disciplinary action by state medical boards, including the suspension or revocation of their medical license. Due to their specialized knowledge and training, licensed physicians possess a high degree of public trust and therefore have a powerful platform in society, whether they recognize it or not. They also have an ethical and professional responsibility to practice medicine in the best interests of their patients and must share information that is factual, scientifically grounded, and consensus-driven for the betterment of public health. Spreading inaccurate COVID-19 vaccine information contradicts that responsibility, threatens to further erode public trust in the medical profession and puts all patients at risk," the statement says.
On Sept. 9, the leaders of the American Board of Family Medicine, American Board of Internal Medicine, and American Board of Pediatrics issued a joint statement on the dissemination of misinformation about COVID-19 by board certified physicians.
"We at the American Board of Family Medicine (ABFM), the American Board of Internal Medicine (ABIM), and the American Board of Pediatrics (ABP) support FSMB's position. We also want all physicians certified by our boards to know that such unethical or unprofessional conduct may prompt their respective board to take action that could put their certification at risk," the joint statement says.
Taking a stand against misinformation
Physicians who engage in coronavirus vaccine misinformation are violating hallowed obligations, Richard Baron, MD, president and CEO of the ABIM, told HealthLeaders.
"Physicians have a professional and ethical obligation to advise patients on the current state of scientific knowledge and in their field. That is what patients are relying on physicians to do. Physicians occupy a position of considerable authority and considerable trust—there are a lot of things that you get to do if you are a physician that you cannot do if you are not a physician. Part of why physicians have that privilege is the extent to which they can be counted on to be faithful to a scientific community that defines what good care looks like," he said.
Physicians have a duty to provide accurate information about coronavirus vaccines, Baron said.
"The information physicians should be giving is that vaccines are safe and effective. The number of medical contraindications from getting the vaccine are extremely small—it is mainly people who can have allergic reactions to the vaccines. This is something that has been given to hundreds of millions of people, and the number of complications is tiny. At the same time, we have more than 650,000 people in the United States who have died from a disease that the vaccines seem to prevent successfully. So, physicians should be encouraging their patients to get COVID vaccine because they are at much higher risk of dying of COVID if they do not get vaccinated than they are of any bad outcome from the vaccines," he said.
Coronavirus vaccine misinformation from physicians takes a toll, Baron said. "It is hugely damaging because it provides support for things that are just not true, and that support moves around fast. We know that misinformation moves faster on Twitter than true information. So, when physicians use their position of trust and authority to put out misinformation, the impact ripples far beyond the people who hear it because it gets repeated and disseminated. When misinformation is attributed to a physician, it has more than casual authority."
Coronavirus vaccine misinformation degrades the medical profession, he said.
"Lots of people rely on and trust what physicians tell them, and misinformation is damaging not only for the patients who hear it but also damaging to the profession because it undermines trust in physicians. Frankly, one of the biggest reasons that we put out the statement we did was to provide clear support for the doctors who are trying to do the right thing and feel beleaguered and undercut by other doctors who are putting out information that is terrible, dangerous, and wrong."
Executives who participated in the HealthLeaders CMO Exchange say their organizations are experiencing varying levels of workforce shortages.
Healthcare workforce shortages were one of the key pain points identified at the recent HealthLeaders Chief Medical Officer Exchange.
The coronavirus pandemic has highlighted workforce shortages at health systems and hospitals across the country. On Sept. 1, the American Nurses Association urged the federal Department of Health & Human Services to declare a nurse staffing crisis and to take immediate steps to implement solutions. Last week, Dartmouth-Hitchcock Health announced that the Lebanon, New Hampshire-based health system had raised its minimum rate of pay for all positions from $14 per hour to $17 per hour to address workforce shortages.
Chief Medical Officer Exchange participant Erik Summers, MD, CMO and vice chair of internal medicine at Wake Forest Baptist Medical Center, in Winston-Salem, North Carolina, recently told HealthLeaders that his organization is experiencing widespread workforce shortages.
