Nearly three-quarters of those surveyed reported that healthcare professionals never had brought up end-of-life planning.
End-of-life conversations needs to be a routine part of care for adults, a hospice expert says.
Advance care planning and documentation provides guidance about end-of-life decisions. Advance care planning helps to make sure that a patient's wishes on issues such a resuscitation are known by care teams and families before an end-of-life situation.
A new survey polled Americans about crucial advance care planning topics. The survey, which was commissioned by hospice provider VITAS Healthcare, polled 1,000 Americans in March 2022. The polling sample reflects the U.S. population based on gender, age, race and ethnicity, region, and education.
The survey generated several key findings:
Most (71.4%) survey respondents reported that healthcare professionals never had brought up end-of-life planning and a majority (54.9%) reported that no one had brought it up.
More people reported that they have documented their wishes this year (35.4% in 2022 versus 32% in the 2021 VITAS Healthcare survey). However, that is far less than those who say it's important or very important (68%) and those who have discussed their wishes (55.5%).
The top three reasons for not conducting advance care planning were not being sick or dying (34.7%), it is depressing to face (26.3%), and feeling not old enough to face these topics (21.9%).
The top four reasons for conducting advance care planning were desire to not burden family members with making decisions (56.4%), it was done for financial or estate planning (47.5%), experience of having a loved one who died with their wishes documented (23.1%), and experience of having a loved one who died without their wishes documented (19.4%).
Asian and Hispanic survey respondents were more likely to credit conducting advance care planning to clinicians raising the topic: Asian (24.2%), Hispanic (24.0%), White (11.8%), and Black (7.6%).
Most survey respondents said they were comfortable having end-of-life planning with family members: partner or spouse (52.6%), children (32.4%), primary care physician (27.1%).
Most survey respondents were comfortable having end-of-life planning discussions at home: home (60.1%); legal, financial, or other formal non-medical setting (26.0%), primary care clinic (24.6%).
Encouraging patients to conduct advance care planning
"Patients are ready for these conversations," says Joseph Shega, MD, executive vice president and chief medical officer of VITAS Healthcare.
For clinicians, holding end-of-life discussions is a long-term effort, he says. "I encourage healthcare professionals to initiate advance care planning conversations by simply bringing it up with their patients. It's important to note, however, that advance care planning is not a one-time task—it should be treated as an ongoing conversation that a patient has with their physician, family and loved ones. As healthcare professionals, it's our responsibility to help encourage these conversations by normalizing them and making the conversations a routine part of care."
Physicians have an important role to play and need to get more involved, Shega says. "Americans reported they would be comfortable having these conversations with their doctor—and many times are looking for their doctor to raise the issue. But many times, these conversations are not happening. In fact, 71% of respondents said that a physician has never broached the subject of advance care planning with them. That tells us there is a gap."
VITAS Healthcare recommends that physicians keep the SPIKES method in mind when having advance care planning conversations with patients, he says.
Setting: Choose a private setting where you can sit face-to-face with the patient and a family member or confidant. If the patient does not speak English, rely on a professional interpreter rather than a family member.
Perception: Ask the patient how much they know, perceive, or suspect before you begin the conversation.
Invitation: Subtly invite the patient to provide clues about willingness to receive more information. Ask whether they would like to talk about issues such as test outcomes and treatments. If the patient does not respond favorably, suggest that you talk again later that day or the next. Then follow through.
Knowledge: Share information directly and simply. After you have opened the conversation, stop talking. Listen to the patient's responses and take note of their emotions.
Empathy: Identify with the patient's emotional reaction in a kind way that suggests you understand and appreciate their response and are concerned about their future.
Summation: Summarize the conversation and recommend hospice care.
"No matter what, every end-of-life conversation must be rooted in respect, compassion, and empathy. Healthcare professionals must take the time to understand the whole patient and consider how their age, race, ethnicity, religion, and relationships shape their views and values," Shega says.
Why advance care planning matters
Advance care planning benefits patients, he says. "By knowing a patient's wishes and values, healthcare professionals and families can ensure that the kind of care that person receives at end of life aligns with their goals, preferences, and spiritual beliefs."
The absence of end-of-life planning is problematic for patients and their care teams, Shega says. "One of the most difficult situations is when the families we serve don't know their loved one's wishes or values. The VITAS survey found that almost a quarter of people (24.3%) had either a loved one who was seriously ill or one who had passed away without knowing their wishes or values for end-of-life care. VITAS believes it is vitally important that patients make their wishes known so that they can be honored, while also relieving the burden of decision-making on loved ones."
A study makes estimates with and without COVID-19 vaccination in the United States for deaths, hospitalizations, infections, and healthcare costs.
The COVID-19 vaccination effort in the United States has averted millions of deaths and hospitalizations, according to a new study by The Commonwealth Fund and Yale University.
COVID-19 vaccination has been shown to reduce hospitalization and death rates. Compared to vaccinated Americans, unvaccinated Americans have higher rates of hospitalization and death.
The new study is based on a model that accounted for the characteristics of four coronavirus variants—Alpha, Delta, Iota, and Omicron. The model's parameters included U.S. population demographics, pandemic mobility patterns, and age-specific risks of serious health outcomes linked to COVID-19.
In addition to estimating hospitalizations and deaths with and without vaccination, estimated the number of infections and direct healthcare costs associated with COVID-19 with and without vaccination. The cost calculation accounted for expenses related to outpatient visits, hospitalizations, intensive care, emergency medical services calls, and emergency department visits.
