Clinical event debriefing efforts serve three purposes, linking safety, quality, and staff wellness.
Clinical debriefing efforts can drive several benefits at health systems and hospitals, according to the NYC Health + Hospitals presenters of a session at this week's IHI Forum.
The Agency for Healthcare Research and Quality provides a definition of clinical debriefing: "A dialogue between two or more people whose goals are to discuss the actions and thought processes involved in a particular patient care situation to encourage reflection on those actions and thought processes and incorporate improvement into future performance."
"Three key things stick out to me: dialogue, reflection, and improvement," said Mona Krouse, MD, patient safety officer at NYC Health + Hospitals.
Clinical debriefings are a way to capitalize on information, said Suzanne Bentley, MD, medical director of the Elmhurst Satellite Simulation Center at NYC Health + Hospitals.
"It captures reflections and gets them down with each other and why we are doing things and how we can do them differently. So, it serves to supply information. It allows us to identify knowledge gaps. It offers reflection on local culture, workforce, and team functioning, including identifying issues or struggles when they are present. Above all else, debriefing can serve as a change agent for work toward becoming a culture that has more of these conversations and more sharing so we can all come together to be better," she said.
The purpose of clinical debriefings is trifold, linking safety, quality, and staff wellness, Bentley said, adding that boosting wellness is often underestimated in clinical debriefing efforts.
"Wellness is not a hidden agenda, but it is definitely an unrecognized benefit that comes with debriefing. We should be debriefing with a lens toward wellness and how we are supporting the participants who are filtering in useful information. No one can truly engage in discussions around patient safety and around quality healthcare while they are in distress. There is literature that backs this up. … Additionally, no one can truly heal without having a safe outlet to share their ideas and their suggestions for how things could have gone differently," she said.
Debriefing not only improves patient outcomes but also improves staff outcomes, Krouse said. "Especially now during the COVID-19 pandemic, the crisis hit home for a lot of people in healthcare. Personally speaking, this has been a very tough time, and debriefing offers a space to talk about how you are feeling. In studies, debriefings have been shown to reduce stress and anxiety, improve morale, improve work satisfaction, and decrease burnout."
Overcoming barriers to debriefing
The IHI Forum session also addressed barriers to implementing clinical debriefing efforts.
For example, one of the primary barriers is the perception that it is hard to debrief in the right way, said Komal Bajaj, MD, MS, chief quality officer, Jacobi Medical Center, NYC Health + Hospitals.
"What we have learned over time is that there is not one right way to debrief. There are many published models that all have a few common themes. One is an attention to psychological safety. Two, there is some acknowledgment or solicitation of reactions. Three, there is some discussion about the case itself—what went well and what are the opportunities for improvement. Four, there are takeaways—either takeaways for the individual or takeaways for actions," she said.
Whatever model of debriefing you use, you can craft it to fit your organization, Bajaj said. "It is about picking the tool that meets your needs. As you are thinking about your clinical debriefing program, look at it as a buffet, where you are able to pick and choose formats or questions that seem to make sense for your environment. At the end of the day, we as humans are used to having conversations all the time, with our patients and with each other."
Planning for clinical debriefing programs
Before a clinical event debriefing program is established, key stakeholders and leadership should find answers to a series of questions, Bajaj said.
Who are the stakeholders who need to be engaged? "There are some powerful examples that you can share from the literature as to why debriefing can improve wellness, culture of safety, and quality. Those are powerful examples to share with stakeholders. There is a return on investment for this work," she said.
What debriefing framework works best for your environment? "It depends on what you want to accomplish. There is no one way to debrief," she said.
Who will serve as debriefing champions? "The best examples we have seen are interprofessional. Anyone can serve as a debriefing champion, but there needs to be some discussion about who will serve as a debriefing champion and what training they will need," she said.