"We are experiencing significant nursing shortages and that is impacting the hospital, but it's more than that. We are experiencing workforce shortages in care coordination, social work, nursing assistants, and respiratory therapists. We are not seeing as many shortages among physicians and physician assistants, but we are having some challenges in our staff in general," he said.
The workforce shortages are affecting operating capacity at the medical center, he said. "The biggest impact is that if you do not have the staff that you need, you cannot keep your beds open. We have had some closure of beds. We realize that we need all of our staff, especially at the time of a pandemic, to help as many patients as we can. That is the biggest impact—the inability to put patients in beds."
Chief Medical Officer Exchange participant Donald Whiting, MD, MS, CMO of Allegheny Health Network and president of Allegheny Clinic in Pittsburgh recently told HealthLeaders that AHN is also experiencing significant workforce shortages.
"Nursing shortages are the most notable because that's what keeps us from opening available beds for patients. We have bed availability, but we just don't have enough nurses to cover those beds. However, we have workforce shortages across the board. In nursing, we are competing against other healthcare providers. But across dietary roles, environmental services, ward clerks, and other non-professional roles, we are competing with McDonald's, Target, PNC Bank, and others because they are all increasing their starting pay rates, too. That is a big workforce toll," he said.
Whiting estimates that 15% of AHN's inpatient beds are closed because of workforce shortages.
Chief Medical Officer Exchange participant David Battinelli, MD, senior vice president and CMO of Northwell Health, recently told HealthLeaders that the New Hyde Park, New York-based health system is facing more limited workforce shortages.
"There have been workforce shortages evolving in specialty-specific competency areas for a long time that we will always have because we are constantly innovating and changing technology. It falls largely in all the types of technical workers that we need. For example, we have workforce shortages in information technology because of competing industries vying for the same people. We have workforce shortages in specialty-specific areas from radiology and imaging technicians to ultrasound technicians to laboratory workers. These are all specialty-specific technological areas," he said.
With the exception of coronavirus patient surges, Northwell has been spared nursing shortages, Battinelli said. "In the nursing area, we have workforce shortages during pandemic surges, but we do have adequate numbers of nursing applicants."
Rising to the challenge
Wake Forest Medical Center has been trying to boost recruitment and employee retention in response to workforce shortages, Summers said.
"We have looked at our salary structure—we want to be competitive in the market. Then we looked at supporting our nurses with appropriate nurse-patient ratios in the hospital. It is easy to tell nurses to see more patients, but we need to hold to not only what is going to keep our patients safe, but also what is going to keep our staff from burning out. We have been hesitant to increase our ratios on the floors or in the ICU," he said.
AHN has made a concerted effort to address workforce shortages, Whiting said. "We have tried every trick in the book. We have raised pay rates. We have given retention bonuses. We have given hero bonuses for working through COVID. We have added bonuses if an employee refers workers to us. We are giving sign-on bonuses. We have worked on making childcare available or covering childcare costs. We are looking at redesigning what nurses do to use others to do some of that work."
Employee retention is a priority at AHN, he said. "We celebrate every single event—we make people feel appreciated in every possible way. We have pizza parties. We acknowledge people with events on the nursing floors and elsewhere in the hospitals. We are doing things to create camaraderie. We are focusing on wellness—we have serenity rooms in each of the hospitals. We want people to feel appreciated and to have a sense of belonging as well as focusing on their wellness."
Northwell is focusing on culture to address workforce shortages, Battinelli said. "We want to be able to give people not only the job that they want but also the environment where they want to work. We want to have an adequate amount of respect, collegiality, and engagement. We spend an enormous amount of time on employee engagement. During the pandemic, we have enjoyed the highest employee engagement scores that we ever have had—up over the 90th percentile. We have been recognized as being one of the Top 100 places to work for by Forbes."
Workforce outlook
Workforce shortages at health systems and hospitals are likely to linger for many years, Summers and Battinelli said.
"I always tend to see light at the end of the tunnel—I believe that we can improve our employment efforts through recruiting and having people stay because I believe in the organization. But I also cannot deny that these workforce shortages are going to go beyond the COVID pandemic and will be around for a while. So, I do expect workforce shortages to persist long after the COVID patients go away," Summers said.