The study features four key data points for the period from Dec. 12, 2020, to March 31, 2022:
Deaths averted: 2,265,222
Hospitalizations averted: 17,003,960
Infections averted: 66,159,093
Healthcare costs averted: $899.4 billion
The study builds on data generated from an earlier study conducted by The Commonwealth Fund and Yale University that was published in December, the study co-authors wrote in a blog post. "Our findings highlight the profound and ongoing impact of the vaccination program in reducing infections, hospitalizations, and deaths. As we noted in our December analysis, vaccines spared the U.S. healthcare system an overwhelming number of COVID-19 hospitalizations. The current analysis confirms and extends the earlier results. Investing in vaccination programs also has produced substantial cost savings—approximately the size of one-fifth of annual national health expenditures—by dramatically reducing the amount spent on COVID-19 hospitalizations."
Congress should continue to support vaccination and booster shot efforts, the co-authors wrote. "The success of the vaccination program in preventing deaths and hospitalizations is obscured somewhat by the nearly 1 million COVID-19 deaths that have occurred since the start of the pandemic. As Congress considers the costs and benefits of extending COVID-19 vaccination, our results show that continuing to vaccinate and boost Americans can produce substantial health benefits and financial returns to the country."
Now is not the time to pull back on vaccination, the co-authors wrote. "Redoubling efforts to increase vaccine uptake, especially among the elderly and other vulnerable groups, will be critical to avert outbreaks as pandemic restrictions are lifted. With continued spread of the [Omicron] BA.2 subvariant, our findings point to the tremendous power of vaccination to reduce disease burden from COVID-19. This may be even more important if newer variants arise or population immunity ebbs."
Teresa Malcolm says the "belonging" part of her job title attracted her most to the new position.
Healthcare organizations need to appreciate the benefits that are associated with diversity, the new vice president of diversity, equity, inclusion, and belonging at Dartmouth Health says.
Teresa Malcolm, MD, MBA, began her work in the new role at the Lebanon, New Hampshire-based health system on April 4.
Malcolm, who is a board-certified obstetrician/gynecologist, has more than a decade of experience cultivating inclusion in healthcare settings.
Prior to joining Dartmouth Health, Malcolm served as CEO of the coaching firm Master Physician Leaders. Her physician executive experience includes serving as a chief medical officer at Banner Health in Arizona, where she played a clinical leadership role at a tertiary care center offering inpatient, emergent, and same-day services provided by more than 1,000 specialty physicians.
HealthLeaders recently talked with Malcolm about a range of topics including: her new role; the primary diversity, equity, and inclusion considerations for a healthcare organization's workforce; and the main elements of a culture of inclusion.
The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: How does the "belonging" element of your title fit into your role?
Teresa Malcolm: It was one of the words in the title that attracted me most to this position because belonging is the piece about how individuals feel when they are part of an organization. They feel a sense of connectedness. They feel a sense of attachment. Belonging digs into how you feel emotionally connected, to be able to say, "I belong here. I belong to this workplace." That was appealing and attractive to me because it is much more than having diverse individuals with different ethnic or racial backgrounds, or different clinical backgrounds, or just different skills.
Part of my role is helping us to explore how each of us as individuals can say, "I feel part of this. I feel I belong here." A lot of times, when people leave an organization, part of what they will say is, "I didn't feel that I belonged there." We are hoping people will feel they belong when they are part of the Dartmouth health system, whether they are a patient, an employee, a leader, or member of the community. We want them to feel that who they are is respected, honored, and valued.
HL: You are the first vice president of diversity, equity, inclusion, and belonging at Dartmouth-Hitchcock Health. What are your top priorities in this new role?
Malcolm: I want to start with listening. I want to start by understanding what is important to the members of this organization. I want to know what they think works well—what is Dartmouth Health already excelling at in the areas of diversity, equity, inclusion, and belonging? Once we identify what is working well, I want to propel that forward.
On the opposite end, I want to know what is not working. What do we need to let go of? What do we need to abandon because it may have served us well in the past, but it is not serving us well now in terms of the goals that we have for diversity, equity, inclusion, and belonging?
I want to understand what words describe this organization and what words do we want to use to describe us going forward. I want to know where we are at today, then find out where we want to be a year from now. What do we want to be able to say about ourselves one year from now after we have intensified this work?
HL: What are the primary diversity, equity, and inclusion considerations for a healthcare organization's workforce?
Malcolm: It starts with diversity and appreciating what diversity brings to the organization. Diversity makes us a stronger organization. It increases our bottom line. It attracts more individuals to the organization. It improves innovation. It improves creativity. There are many benefits from diversity alone, but it doesn't stop with just diversity.
Diversity must be activated. You must put it into place. It is not enough just to say, "We have diversity metrics, and we are going to meet these metrics." We must be able to move from just diversity metrics to a sense of inclusion. We must move to a place where people are speaking up and saying things that may have not been said before. We need to challenge the status quo. We need to redefine the culture and move beyond where we are right now.
HL: What are the primary elements of a culture of inclusion?
Malcolm: One of the primary elements is psychological safety. There needs to be a sense that you can speak aloud about mistakes and about differences of opinion. You should be able to raise objections without retribution and knowing that you will not be punished. Psychological safety allows for openness of dialogue.
Empathy and compassion are essential. We must understand the positions and perspectives of others that are different from our own. We must extend empathy to others who may not be where we are and may not share our beliefs. We also must extend empathy and compassion to ourselves if we are not where somebody else is. We are all on a journey. We are all on a continuum. We need to give ourselves grace and space as individuals, as departments, and as organizations for wherever we are on that journey and that continuum.