How can you foster psychological safety? "We implemented our first debriefing program eight years ago, when debriefing was a dirty word. For the weeks and months leading up to launching our debriefing program, we asked, 'What is debriefing?' It is not meant for individual blame—it is meant for conversations. Our intention was to learn and to be better. The first couple of debriefings we had, there were only two or three people participating. … As people saw that what we talked about got fixed and changed—the idea of closed loop debriefing—debriefing began to be embedded into the culture," she said.
What clinical events should be debriefed? "It is good to start with events that are not the most serious or have the most unfavorable outcomes. You should think about the day-to-day things that can be debriefed, so those muscles are ready when there is a more challenging discussion," she said.
The Institute for Healthcare Improvement has developed five guiding principles to promote workplace equity: assess, build, commit, defend, and evaluate (ABCDE).
As part of its effort to promote joy in work at healthcare organizations, the Institute for Healthcare Improvement has adopted a framework of five guiding principles to foster workplace equity.
"When we are talking about workplace equity, one of the drivers of joy and wellbeing in work is psychological safety," says Marina Renton, MPhil, a research associate at the Institute for Healthcare Improvement. "We see workplace equity as an important component of ensuring psychological safety for staff members. Workplace equity is a vital component of their ability to find joy in the workplace and to feel safe at work. It is foundational to starting to work toward improving staff experience."
1. Assess: The first step for an organization is to assess workplace equity to gain an understanding of the gaps that exist for staff members in the particular settings targeted for improvement.
"Assessment is the first component of the framework because it is fundamental. Collecting and reviewing organizational data allows you to understand where the equity issues are at the organizational level, and that allows you to think about what changes you would like to test. You can find out whether disparities in staff experience exist," Renton says.
Organizations should stratify the data that they collect, she says. "For example, you should stratify data by racial equity in the workplace. If you just ask staff how satisfied they are with their job, and you do not look at that by race, you will get an overall picture, but you may miss disparities."
Assessment should be a collaborative effort between leadership and staff members, Renton says. "In the assessment phase, it is also important to get information on what matters to staff. What is impacting their joy in work? What aspects could be improved? This foundational data collection will allow you to make staff-centered changes that do not involve assumptions."
2. Build: Once the gaps are understood and an aim is identified, the next step is to build—to make structural changes from the top down, with engagement at all levels to prevent equity work from running into barriers.
Leadership must be actively involved in workplace equity efforts, she says. "One of the reasons it is important to make structural changes is you cannot expect staff members to take on this work or for satisfaction to improve without a clear commitment from leadership. For example, achieving equity goals is embedded into executive compensation at Robert Wood Johnson University Hospital."
Planning and allowing time for change to occur are pivotal, Renton says. "You cannot launch into this work without a clear plan and clear supports in place. The building principle includes ensuring that you are guaranteeing adequate time to addressing workplace equity."
3. Commit: Organizations need to make a concrete commitment to equity improvement initiatives through allocating financial and staff resources to the work, rather than expecting staff members to take on the work in addition to their regular responsibilities.
Commitment is a factor in ensuring that initiatives get off the ground and are sustainable, she says. "You have collected the data. You know that you want to make a change. You know you are committed to equity in the workplace. But you need to make the next step. Dedicating financial resources and staffing resources is an important piece of making a commitment to workplace equity. Without a budget, there is risk of the work stalling or being relegated to the periphery. A clear and concrete commitment is crucial."
Robert Wood Johnson University Hospital has business resource groups—affinity groups for employees with shared identities—that have executive sponsors and equity budgets to support equity at the workforce, patient, and community levels.
4. Defend: Equity intersects with principles of physical and psychological safety if there is biased behavior from patients. Organizations can enact systems and workflows to defend and protect staff members quickly and decisively.
The defend principle applies directly to workplace equity during the coronavirus pandemic, Renton says. "Tensions are running high, healthcare decisions are being politicized, and the political climate has been polarizing. So, staff members are at risk of facing instances of bias from patients."