"As you emerge with new technical competencies, you will always be faced with workforce shortages. If you cannot retrain and refocus certain jobs that are going to become less prevalent, you will end up with more shortages. It takes an investment in people. When you do the financial analysis of this process, even though it is an investment, it does pay to educate and train staff rather than to find new people, which invariably does cost more money," Battinelli said.
Major increases were found in 2020 compared to 2019 in four serious infection types: central line-associated bloodstream infections, catheter-associated urinary tract infections, ventilator-associated events, and antibiotic resistant staph infections.
There has been a significant increase in healthcare-associated infections (HAIs) during the coronavirus pandemic, a recent research article found.
From 2015 to 2019, there were decreases in the prevalence of central-line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), and Clostridiodes difficile infections (CDIs). Since 2010, there have been significant year-to-year decreases in methicillin-resistant Staphylococcus aureus (MRSA).
The recent research article, which was published by Infection Control & Hospital Epidemiology, examined national- and state-level standardized infection ratios (SIRs) for each quarter in 2020 compared to each quarter in 2019. SIRs were determined for each HAI by dividing the number of reported infections by the number of predicted infections, calculated using 2015 national baseline data.
The study includes several key data points.
CLABSI: SIRs were significantly higher in the second, third and fourth quarters of 2020 compared to 2019. The largest increased SIRs occurred in the third and fourth quarters (46% to 47%).
CAUTI: The national CAUTI SIR increased steadily throughout 2020. In the fourth quarter of 2020, the CAUTI SIR increased 19%.
Ventilator-associated events (VAEs): The national VAE SIR increased throughout 2020, with the largest increase occurring in the fourth quarter (45%).
MRSA bacteremia: In the second quarter of 2020, the national MRSA bacteremia SIR increased 12% compared to the second quarter of 2019.
"This report provides a national view of the increases in HAI incidence in 2020. These data highlight the need to return to conventional infection prevention and control practices and build resiliency in these programs to withstand future pandemics," the research article's co-authors wrote.
Interpreting the data
The characteristics of the coronavirus pandemic that drove increases in CLABSIs, CAUTIs, VAEs and antibiotic resistant staph infections were "clearly multifactorial," says Arjun Srinivasan, MD, associate director for healthcare-associated infection programs at the Centers for Disease Control and Prevention (CDC).
"There are issues that drove the increases both with respect to the patients themselves and the healthcare delivery system, which were both put under enormous stress. When we look at the patients who were most likely to be hospitalized with COVID, they tended to be patients who were older with significant comorbidities. So, those were the patients who were at the highest risk to have healthcare-associated infections because they have underlying, predisposing factors," he says.
The healthcare system was under unprecedented strain, Srinivasan says.
"There were large numbers of patients presenting for care. There was very high acuity of illness. There were shortages of staffing—we had staffing problems because staff themselves were getting COVID or they were exposed and unable to work. So, we didn't have enough people to take care of the patients. Then, we also had some significant shortages of personal protective equipment—the things that we need to deliver and provide safe care. You had a perfect storm of very high-risk patients meeting a healthcare system under unprecedented pressure. Those are the factors that resulted in what we saw," he says.
There is hope to reverse the increases in HAIs during the ongoing pandemic, Srinivasan says.
"The first thing is to be aware of the data. What has been wonderful to see is that hospitals have continued to monitor these infections and to report them to the CDC, even though for the first six months of 2020, they did not have to report them. The Centers for Medicare & Medicaid Services gave hospitals permission to stop reporting because they were under a lot of strain. But 80% to 90% of hospitals kept reporting. So, assessing and monitoring this information and knowing that you have this problem is absolutely the first step toward correcting it," he says.
The other part of reversing the trend is a more challenging because we are still faced with the same set of challenges, Srinivasan says. "Granted, the supplies of personal protective equipment have gotten better, but the large number of patients getting ill and the comorbidities that those patients have remains a challenge. The strain on the healthcare system remains a challenge. Fortunately, we have many healthcare workers who are vaccinated, so hopefully that helps with some of the staffing issues."