Another element is striving for excellence, which is different than striving to be the best. There is not an endpoint for inclusion. There is not a final destination where we can pat ourselves on the back and say, "Job well done!" There is going to be constant and continuous effort, energy, and intention that we need to put toward inclusion because we are going to be making incremental progress.
HL: What are the keys to success in coaching leaders and care teams to build a culture of inclusion?
Malcolm: People need to know that we all play a role in this work. This is not one person's responsibility or one department's responsibility. We are all responsible for this work and we all need to hold each other accountable.
We are blessed to be able to be in the positions we have and to make the kind of impact that we want to make. We need to make an inclusive culture where people feel they are a part of providing care to others. There are small things that we can do to help benefit inclusion and small things that we can do to impede it. We need to use the energy we have to make positive small changes.
HL: Diversity, equity, and inclusion can be sensitive topics for healthcare organizations. How can healthcare organization leaders be encouraged to tackle diversity, equity, and inclusion challenges?
Malcolm: It is important to remember that unless we talk about these issues, we cannot achieve change. If we cannot talk about creating an inclusive environment, if we cannot talk about racial differences, if we cannot talk about ethnic differences, if we cannot talk about gender differences, if we cannot engage in healthy and crucial conversations about our differences, then how are we going to be able to move forward as an organization?
While these might be sensitive topics, how can we expect that anything will change if we do not address them? If we come into these conversations with a level of humility—recognizing that we do not have all the answers and we are here to learn—and if we can enter these conversations with less of a desire to be right and more of a desire to learn, then we can move the organization forward.
Healthcare organization leaders need to understand that there is no absolute way that they need to engage in this work. They need to come with an open heart and an open mind and be willing to listen and to learn from people who have different perspectives.
A new website provides information on Food is Medicine services across The Bay State.
The Massachusetts Food is Medicine Service Inventory website has been launched to connect individuals, healthcare providers, and community-based organizations to Food is Medicine services in their communities.
The service inventory website was created by Community Servings and the Center for Health Law and Policy Innovation (CHLPI) at Harvard Law School in Boston. "Diet quality is the Number One risk factor for death in the United States," says Katie Garfield, JD, director of whole person care and clinical instructor at CHLPI.
The Massachusetts Food is Medicine Service Inventory has information on the four types of Food is Medicine interventions, which can be conceptualized as a pyramid.
1. Medically tailored meals: At the top of the pyramid are medically tailored meals, which are designed for individuals with the highest healthcare needs who need the most intensive intervention. Medically tailored meals are meals developed by a registered nutritionist to address the dietary needs of an individual's medical condition, and individuals are referred by a healthcare provider or health plan.
2. Medically tailored food packages: The next category of nutrition intervention programs is slightly broader. Medically tailored food packages include a selection of minimally prepared grocery items selected by a registered nutritionist or other qualified nutrition professional as part of a treatment plan for an individual with a medical diagnosis. This is an intervention for someone who can shop and cook for themselves, but they have a specific medical diagnosis and nutrition needs, so they need some assistance in making sure that they are eating foods that benefit their health.
3. Nutritious food referrals: Instead of directly providing food, nutritious food referrals tend to provide funds for nutritious foods that may be redeemed in a variety of retail environments such as farmers markets or grocery stores. The most common example of a nutritious food referral is a produce prescription program, where a healthcare provider can refer a patient to programs that provide a voucher or gift card that is designed for the purchase of fruits and vegetables to address a health condition.
4. Community-level healthy food programs: The broadest category of Food is Medicine interventions is community-level healthy food programs. These programs provide nutritious food for a population that currently has or is at increased risk for chronic disease associated with food insecurity. These programs are done in partnership or consultation with a healthcare stakeholder such as a healthcare payer, provider, or nutrition professional. For example, there could be a mobile market that is providing healthy food at a community health center or another healthcare facility.
How the Massachusetts Food is Medicine Service Inventory works
Three years ago, CHLPI, Community Servings, and a range of other organizations across Massachusetts developed the Food is Medicine State Plan, and the service inventory is a fruit of that labor, Garfield says.
"As part of that effort, we surveyed more than two hundred organizations across Massachusetts and held 11 regional listening sessions across the state. Our goal was to understand what access to Food is Medicine interventions looked like, how that compared to the need, and what we could do to expand access. Through that process, a common theme that we heard was that healthcare providers and other organizations were interested in connecting patients to Food is Medicine interventions, but they did not know where to find them," she says.
A key feature of the Massachusetts Food is Medicine Service Inventory is an interactive map, Garfield says. "The interactive map shows where programs exist across the state. You can click on an icon and see the contact information for programs and see where they are located."
The website also provides a much more detailed searchable list of programs, she says.
"When you do a search, you get a list of programs meeting your criteria and detailed information on what those programs look like. For example, you can filter the list by what age groups the programs are serving, by the type of intervention based on the four types of Food is Medicine interventions, and by county to get a sense of service areas. When you click on a program, you get detailed information, including information on eligibility requirements, service areas, what health conditions the programs can be tailored to address, and the best way to get in contact with the program to see whether you can enroll," Garfield says.
Food is Medicine impact
Food is Medicine has a positive effect on health outcomes, she says. "We are seeing some great research that shows Food is Medicine services, which include medically tailored meals, medically tailored food packages, and produce prescriptions, can make a big impact on improving diet and health. For example, studies have shown that connecting seriously ill patients to programs such as medically tailored meals can result in a huge drop in the need for hospital admissions and emergency department visits."
Food is Medicine also drives down healthcare costs, Garfield says.