An Annals of Internal Medicinearticle published last year lists recommendations for medical centers to address patient bias toward healthcare workers, including the following:
Creating a policy that explicitly addresses patient bias
Establishing trainee-specific procedures because they are at higher risk
Making considerations for the role of bedside nurses
Creating a mechanism for reporting patient bias toward healthcare workers and supporting staff members to use it
Designating a team to support staff and implement policies and procedures
Ensuring adequate training for confronting bias-based patient behavior
5. Evaluate: An organization's progress on workplace equity and staff wellbeing should be continuously evaluated and overseen by a board-level committee.
Every project can start with the best of intentions, but you need to make sure that the aim is being achieved, Renton says. "We recommend that this work start at the board level because that is the governing body of the healthcare organization. The charter of whatever committee is devoted to equity should include looking at equity within the workforce. Ongoing evaluation makes sure that your efforts are being directed in the right way and have the intended consequences."
Selecting metrics should be guided by the aims of workplace equity efforts, she says. "What is the organization aiming to achieve? What is the organization aiming to understand? What is the organization aiming to learn about workplace equity? Based on that selection process, an organization can determine what measures might be most meaningful and valuable to both leaders and staff in understanding equity."
For any data collected, there should be a clear plan for how the data will be used, Renton says. "That plan should be clearly communicated to the people being asked to contribute the data. Better yet, that plan should be co-designed with staff."
The president and CEO of the Institute for Healthcare Improvement predicts there will be a movement toward outcome-based measurement for health equity next year.
The IHI Forum is being held virtually this week. More than 6,000 people have registered to attend the annual event, which features more than 150 sessions and 375 presenters.
Yesterday during a press briefing, IHI President and CEO Kedar Mate, MD, and IHI President Emeritus and Senior Fellow Donald Berwick MD, MPP, discussed health equity trends for 2022.
Next year, there likely will be a movement toward outcome-based measurement for health equity, Mate said.
"There is new leadership at the National Quality Forum, with Dana Safran at the helm there. She is a patient-centered outcomes researcher. You are going to see a lot more movement toward outcome-focused measurement, and part of that will be about guidance around outcomes stratification using race, ethnicity, language, disability, sexual orientation, and gender identification. There will be guidance around how to stratify measures of outcomes on those dimensions," he said.
Stratification of health equity data likely will be a key trend in 2022, Mate said.
"With outcome-based measurement in hand, we are also going to see organizations such as the National Committee for Quality Assurance inviting healthcare organizations to start stratifying their data. So, we are going to have outcome measurement, more stratification, and encouragement from organizations that manage large measure sets such as the HEDIS measures at NCQA to use those standard definitions of what outcomes look like and how they should be stratified so that we are looking at data in a more stratified manner," he said.
There likely will be more public reporting of health equity data in 2022, Mate said. "You will see more public reporting of stratified measures particularly around race and ethnicity. We are already beginning to see that. You are going to see more health plans and other organizations publish that data going forward."
Mate expects modest progress on health equity incentives in 2022.
"I don't think we will see incentives to remediate inequities. What we will see is economic incentives to collect the data and report the data in a more transparent fashion over the next year. Two to three years out from now, we will start to see incentives from payers to provider organizations not only to collect the data but also to reward health systems for having made meaningful progress on remediating specific inequities," he said.
Berwick said federal legislation bodes well for health equity in 2022.
"The legislation that has passed in Congress and the pending Build Back Better bill have embedded in them the biggest potential progress on health equity this country has seen since the 1960s. So, a lot of the progress on health equity depends on whether Congress will end up supporting the Build Back Better bill, which has levers for health equity embedded in it. Already, we have the infrastructure bill, which has a lot in it. If these pieces of legislation are properly executed, it should be helpful," he said.
Officials in the Biden administration appear to be committed to tackling health equity, Berwick said.