The increase in HAIs should not discourage patients from going to a hospital when they need acute care, he says.
"There have been more infections in hospitals than there were two years ago. At the same time, we know that people have needed hospital care for COVID. There is no doubt that many people have had their lives saved because they went to a hospital in a timely manner when they got sick and were able to get treatment for COVID. There are always risks associated with seeking medical care, and some of those risks are infections. Yes, there have been more infections over the past year, but when you need to be in a hospital, we want you to go to a hospital. That is a place where there are people dedicated to making you better and saving your life. So, we do not want this data to scare people away from getting the care that they need."
The CDC is hopeful that the increases in HAIs during the coronavirus pandemic will be reversed once the crisis state of the pandemic has passed, Srinivasan says.
"Our hope is that these increased infections are situational due to the unusual circumstances that arose during the pandemic. Once the pandemic has passed, we expect that as hospitals return to their normal state that we will see these infections go back down to where they were. We are going to be focusing on this area—making sure that we are doing everything to rebuild that firm foundation that we had. There were policies and procedures that were in place that resulted in the decreases in these infections."
In addition to physical symptoms such as cough and fatigue, coronavirus 'long haulers' are experiencing a range of behavioral health conditions.
Coronavirus "long haulers" are experiencing several behavioral health conditions, according to an expert at Doctor On Demand.
One of the more mysterious characteristics of COVID-19 is that a significant number of patients who are long haulers experience symptoms for weeks or months after recovering from the acute phase of the illness. Long haulers have a range of physical symptoms, including cough, shortness of breath, constitutional symptoms such as numbness and tingling, cardiac issues, hair loss, and deconditioning.
Coronavirus long haulers are also experiencing behavioral health issues, says Nikole Benders-Hadi, MD, medical director of behavioral health at Doctor On Demand.
"At Doctor On Demand, we are seeing a lot of depression and anxiety among long haulers. Particularly when you experience long-term anxiety symptoms, the condition has the opportunity to differentiate itself into other more specific anxiety disorders such as generalized anxiety disorder, panic disorders, and posttraumatic stress disorder. PTSD is defined as anxiety symptoms related to a trauma that lasts for greater than six months. Unfortunately, we are seeing an uptick in those types of diagnoses now. The impact of those kinds of symptoms are wide and varied. We are seeing people come to us talking about the impact on their relationships, on their work productivity, and on their ability to function day to day," she says.
Coronavirus long haulers are experiencing behavioral health conditions beyond anxiety and depression, Benders-Hadi says. "We are seeing increases in substance abuse disorders. We are also seeing an increase in the prevalence of obsessive-compulsive disorder in people who are overly focused on cleanliness. There was a recent Lancet study that showed increases in diagnoses of psychotic disorders, where people become very paranoid about cleanliness, and it advances to the point where they have delusions."
Addressing behavioral health issues among coronavirus long haulers
Treatments are available for coronavirus long haulers who are experiencing behavioral health conditions, she says.
"Unfortunately, there are not quick solutions to any of these symptoms—there is no magic pill that you can offer. We can provide supportive therapy and cognitive behavioral therapy. CBT has been shown to be effective because CBT specifically works to identify anxiety triggers. The work becomes practicing a different type of response when you feel anxiety rising up. It involves recognizing acute changes in your body and empowering the patient to exhibit more control over their anxiety," Benders-Hadi says.
Many people can provide emotional support to coronavirus long haulers with behavioral health issues, she says. "Being proactive about checking in with friends, loved ones, and co-workers who are experiencing long COVID symptoms is a great first step to making sure that they are getting the support they need. As a clinician, for me it comes down to early intervention being key. We need to offer practical advice on how to counter brain fog, for example. We need to encourage patients to be able to talk to their managers at work if there are work accommodations that are needed."
Increase in patient volume
During the pandemic, Doctor On Demand has seen a dramatic increase in behavioral health visits, including visits with coronavirus long haulers, Benders-Hadi says.