"Because food insecurity and diet quality are linked to chronic illness, they are important drivers of healthcare costs. For example, a Massachusetts study found that food insecurity increases healthcare costs in the state by $1.9 billion each year. … A recent study has shown that providing medically tailored meals can result in a 16% net reduction in healthcare costs—that is net, so it includes the cost of the meals. There is research that is forthcoming that is looking at the impact on healthcare costs for other Food is Medicine interventions," she says.
Researchers compared moral injury experienced by combat veterans after Sept. 11, 2001, and healthcare workers during the coronavirus pandemic.
During in the coronavirus pandemic, healthcare workers have experienced moral injury at levels comparable to combat veterans, a new research article found.
The pandemic has put tremendous pressure on healthcare workers. Prior to the pandemic, healthcare workers burnout rates averaged in the range of 30% to 50%; now, average burnout rates range from 40% to 70%, a healthcare worker well-being expert recently told HealthLeaders.
The new research article, which was published by the Journal of General Internal Medicine, is based on information gathered from 618 veterans who served in a combat zone after Sept. 11, 2001, and 2,099 healthcare workers who have provided care during the pandemic.
Moral injury has been defined as the "psychological, biological, spiritual, behavioral and social impact of perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations." The new research article examined two kinds of potential moral injury: other-induced potential moral injury, which involves being disturbed by the immoral acts of others, and self-induced potential moral injury, which involves being disturbed by violating your own morals.
The study includes several key data points.
46.1% of combat veterans and 50.7% of healthcare workers reported other-induced potential moral injury
24.1% of combat veterans and 18.2% of healthcare workers reported self-induced potential moral injury
For healthcare workers, other-induced potential moral injury was linked to younger age and COVID-19 exposure
For healthcare workers, self-induced potential moral injury was linked to younger age, nonwhite race, working in a high-risk setting, and COVID-19 exposure
Healthcare workers who reported other-induced potential moral injury had higher levels of depression and lower quality of life compared to healthcare workers who did not report other-induced potential moral injury
Healthcare workers who reported self-induced potential moral injury had higher levels of depression and lower quality of life compared to healthcare workers who did not report self-induced potential moral injury
Healthcare workers who reported other-induced or self-induced potential moral injury experienced significantly higher levels of burnout compared to healthcare workers who did not report other-induced or self-induced potential moral injury
"The potential for moral injury is relatively high among combat veterans and COVID-19 [healthcare workers], with deleterious consequences for mental health and burnout," the study's co-authors wrote.
Interpreting the data
The time of reported events is an important difference between the combat veterans and the healthcare workers, the lead author of the study told HealthLeaders.
"Veterans in our sample were reporting on experiences from their military service. While they were all combat veterans, those we interviewed about morally injurious experiences reported on both combat-related events and non-combat related experiences. Healthcare workers were reporting on experiences that were more recent in most cases. This is an important difference, and it will be important to monitor healthcare workers over time," said Jason Nieuwsma, PhD, an associate professor at Duke University Medical Center in Durham, North Carolina.
There are other key differences between the combat veterans and the healthcare workers, he said.
"There are also of course differences between serving in the military during a deployment, where you don't go home at night and don't really have the option to quit or take leave, and in healthcare during a pandemic, where you do go home at night and can make decisions about quitting or leaving. These differences can cut both ways in terms of the stress involved. While there is clear potential for intense pressure and stress in a deployment situation that one can't escape, I've also known many service members and veterans who would rather not have easy contact with their families during deployments because switching between those mindsets can be difficult and jarring—something healthcare workers reported in juxtaposing their experiences in hospitals with how upon leaving the hospital outside parts of society seemed ambivalent at times," Nieuwsma said.
Among healthcare workers, younger age was associated with both other-induced and self-induced potential moral injury. He said demographic characteristics like this may be associated with lower social status or empowerment.
"Jonathan Shay, a psychiatrist who did a lot of earlier work on moral injury among Vietnam War era veterans, defined moral injury as a betrayal by a legitimate authority in a high-stakes situation. Among healthcare workers, we heard anecdotes from persons who felt betrayed by leadership and/or felt like they were in situations with no good options, sometimes leading to providing lower quality patient care and associated feelings of guilt about that. Younger persons are more likely to be earlier in their careers and potentially finding themselves in these kinds of situations more often," Nieuwsma said.
For healthcare workers, the relationship between burnout and potential moral injury can go in both directions, he said.
"When people feel exhausted and burned out, we know that we as humans make worse decisions. This includes our ability to make moral decisions. To cite Shay again, he talked about how important sleep was for service members in combat because sleep deprived combatants are more likely to make worse decisions, again including morally consequential decisions. For example, firing on a vehicle that you think is an enemy combatant but turns out to be civilians. We heard similar things from healthcare workers, who said that they felt so exhausted and burned out that they ended up at higher risk for violating their own values and standards of patient care. Conversely, those who felt they had experienced a potential moral injury also reported feeling further demotivated and burned out, so, it can be a cycle," Nieuwsma said.
New study raises questions about when telehealth is best used as a substitute for in-person care and when telehealth is best used to complement in-person care.
Early in the coronavirus pandemic, telehealth helped to offset a sharp drop of in-person mental health visits, but the volume of visits for several conditions such as bipolar disorder declined in part because of relatively low telehealth uptake by patients with these conditions, a new study says.
Stay-at-home orders and fear of contracting coronavirus at healthcare facilities drove down in-person visits for medical care early in the pandemic. Healthcare providers responded to the decrease in in-person visits with an unprecedented expansion of telehealth visits.
The new study was published by HealthAffairs. The study is based on an analysis of claims data from Office Ally, a claims clearinghouse for Medicare, Medicaid, and commercial payers. The researchers compared mental health service utilization from time periods before and during the pandemic: 2016 to 2018 and March to December 2020.