"In conversations with Biden administration officials, I don't think I have had a single conversation with anyone in this administration that has not included—and often led with—the pursuit of health equity as a priority. President Biden is walking the talk on health equity. The optimist in me wants to say that we will be seeing progress. … I am excited by the policy initiatives we are seeing coming out of this administration," he said.
Data analysis finds the male-female gender pay gap for physicians accelerates in the first 10 years of practice.
Through a simulated 40-year career, male physicians earn an average adjusted gross income that is about $2 million higher than female physicians, a new study found.
Earlier research has shown a persistent gender pay gap in physician compensation. Other recent research indicates that bias impacts job satisfaction for female physicians and medical researchers.
The new study, which was published today by Health Affairs, is based on data collected from more than 80,000 full-time physicians. Physician characteristics and annual income data were collected from Doximity, an online professional network for physicians. The study includes data collected from 2014 to 2019. Income was adjusted for factors that could impact compensation, including hours worked, clinical revenue, practice type, and specialty.
The study features several key data points.
On average, male physicians had higher income ($42,454 difference) than female physicians in the first year of practice. The gender pay gap increased in the first 10 years of practice then remained stable thereafter. On average, male physicians earned $90,298 more than female physicians in the 10th year of practice.
In the first year of practice, the gender pay gap was similar for primary care and other specialties: the adjusted income difference between male and female physicians was $18,245 for primary care, $19,150 for nonsurgical specialties, and $21,999 for surgical specialties. By the 10th year of practice, the gender pay gap by specialty had widened: the adjusted income difference between male and female physicians was $30,245 for primary care specialties, $38,611 for nonsurgical specialties, and $54,777 for surgical specialties.
For physicians overall, the 40-year simulated career income for male physicians was $8,307,327 and $6,263,446 for female physicians, for a difference in adjusted income of $2,043,881. The career gender pay gap was lowest for primary care physicians ($917,851) and highest in surgical specialties ($2,481,622).
Several factors likely contribute to the gender pay gap, the study's co-authors wrote.
"Gender bias on the part of employers, structural sexism, compensation models that disadvantage female practice styles, and different expectations of female physicians may be important drivers of the gender differences in income that were observed to start early in women's careers and remain elevated over time. In addition to these more traditional explanations, other explanations may be needed to account for the fact that the gap in salary between male and female physicians widens in the first decade of practice. One possibility is that female physicians are less willing or able to change jobs or practices, limiting their bargaining power for a raise," they wrote.
The study's co-authors offered an explanation for why the gender pay gap accelerates in the early years of practice.
"The observed early acceleration of gender differences in income occurs at a time when many female physicians bear a disproportionate burden of domestic and family responsibilities, such as childrearing, or are facing fertility challenges including fertility treatment. Similar income trajectories have been observed for other highly trained professionals. In these other settings, policies such as family leave provisions and broader coverage of childcare have been linked to reduced gender differences in income," they wrote.
Several mitigation strategies could address the gender pay gap, the study's co-authors wrote.
"Increased salary transparency, protections via laws such as the Massachusetts Equal Pay Act, and systematic measurement and reporting of gender differences in income by organizations could help lessen income differences between female and male physicians. To the extent that gender differences in income early in women’s careers persist throughout their careers, policies that eliminate those differences early on may lead to reduced differences over time as well," they wrote.
The strongest negative predictors of workplace satisfaction among female physicians and researchers were male-dominated culture, lack of sponsorship, and lack of mentoring.
Gender biases negatively affect workplace satisfaction for female physicians and researchers at academic health organizations, a new research article indicates.
Earlier research has established the existence of gender bias against female healthcare staff members. For example, bias experienced by women in medicine includes harassment and discrimination as well as gender wage gaps.
The new research article, which was published by Advances in Health Care Management, is based on survey data collected from nearly 300 women working in medicine. The organizations where the women worked included academic medical centers in 19 states.
The study features several key data points.
The strongest negative predictors of workplace satisfaction were male-dominated culture, lack of sponsorship, and lack of mentoring.