"In 2020, we saw a 140% year-over-year growth in behavioral health visits, and the demand for behavioral health visits remains high. We have seen the demand for medical visits come and go with different coronavirus variants and concern about acute COVID infections, but we have not seen a decrease in the need for behavioral health visits. The depression, anxiety, and other behavioral health conditions that are resulting from the long-term symptoms that patients are experiencing show that COVID is having a continuing impact," she says.
Healthcare providers need to think about coronavirus long haulers in the same way they think about other chronic illness patients, Benders-Hadi says. "We need to pull together research and data. We need to bring together both behavioral health specialists as well as medical and rehabilitation specialists to help treat individuals holistically rather than in isolation. That is going to be key given the widespread impact of both the physical and behavioral health symptoms that COVID long haulers are struggling with."
Jennifer Orozco sees physician assistants as a vital part of care teams and expects continued growth of the profession.
The new president of the American Academy of PAs (AAPA) is bullish on the future of the physician assistant profession.
Jennifer Orozco, MMS, PA-C, began her AAPA presidency on July 1. She practices in vascular surgery and serves as director of advanced practice providers at Rush University Medical Center in Chicago.
Orozco spoke recently with HealthLeaders about a range of issues, including the agenda for her AAPA presidency, the role of PAs in care teams, and her vision for the future of the PA profession. The following is a lightly edited transcript of that conversation.
HealthLeaders: What are the primary elements of your agenda as president of the AAPA?
Jennifer Orozco: There are three things that are important to me and many in the PA profession.
First is patient access to care. We continue to have major patient access issues across the United States.
Second is removing barriers to PA practice. PAs cannot be part of the solution to improve patient access to care until we remove antiquated legislative and regulatory barriers.
Third is a focus on mental health, which is one of my passions. I have been knee-deep in the coronavirus pandemic for the past 18 months in Chicago. I have seen the effects not only on the patients but also on the healthcare workforce. I want to shine light on mental health and remove the stigma.
HL: Are there particular restrictions on PAs that you would like to target?
Orozco: There are only three states that remove a specific relationship with a physician for PAs to practice. In every other state, PAs must be tied legally to a physician filed with the state. There is a lot of paperwork associated with this requirement.
This requirement does not accurately reflect how we have practiced for more than 50 years, and it has been a huge barrier during the coronavirus pandemic. Our profession is flexible, and PAs are generalists, so they can move to different specialties. But we often could not move them during the pandemic because there were so many regulatory barriers. Many governors issued executive orders to remove the requirement that PAs be tied to a physician at the state level. This allowed us to move PAs who were trained to take care of critically ill patients across state lines to coronavirus hotspots.
PAs are highly trained. They have many hours of clinical training as well as administrative training. They do not have as many years of training as a physician, but they are next in line in terms of training.
Another area I would like to address is allowing PAs to govern themselves in the states and have PA boards. We would not have a physician board governing all the nurses in a state. The nurses do that for themselves. We have more than 150,000 PAs in the country, and they should be governing their profession because they know their education, training, and background.
HL: How have PAs played a role in responding to the coronavirus pandemic?
Orozco: Like all frontline providers, PAs have had a very challenging 18 months. They have not only been trying to take care of COVID-19 patients, but also trying to make sure that the basic healthcare needs of their own patients are met. But this is what we are trained for. When there is a crisis, our commitment to patients is stronger than ever.
The AAPA put out a survey in 2020 that showed three out of five PAs had tested, diagnosed, or treated COVID-19 patients. For PAs, the key during the pandemic has been our ability to be flexible.
As a healthcare administrator my life was made easier because I was able to take PAs and move them to wherever I needed to. I knew they had the education, the training, and the skillset to take care of COVID-19 patients, whether it was testing, critical care in the ICU, or care in the emergency department. Wherever there was a need, I knew there were PAs who were trained and ready to go. During the pandemic, PAs became part of the "go to" workforce.
HL: How should PAs fit into care teams at physician practices?
Orozco: The most successful clinical teams are the ones that utilize the skillsets and the abilities of each individual team member to the fullest extent. No single person cares solely for a patient. It is not just a doctor. It is not just a nurse. It is not just a respiratory therapist. Every single team member brings a skillset and an expertise. That is the way healthcare is delivered, and the PA profession was founded on the concept of collaborative practice.