The claims data provided information on 101.7 million outpatient mental
health visits. Three-quarters of the visits occurred from 2016 to 2018 and one-quarter of the visits occurred from March to December 2020.
The study features several key data points.
In March 2020, there was a 21.9% decrease in in-person mental health visits compared to the same month in the pre-pandemic period.
In April 2020, there was a 49.6% decrease in in-person mental health visits compared to the same month in the pre-pandemic period.
In May 2020, there was a 55.9% decrease in in-person mental health visits compared to the same month in the pre-pandemic period.
Telehealth visits quickly led to recovery in outpatient mental health utilization. In April 2020, the combination of in-person and telehealth visits was 10.4% higher than average monthly visits in the same month in the pre-pandemic period.
The average number of monthly mental health visits was 2.12 million in the pre-pandemic period compared to 2.11 million during the pandemic period, which was a 0.7% decrease in service volume.
During the pandemic period, the number of average monthly visits decreased by 10.6% for bipolar disorders, 8.5% for schizophrenia and psychotic disorders, and 8.2% for depressive disorders.
During the pandemic period, the number of average monthly visits increased by 12.1% for anxiety and fear-related disorders.
During the pandemic period, telehealth visits compared to in-person visits varied for diagnosis groups. For schizophrenia, telehealth visits accounted for a lower proportion of total outpatient visits compared to in-person visits (1.7% versus 2.7%). For anxiety and fear-related disorders, telehealth visits accounted for a higher proportion of outpatient visits compared to in-person visits (27.5% versus 25.5%).
"We found substantial declines in in-person mental health services use in the initial lockdown phase of the COVID-19 pandemic, followed by a rapid rebound in utilization volume driven chiefly by uptake of telehealth appointments. … We also found relative reductions in encounter volume for certain groups of mental health conditions, specifically for serious mental illnesses such as bipolar and mood disorders and schizophrenia and psychotic disorders, whereas encounters for anxiety and fear-related disorders rose slightly," the study's co-authors wrote.
Interpreting the data
During the pandemic, decreases in average monthly visits for bipolar disorders, schizophrenia and psychotic disorders, and depressive disorders is a troubling, the lead author of the study told HealthLeaders.
"Evidence suggests that during the pandemic more people had mental health symptoms, and that those with mental health conditions had increased symptom acuity. So, our findings of reduced utilization for certain mental health conditions is concerning in this setting, because it suggests that some groups may have been more sensitive to care disruptions that occurred. Individuals with mental health conditions, including those with serious mental illness, are already facing challenges in accessing mental health care, due to socioeconomic factors, difficulty accessing or navigating care, clinician turnover and lack of continuity, financial barriers, and even the nature of the illness itself. It is likely that these factors were exacerbated during the pandemic," said Jane Zhu, MD, MPP, MSHP, assistant professor of medicine at Oregon Health & Science University in Portland, Oregon.
Telehealth appears to be a good care fit for anxiety and fear-related disorders, she said. "We found that telehealth encounters for anxiety and fear related disorders went up significantly during the pandemic, likely driving an increase in total outpatient volume. Many others have reported that rates of anxiety and depression increased substantially during the pandemic, particularly among younger people. So, for this population subgroup, telehealth may be a suitable and acceptable modality of care, and it helped bridge access gaps during the pandemic."
The finding that telehealth encounters for schizophrenia made up a lower proportion of total outpatient encounters relative to in-person visits in 2020 has a significant implication for telehealth and mental health care, Zhu said.
"Telehealth for mental health conditions has been shown to be as effective as in-person care for a variety of purposes, including diagnosis, psychotherapy, and medication adjustment. But it's not yet known the extent to which different groups might have different clinical needs and preferences that may change the acceptability, accessibility, and efficacy of telehealth. For example, as a primary care physician, I have patients with mental health conditions like schizophrenia who prefer in-person visits because they don't like using audio visual tools on the Internet. While our study doesn't evaluate specific reasons for this finding, it raises questions about introducing telehealth as a one-size-fits-all tech solution to mental health care," she said.
The appropriate use of telehealth relative to in-person visits has yet to be determined, Zhu said. "Telehealth is here to stay, it's certainly a critical tool to increase access to mental health care and its applications in this space are incredibly promising, but we need to understand when it's best used as a substitute for in-person care, and when it's best used as a complement, and for whom. Flexibilities may be needed to allow for hybrid models of care."
Vince Jensen says National Cancer Institute-designated comprehensive cancer centers need to deliver the newest therapies and discover new treatments.
City of Hope’s new chief clinical operating officer will lead clinical operations at the organization’s main campus in Los Angeles and throughout its network of more than three dozen care locations in southern California.
Vince Jensen, MBA, started his new position in February and has worked at City of Hope for 22 years. He joined City of Hope as a managed care executive and served as senior vice president of ambulatory operations before taking on his current role.
HealthLeaders recently talked with Jensen about his new position and a range of issues including growth opportunities, adding a physician group to City of Hope, and national centers of excellence relationships. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders:What are some of the major initiatives occurring within clinical operations management at City of Hope?
Vince Jensen: City of Hope is one of the largest cancer research and treatment organizations in the United States. In southern California alone, we have 37 care locations focused on bringing leading-edge oncology care and clinical research trials to those who need us.
My focus is to strategically position City of Hope's clinical enterprise for future growth, excellence in care, and efficiency. As a country, we have a long way to go in removing health disparities. Patients continue to face geographic, insurance, and socioeconomic barriers in accessing lifesaving care and research in oncology. Oftentimes, our most vulnerable populations have the least access to highly advanced care.