"Queen bee syndrome," in which women are targets of aggression from other women in leadership positions, was also associated with workplace dissatisfaction.
Survey respondents reported the highest degree of agreement about constrained communication. "Most notably, women in our sample reported being mindful of their communication approach when exercising authority (96%); downplaying accomplishments (89%); and exercising caution when self-promoting (87%). Similarly, 68% of participants reported being interrupted by men while speaking," the study's co-authors wrote.
Survey respondents reported several gender gaps. "Women in our sample also reported having to work harder than male colleagues for the same credibility (70%); that decisions in their organization are made by men (61%); and that they have made less money than their male counterparts (66%)," the study's co-authors wrote.
With the number of women enrolled in medical schools exceeding the number of men, addressing gender bias in medicine should be a priority, the co-authors wrote. "As more women enter the field of medicine, identifying and eliminating gender bias is vital to reducing its harmful effects on the personal lives and career trajectory of these women as well as the industry as a whole."
Addressing gender bias
Healthcare organizations can take several steps to mitigate gender bias, the co-authors wrote:
"Institutions should first endeavor to assess bias against their women employees. Using the assessment data on aspects of bias present in their organizations, managers should conduct an inventory of structure, hierarchy, and processes to determine where points of inequity reside."
"To address male culture, institutions should ensure equity in decision-making, alter promotion policies, adjust meeting schedules, restructure the role of the chair, and improve reporting relationships. Organizations will benefit by developing formal career pathways early in the onboarding process and developing communication channels that celebrate achievements of women and men equally."
"By focusing on lack of mentoring and lack of sponsorship, leaders should implement targeted initiatives that support women through formal mentorship as well as advocacy and sponsorship activities while attenuating men's fear or apprehension of mentoring women. Leaders who mentor and sponsor junior women should be rewarded."
"Organizations should communicate clearly that queen bee behaviors will not be tolerated and create safe reporting mechanisms for victims."
Despite its power and pervasiveness, there are practical steps institutions can take to mitigate the impact of male-dominated cultures on female physicians and researchers, the lead author of the study, Amber Stephenson, PhD, MPH, associate professor of healthcare management at Clarkson University, told HealthLeaders.
"Leaders of academic health science environments should first publicly acknowledge the existence of gender bias to begin to challenge deeply established—yet inequitable—social norms. Openly rejecting male-dominated social norms sends a clear message that such practices are not endorsed. Organizations should engage in a deep and honest assessment of the prevalence of male-dominated culture within divisions and departments. Academic medical centers can analyze organizational structures to identify unbalanced power within the hierarchy and assess the representation of women in leadership. They can safeguard equitable decision-making through the establishment of formal processes that include broad stakeholder groups and standardize processes for hiring and promotion," she said.
A lack of women to serve as mentors should not stop organizations from creating and supporting mentoring opportunities for women, study co-author Leanne Dzubinski, PhD, interim dean at the Cook School of Intercultural Studies at Biola University, told HealthLeaders.
"Organizations can sponsor formal mentoring programs for women and find creative ways to support and encourage informal mentoring relationships. Something as simple as providing a monthly lunch meeting to discuss professional development can be highly effective. Additionally, mentoring can happen one-on-one or in small groups. And those relationships could be formally organized or could be encouraged to develop organically through affinity groups such as research support groups. Finally, women can benefit from female mentors who have successfully navigated issues unique to women. Male mentors can also be beneficial as they may have better access to institutional knowledge and resources, and they may be better positioned to act as a sponsor," she said.
There are several ways that organizational leaders can help female physicians and researchers be heard and acknowledged, study co-author Amy Diehl, PhD, chief information officer at Wilson College, told HealthLeaders.
"First, help women with self-promotion by soliciting reports of their achievements and by naming and celebrating accomplishments in meetings and other public forums. Second, to combat interruptions, meeting organizers can set a 'no interruptions' rule for meetings. When interruptions happen, the facilitator should intervene: 'Julie was speaking, let's let her finish her thought.' Last, train your entire staff on bystander interventions. For example, when women are ignored or their ideas are stolen, meeting facilitators and bystanders can help by calling it out: 'Aisha just mentioned that idea, let's hear her thoughts,'" she said.