PAs fit into the team-based healthcare model. We have the training to care for the patient from start to finish. Evidence has shown that the most successful teams are the ones that decide what works best for them. We need to allow teams to be flexible.
HL: What is your vision for the future of PAs?
Orozco: The PA profession was named the Number One job by U.S. News & World Report this past January. That demonstrates that patients and employers know and value the PA role. The profession is expected to continue to grow. The federal Bureau of Labor Statistics estimates that PA employment will grow 31 percent from 2020 to 2030, much faster than the average for all occupations.
As PAs continue to grow, we can help improve access to care and provide high quality care despite the gaps that we have seen during the pandemic. We have an aging population, healthcare is complex, and patients need a comprehensive approach to medicine, especially in the primary care arena, where we have challenges getting enough physicians.
Additionally, PAs are leadership trained, so I envision PAs serving in leadership roles across all medical settings and specialties. These leadership roles could be at medical centers, departments of public health, and at the state, regional, and national levels.
HL: What advice do you have to offer to new PAs?
Orozco: It is a difficult time for new PAs. We are surviving a pandemic. New PAs were in school during a global pandemic, which is unprecedented.
Given the mental health pressures of the pandemic, my advice to new PAs is you must take care of yourself first. You cannot care for other people if you are not taking care of yourself. Provider burnout among PAs, physicians, and nurses is serious and devastating. Burnout has been an issue for many years, but the pandemic has elevated the problem. PAs need to prioritize their mental health and wellbeing so they can deliver healthcare to patients.
I also encourage new PAs to look for ways they can innovate as well as lead healthcare teams. Do not be afraid—be bold. Go out and deliver the healthcare that you are trained to do. We also need to keep the patient-centered focus at the core of all that we do.
New PAs should not get lost in their administrative duties and their student loans. If you keep the patient focus at the forefront, along with your mental health and wellbeing, you are going to be a successful PA throughout your career.
Southwestern Health Resources is working with Landmark Health to boost the care of medically complex patients.
Dallas-based Southwestern Health Resources (SWHR) has established a partnership with a provider of home-based medical services to improve the care of medically complex patients.
Medically complex patients such as older patients with multiple chronic conditions are a driver of medical service utilization, including hospital admissions and emergency department visits. Introducing medical services in the home can drive down utilization rates and improve clinical outcomes.
A key element of SWHR's partnership with Landmark Health is the ability to boost care management in between office visits with medically complex patients, says Pamela Sullivan, MD, chief clinical officer at the Huntington Beach, California home-based medical services provider.
"At Landmark, we have a very comprehensive approach to geriatric and chronically ill patients, which is hard to do when you are managing a large population of patients. So, we focus on this group, and we are very proactive. We look at social determinants of health. We also have a robust predictive analytics team that analyzes our patients, and we know when a patient is likely to get admitted to a hospital or have other needs. So, we can target patients and focus on making sure they get the right touches from the right care providers at the right time to make sure that we decrease hospitalizations," she says.
Landmark also works with SWHR to refine individual care plans for medically complex patients, Sullivan says.
"When we go into the home, we can spend a lot more time with the patient than a SWHR provider can spend with the patient in the office. By seeing each individual patient's needs and using our predictive analytics, that helps us to come up with a care plan that not only meets the patient's goals and wishes, but also puts a family member at ease or a caretaker at ease. We have multiple touch points with social workers and providers going into the home along with a nurse calling and following up, or a pharmacist consulting with the team. Then we can coordinate that care with the care managers in the PCP offices or the primary care physicians," she says.
The partnership with Landmark is expected to reduce total cost of care for SWHR's medically complex patients, says Jason Fish, MD, senior vice president and CMO of the health system. "If you manage complex patients well, you absolutely will cut waste and you should see a decrease in total cost of care."
The partnership should help address physician burnout, he says. "With a busy practice that has 2,000 to 2,500 patients and a set of complex patients, this partnership serves to reduce the risk of burnout among our providers. With complex patients, we now know Landmark is looking at these patients between visits and communicating back to the PCP. For those complex patients, it is a breath of fresh air knowing that we now have a greater opportunity to manage them."