We are working to overcome some of these challenges through advocacy efforts on behalf of cancer patients and by operationally expanding our reach so we can care for patients closer to their home. We believe access to world-class and highly specialized cancer treatment should be widely available to those need it most.
Recently, City of Hope signed an agreement with Pacific Shores Medical Group that expanded our clinical network presence to thousands of patients in southern California—adding seven new locations: Glendale, Huntington Beach, Irvine, Newport Beach, Torrance, and two in Long Beach. In addition, earlier this month, we opened a new 32,500-square-foot cancer care location in Corona, expanding our programs and services to that community and significantly increasing the size of our site in that city to meet growing demand.
HL: What are the key benefits of adding Pacific Shores Medical Group to your network?
Jensen: Selecting physicians who have intense passion for City of Hope’s clinical and research mission is an important part of delivering excellence in cancer care. As cancer therapies become more complex, the power of knowledge really can save lives. Adding talented physicians gives us an opportunity to further share and collaborate in new and exciting ways.
For example, our Pacific Shores physicians brought with them a portfolio of new clinical research and ways of providing care in the community setting. Our goal is to share best practices, learn from each other, and develop an evolved organization that is constantly learning and adapting.
HL: You led the opening of a new 34,000-square-foot outpatient clinic. Why was this facility important to City of Hope?
Jensen: The Southeast Ambulatory Clinic is the first of a few planned outpatient expansions on City of Hope’s main campus in Los Angeles. The exciting part of this new development was the opportunity to think more strategically about how we can better utilize existing space to serve the needs of our patients. This will be done through a combination of new buildings and a redesign of existing spaces to achieve new capacity with reasonable speed.
This new center was unique in that we converted administrative space into a large clinical area—adding about 30% more exam rooms for patients and physicians. New capacity means we can reduce wait times for critical cancer care. As an added benefit, the new space is a beautiful and tranquil environment for our patients and physicians.
HL: What elements of clinical operations are unique to a cancer research and treatment institution?
Jensen: As a National Cancer Institute-designated comprehensive cancer center, City of Hope offers patients breakthrough cancer care not yet available to the general population. Every year, City of Hope conducts nearly 1,000 clinical trials. Compared to other diseases, operations in a cancer research and clinical medical institution is quite different. Our focus must be on speed—whether that’s delivering the newest therapies, discovering new treatments, or delivering a new cancer center to serve a population—we carry the responsibility of knowing there are newly diagnosed patients in need of these novel advancements now.
Among our priorities, we are working to ensure leading-edge cancer care is available to more people, not just to those who live near a comprehensive cancer center or an academic institution. As a result, City of Hope is offering clinical trials in our community practice sites, such as Antelope Valley, South Bay, South Pasadena, and more. We hire trained professionals, including clinical trial nurses, who are experienced in research operations and able to deliver high-quality clinical care in community locations. To succeed in this effort, we’ve created infrastructure where we have clinical trial champions—physicians who can help build that bridge from our campus in Los Angeles to our community practice sites. As we look to the future, City of Hope will continue to open new research care locations focused on bringing new and innovative trials to communities that may not otherwise have access to them.
HL: What are areas of future growth for City of Hope?
Cancer screening and precision medicine are important initiatives for us. The pandemic slowed cancer screening across the country, increasing the risk that cancers are discovered at later and more complex stages. City of Hope continues to be an advanced screening center for all cancers, and we continue to encourage the community to be diligent about routine breast, prostate, and colon screenings.
Our precision medicine program continues to transform care by delivering new treatments customized to a patient’s own diagnosis and personal genomics. We are also leading the country in cellular therapies designed to "teach" a patient's own immune system, such as its T cells, to find and destroy cancer by looking for specific proteins.
These new therapies offer exciting results and new possibilities for patients who did not respond to other types of cancer treatments. In the near future, we will see the most promising of these treatments become the preferred approach after cancer diagnosis. However, given the complexity of the therapies, it will be important that patients have access to an academic center that can deliver this critical care.
HL: What role have you played in the creation of national centers of excellence relationships?
Jensen: The role of a center of excellence is to highlight institutions that are among the best in the country for quality, volume, safety, and effectiveness. This determination is made only after a rigorous review of data, including clinical outcomes. In my early days at City of Hope, I was focused on the development of these center of excellence relationships. Today as chief clinical operation officer, my role is to ensure we can continue to exceed the rigorous quality and operational standards we are held to as a center of excellence.
To be successful, physicians who participate in supply chain must have good communication skills and curiosity about supplies.
Physicians play a variety of roles in supply chain at hospitals and health systems, a healthcare supply chain expert says.
Eugene Schneller, PhD, is a professor in the Department of Supply Chain Management at Arizona State University's W.P. Carey School of Business and cofounder of Healthcare Supply Chain eXcellence. He is also director of the Health Sector Supply Chain Research Consortium, which is a university-industry cooperative committed to advancing healthcare supply chain practice.
HealthLeaders recently interviewed Schneller about the roles that physicians can play in hospital and health system supply chains. The following transcript of that conversation has been edited for clarity and brevity.
HealthLeaders: Are there formal roles that physicians can play in a health system's or hospital's supply chain department?
Eugene Schneller: Physicians can participate in several ways. One way is as a member of a value analysis team organized and managed by supply chain. In many cases, these are standing committees to look at products such as in orthopedics or cardiology. These committees meet monthly or several times a year to look at products that the hospital is using. Physicians are demanders of products, and there needs to be a very clear relationship or mechanism by which physicians can provide input to supply chains. Value analysis teams are one way to do that.
As hospitals look at new products, they invite physicians to bring those products to them. In that case, the physician is a proposer.
Physicians can sit in on sessions where the hospital is looking at a class or category of goods, and physicians participate at looking at those goods. That happens frequently when a contract is ending.
Physicians can also serve as liaisons or "linking pins" to the supply chain department representing their clinical departments. If you think of supply-intensive admissions such as orthopedics and cardiology, those are areas where new products are evolving constantly, so you may have a physician working in a liaison role that is part of the physician's total responsibility.
Physicians can also participate in quality assurance processes that are conducted by supply chain.
Often, there are physicians who are full-time employees of supply chain departments. Some large health systems have physicians embedded within supply chain.
HL: For physicians more broadly, how can they play a role in supply chain functions and activities?
Schneller: Physicians can serve as scouts for new products because they go to meetings that frequently have demonstrations of new products.
Physicians can communicate when the relationship with a supplier is not what has been agreed upon in a contractual relationship in terms of the supplier providing support for the product.
Physicians can also communicate the criticality of a product in a procedure. Increasingly, we are thinking not just in terms of individual products but in terms of an episode of care. For example, you can have a hip replacement or a knee replacement with several products involved, so the interaction of several products is important. Physicians can communicate about that interaction. A group of surgeons may decide that a product is not necessary, so they need to communicate with supply chain about what is happening.
Physicians may be the first to find out about the absence of a product. They need to communicate with supply chain about these "stock outs."
Physicians also may be the first to know about problems with products such as products that are not working properly. There can be products that the Food and Drug Administration has not yet recalled but a clinician may recognize that the product is not performing correctly and communication with supply chain is important.
HL: For physicians who participate in supply chain management, what kind of qualities should they have to be successful?
Schneller: They need to be able to communicate in all directions. They need to be able to communicate with their physician colleagues about discussions related to products. If a hospital has several physicians within a specialty, those physicians collectively have an interest in what products are available and they have strong preferences. Physicians have preferences for brands on the basis of their perceptions of brand performance, on the basis of the outcomes they achieve, and their relationships with companies. As supply chain considers reduction in the number of products, addition of new products, or maintaining a robust mix of products, communication between physicians and supply chain is critical.
Physicians who work with supply chain also need to have curiosity about supplies. In most medical schools, there is relatively little education about supply chain or how supplies are chosen. So, a physician who plays a supply chain role needs to have curiosity about supplies, the information about supplies, and their relative effectiveness and comparability to other supplies.
HL: How should supply chain leaders communicate with physicians?
Schneller: The most important thing is establishing relationships and communication channels. A supply chain leader should not only show up when there is bad news such as a product not being available or when there is a delay in a product coming from overseas. There needs to be relationships so supply chain leaders are not just delivering bad news—they must understand the needs of the clinicians.
Critical to the relationship is bringing data. When you want to influence a clinician or a clinician is curious about a new product, it is important to have data about products and their performance that is provided by the supplier or generated through comparative work. At some of the more progressive health systems, artificial intelligence is being used to look at what products are used in an episode of care. For example, with hip and knee replacements, information systems can be used to understand which products contribute to the cost, quality, and outcome of the episode of care.
Increasingly, clinicians are being incentivized to reduce costs through bundled payments, where a hospital gets a single sum of reimbursement for an episode of care. Within a bundled payment for a surgery, there are all of the costs for the episode of care including the costs for supplies, and any savings can be distributed by the hospital through a gain-sharing arrangement. Under these circumstances, having data about supplies is important.
You need to be able to communicate with physicians about supply issues and anticipate them ahead of time. During the pandemic, we have seen problems related to the availability of products, and you need to let physicians know about these problems ahead of time and provide alternative products that are satisfactory. To have these conversations, you need to have relationships and to be able to communicate effectively.
The American Hospital Association's new Health Equity Roadmap provides a model for transformation and resources to make progress.
The American Hospital Association (AHA) has released a Health Equity Roadmap to help the organization's members make advancements in equity and inclusion.
Health equity has emerged as a pressing issue in U.S. healthcare during the coronavirus pandemic. In particular, there have been COVID-19 health disparities for many racial and ethnic groups that have been at higher risk of getting sick and experiencing relatively high mortality rates.
"The Health Equity Roadmap is a framework to support our member hospitals and health systems in their efforts to become more inclusive and more equitable organizations as we work toward dismantling the structural barriers that exist for some of our patient populations," says Joy Lewis, MPH, MSW, senior vice president of health equity strategies at AHA.
The AHA's Health Equity Roadmap has five components and resources, she says.
1. Transformation model: "There are six levers of transformation in the model. If our members focus on these six areas, they will be well-positioned to mobilize and make positive change toward becoming more equitable. The six levers of transformation are community collaboration for solutions, equitable and inclusive organizational policies, culturally appropriate patient care, collection and use of data to drive action, diverse representation in leadership and governance, and systemic and shared accountability," Lewis says.
2. Transformation assessment: "The transformation assessment serves as both a diagnostic of a hospital's current state and a baseline of where they are to help create a structure and process for continuous improvement toward transforming to more equitable and inclusive environments for both their workforce and the patients and communities they serve. The assessment calls out key performance indicators across each of the six levers of transformation," she says.