The partnership also improves transitions of care, Sullivan says. "If you are a primary care provider and you see a patient in the office who has congestive heart failure or pneumonia, and you are concerned about how the patient is going to do if you send them home, we can provide safe care in the home. The PCP can contact us, and we can be in the home that same day or the next day and coordinate care. We can keep the patient out of the hospital."
Landmark helps to keep patients in their homes and out of hospitals and emergency departments, she says.
"When you talk about our group of patients, they are patients who want to stay in their homes. Sometimes, they are afraid to share some things or have us in their homes because they do not want to be forced out of their homes to other living situations. Once they learn that we are a trusted partner and that we are going to work with their PCPs, they realize that our goals are their goals. They realize that we are not trying to displace them and that we are working to get them community resources so that they can live in their homes. We can make the quality of life better in their homes," she says.
Measuring the partnership's impact
The effects of the partnership will be measured with several metrics, Fish says.
"The impact involves a few things. From the patient's view, if the goal here is to improve the quality of life and reduce unnecessary care, then you measure that through traditional utilization measures such as ED utilization, acute admissions, readmissions, and patient satisfaction. You measure by patient engagement—are patients continuing the engagement or are they discontinuing engagement?" he says.
SWHR also will measure the partnership through its providers, Fish says. "Are they satisfied? Do they like the partnership? Do they think the partnership is adding value? We do routine questionnaires with our providers to ascertain that information."
Lastly, the health system will measure the medical-economic impact of the partnership, he says. "You should see one of two things. You should see that your total cost of care comes down because you have engaged the appropriate service lines in a way that reduces waste and improves outcomes. Or you could see improved clinical outcomes and somewhat increased costs because you have engaged patients who were at risk, and it takes more services to care for them. In the short term, you may see a little increase in costs; but in the long term, you will see costs decrease."
A sepsis early warning system at a Cleveland-based health system triggered an alert in the electronic health record and a notification message to emergency department pharmacists.
An early warning system for sepsis embedded in an electronic health record (EHR) can have a significant impact on sepsis care, according to a recent research article.
Sepsis is a life-threatening condition caused by the body's extreme reaction to an infection. Annually, at least 1.7 million American adults develop sepsis and about 270,000 Americans die due to sepsis, according to the Centers for Disease Control and Prevention.
The recent research article, which was published by Critical Care Medicine, describes the results of a randomized, controlled quality improvement initiative conducted at The MetroHealth System in Cleveland. The article features data collected from 598 patients, with 285 patients in the intervention group and 313 in the standard care group.
The intervention involved using a sepsis early warning system embedded in the health system's EHR. The early warning system is based on structured EHR variables used to predict whether a patient will develop sepsis during their hospitalization. The variables include demographic data, vital signs, laboratory results, orders, and comorbidities.
When the early warning system determined there was a likelihood of sepsis, two actions were triggered: an alert appeared in the EHR, and a message was sent to emergency department pharmacists. The pharmacist would review the chart and huddle with the primary ED provider. If sepsis was suspected, the pharmacist would expedite ordering and collection of blood work as well as ordering and administration of antibiotics and fluid boluses.
The research article features two primary data points.
The time to antibiotic administration from ED arrival was shorter for the intervention group compared to the standard care group (2.3 hours versus 3.0 hours). It is widely accepted that timely administration of antibiotics results in better outcomes for sepsis patients.
Days alive and out of hospital at 28 days was greater for the intervention group compared to the standard care group (24.1 days versus 22.5 days).
"In this single-center randomized quality improvement initiative, the display of an electronic health record–based sepsis early warning system–triggered flag combined with electronic health record–based pharmacist notification was associated with shorter time to antibiotic administration without an increase in undesirable or potentially harmful clinical interventions," the research article's co-authors wrote.
Assessing the sepsis early warning system
Although the research article documented modest improvements in the timeliness of antibiotics administration as well as days alive and out of hospital, the early warning system intervention's benefits were significant, the lead author of the study told HealthLeaders.
"While earlier research on the management of sepsis led to major improvements in sepsis-related outcomes, there have not been any major breakthroughs in the past decade. As a result, healthcare systems looking to improve their sepsis outcomes are more likely to do so by focusing on improving their current processes, with an attention to appropriate and rapid antibiotic usage. Our study shows exactly how one could use a sepsis early warning system to make such a change," said Yasir Tarabichi, MD, director of Clinical Informatics for Research Support at The MetroHealth System.
There were no negative consequences from using the sepsis early warning system, he said. "The potential downsides of such a system include alert fatigue, antibiotic overuse, and misdiagnosis. We did not see any evidence of antibiotic overuse or sepsis misdiagnosis. Our alert did not interrupt providers' workflows and alert fatigue was not reported during our intervention. Our pharmacists also felt that the early warning system did not add any substantial time stress on top of the numerous other responsibilities they have in the ED setting."
ED pharmacists were a key component of the early warning system intervention, Tarabichi said. "In their role, they are well-positioned to hasten the selection, preparation, and administration of an antibiotic to patients with sepsis. This was reflected in our analysis that showed that the time from the provider ordering an antibiotic to the time it was delivered was significantly hastened when the early warning system was available."
With both internal and external factors pressing on the healthcare sector, health systems and hospitals have several golden opportunities for change in clinical care.
Editor's Note: This article is based on roundtable discussion report sponsored by Halo Health. The full report, The Next Evolution of Clinical Care, is available as a free download.
Clinical care is undergoing transformative changes exemplified by the rapid expansion of telehealth services during the coronavirus pandemic.
At health systems and hospitals, there is an opportunity to gain efficiency by making specialty care available through telehealth, says Peter Hill, MD, senior vice president of medical affairs at Johns Hopkins Medicine in Baltimore, Maryland.
"Even in more urban areas, with the contraction of subspecialist coverage at many hospitals, there was movement prior to COVID of patients from one hospital to another simply for subspecialty consultation; I am speaking more of the inpatient side. A lot of that does not need to occur, right? I think bringing the specialists to the hospital via telehealth rather than bringing the patient from one hospital to another is a much more efficient use of resources," he says.
The coronavirus pandemic has had several silver linings for healthcare organizations, such as breaking down barriers to changing the status quo. The pandemic has increased nimbleness and unity at health systems, says David Williams, MD, chief clinical officer at UnityPoint Health in West Des Moines, Iowa.
"U.S. healthcare has never been called nimble before. But during the pandemic, because of necessity, we did not take eight years to determine the best evidence-based practice, then spend another eight years to get it to our patients. We changed on the fly. So far, that spirit has not gone away. And we are coming to consensus. UnityPoint Health is in three states and nine regions across the middle of the country. We have never been a health system before. We have never acted like a unified clinical enterprise. COVID changed that. Now, people care about what happens from state to state, and people on the ambulatory side care about the hospital and vice versa," he says.
With new players in the healthcare sector such as Amazon, health systems and hospitals must be on guard for disruption, says Jason Mitchell, MD, senior vice president as well as chief medical and transformation officer at Presbyterian Healthcare Services in Albuquerque, New Mexico.
"The biggest risk is being picked apart. Everybody is looking at slices where they can pull off a profit and a customer segment, deliver a great experience, and do it better than you can if you are a big health system. Wal-Mart has the potential to be very disruptive. Wal-Mart is everywhere. It has access to the aging population, and now it is putting in a delivery system capability and partnering with health plans. The way to deal with disruptors is to disrupt yourself first. You need to disrupt yourself, move patients out of your hospitals to lower-cost-of-care locations, provide an excellent digital experience, and look for partnerships," he says.
Focusing on quality is the key to making the shift from fee-for-service care to value-based care financially viable, Hill says. "From my perspective, it starts with the quality and ensuring that we are producing the clinical outcomes that we should produce. That is one of the two tenets of value—you need to control cost as well as quality. So, if you do not have quality, then you are dead in the water. For us, that is certainly what we are focusing on right now."