3. Transformation profile: "When a hospital conducts the assessment, they get the results in the form of a transformation profile. The profile says, 'Here is where you are. Here is your placement on the equity continuum.' There are five placements on the equity continuum—exploring, which is an embryonic stage of development; committing; affirming; immersing; and transforming, which is the most advanced stage. The profile provides data around where you are in each of the six levers of transformation. For example, a hospital could be transforming in their data collection and how they use data to improve care, but they could be exploring when it comes to addressing the issue of diverse representation in leadership and governance," Lewis says.
4. Action planners: "Once a member has the profile, they are then able to access the action planners, which are like a workbook. You gather a team of leaders from across the hospital who would be making contributions in each of the levers of transformation. This team thinks through and crafts actions that need to be taken to move from exploring to committing, for example," she says.
There 30 different action planners in total given the six levers in the transformation model and five placement levels of the equity continuum. Each action planner includes reflective questions that hospitals should ask of themselves and best practices.
For example, there is an action planner for the affirming placement level of the equity continuum for community collaboration for solutions. Reflective questions that hospitals should ask of themselves for this action planner include: What are the obstacles related to community collaboration for solutions at your organization? What are the impacts of these obstacles? Who is most impacted by these obstacles? Best practices for this action planner include: Conduct an audit to determine what barriers exist for individuals and marginalized communities in their ability to achieve good health and access healthcare services. Assess how well your existing services are reaching marginalized communities. Gather information on patient experience and disaggregate by race to determine common barriers for communities.
5. Health Equity Action Library: "When our members get their profile and they receive their placements on the equity continuum, they are also given a link to the resources in the Health Equity Action Library that can help them to mobilize and take actions to move from one placement to another on the equity continuum," Lewis says.
The Health Equity Action Library is accessible to all hospitals and health systems. Access to the rest of the Health Equity Roadmap is limited to AHA members.
Benefits of addressing health inequities
Addressing health inequities benefits patients, she says. "Given that the goal of the healthcare system is promoting health, it is clear that eliminating disparities is the right thing to do for patients. We want each patient to have the opportunity to achieve their optimal health status, and the same goes for communities. For example, if you look at racial health inequities, studies have shown that racial health inequities can cost billions of dollars in lost productivity and can result in premature death."
Addressing health inequities also improve the performance of hospitals and health systems, Lewis says. "For hospitals and health systems, eliminating inequities improves patient engagement, decreases readmissions, and improves health outcomes. Eliminating inequities also improves performance and reduces healthcare costs. Addressing health disparities allows hospitals and health systems to perform better in value-based payment arrangements. So, there is a business case for addressing health inequities."
Racial, ethnic, and linguistic concordance between healthcare providers and patients is low for people of color, a new report says.
Lack of diversity in the healthcare workforce risks undermining trust and patient health, according to a new report published by the Urban Institute.
Past medical mistreatment of people of color such as ignoring patients’ health concerns has resulted in mistrust of healthcare providers in these populations. “Perceptions of a shared identity between patients and their healthcare providers could be one way to improve the patient-provider relationship and foster trust and better communication,” the new report says.
Earlier research has shown benefits of having healthcare providers of the same race as patients or who speak the same language as patients. These kinds of concordances have “been associated with a greater likelihood of patients agreeing to and receiving preventive care, better patient experience ratings, and higher ratings on patient-reported measures of care quality,” the report says.
The report, which received funding from the Robert Wood Johnson Foundation, includes two key findings.
Only 22.2% of Black adults reported being of the same race as their healthcare providers compared to 73.8% of White adults.
Only 23.1% of Hispanic/Latinx adults reported racial, ethnic, and language concordance with their usual healthcare provider.
“Trust is part of the foundation of good patient-provider relationships and is especially important for communities of color, who have long been discriminated against in healthcare. Having a provider who looks like you and shares your experiences builds trust. Diversifying the healthcare workforce and increasing access to culturally competent care are significant opportunities to promote health equity and reduce disparities,” Jacquelynn Orr, DrPH, Robert Wood Johnson Foundation program officer, said in a prepared statement.
Addressing healthcare workforce diversity
Medical education should be a focal point in efforts to increase diversity in the physician workforce, the report says. “Because Black medical institutions play a key role in training Black providers and other providers of color, creating and supporting medical schools at historically Black colleges and universities and other minority-serving institutions could help increase the diversity of the healthcare workforce,” the report says.
Barriers for people of color who apply to medical school include the high cost of medical education programs, inadequate guidance in navigating admissions, and insufficient support systems to make sure people of color have the resources necessary to pursue a medical education, the report says.
“Cost barriers are particularly salient, given that the median cost of attending an in-state four-year medical school is about $260,000 for public institutions and more than $350,000 for private ones. … Tuition-free programs, debt-free medical education programs for students qualifying for financial aid, and scholarships and grants for underrepresented students are promising strategies for lowering the price of medical education and increasing the representation of Black students and other students of color,” the report says.
Importance of language
Earlier research has shown that patients for whom English is not the primary language have worse health outcomes than patients with English proficiency.
There are two primary strategies to address language gaps, the report says.
First, healthcare providers can offer interpretation services. “Most Medicaid programs reimburse for professional medical interpretation, but reimbursement ranges from $30 to $50 per visit, and interpretation for an encounter could cost up to $200; private insurers seldom reimburse for interpretation services. Stronger enforcement of language access regulations and higher reimbursement for medical interpretation services by health insurance payers could improve language access in healthcare,” the report says.
Second, healthcare providers can be encouraged to be multilingual. “Although some medical schools recommend students be fluent in a language other than English, making this a requirement or a heavily positively weighted factor for medical school admissions could also help diversify the languages spoken in the healthcare workforce. Offering bonuses and higher pay for healthcare workers who speak multiple languages could also incentivize providers to add staff who speak languages other than English,” the report says.