HealthLeaders talked to several health system and hospital executives who identified three primary challenges in their behavioral health programs. They struggle with inadequate reimbursement for behavioral health services, patient access, and workforce shortages of psychiatrists and other behavioral health professionals.
Sabina Lim, MD, MPH, system vice president for behavioral health safety and quality at Mount Sinai Health System in New York, says inadequate reimbursement has far-reaching consequences. "One of the biggest challenges is the lack of appropriate reimbursement for behavioral health services. In many ways, this challenge drives a lot of the other issues. Most behavioral health providers are under-reimbursed. That affects the ability to attract workforce, which affects access issues."
Wayne Sparks, MD, senior medical director of behavioral health services at Atrium Health, says meeting the demand for patient access is a daunting challenge. "For us, the biggest challenge is access for patients to get care. We know there are many people dealing with mental health issues, and that has been on the rise even before the pandemic. One in five American adults have a diagnosed mental illness, and about half of those with chronic mental illness start before the age of 14. So, we are trying to do more to provide screening and access."
The shortage of psychiatrists is acute, he says. "There is a shortage of about 25,000 psychiatrists in the country. An amazing stat is that about 60% of practicing psychiatrists are over the age of 60. That is a frightening stat."
Behavioral health nurses are also in short supply, says Christian Thurstone, MD, director of behavioral health at Denver Health. "On the inpatient side, there are staffing shortages particularly with respect to nurses. We have 57 beds on the adult side, and our average daily census for the year is at about 41, but that is only because of staffing. If we were fully staffed, we believe we would fill all 57 beds every day. The challenge of hiring nurses and retaining them has been considerable and has limited our census."
While these challenges exist, the health system executives also shared insights about how they solved these three top issues at their organizations.
Address inadequate reimbursement
A primary strategy to address inadequate reimbursement of behavioral health services is subsidization, says Doug Henry, PhD, vice president of the Allegheny Health Network Psychiatry and Behavioral Health Institute.
"What we do is rely on the generosity of our network and our enterprise, which is Highmark Health. AHN and Highmark recognize that underdiagnosed and undertreated mental health disorders are a great burden on the community. They contribute negatively to overall medical spend and community unwellness. Our health system is willing to accept losses in behavioral health for a larger cause, which is community wellness. It is both good business for the health network and good dedication to the community," he says.
Lim says subsidization is critical to keep Mount Sinai's behavioral health programs running. "We need to continue to be subsidized because our health system is heavily invested in behavioral health. They believe it is the right thing to do. Behavioral health needs keep growing and growing. So, the health system is invested, but it puts pressure on other parts of the health system. We have about a $200 million budget. We are close to meeting our direct costs, but the indirect costs are subsidized substantially."
Subsidization is necessary because patient revenue does not cover the costs of all behavioral health services, Sparks says. "We do get subsidy from the overall system because if we only relied on patient revenue, it would not cover what we are doing."
Even in a good financial year, subsidization is required, says Thurstone.
"As a department, we are typically budgeted to lose about $4 million. This year, we will lose much less than that. I attribute a lot of this performance to the increase in telehealth and the increase in demand. For example, our outpatient visits are up 30%, and we attribute that to COVID and telehealth, which leads to fewer no-shows. Our inpatient child unit has been running at capacity because of COVID demand. We are not making money for the hospital system, but we are losing a lot less money than we were budgeted to lose. We were budgeted to lose about $4 million, and we will probably lose about $1.5 million," he says.
Optimizing revenue cycle helps to ease financial losses in behavioral health programs, Lim says.
"Behavioral health finances are complicated—they are often paid under different payment systems. We have many codes that are difficult, and there is a tremendous variation in the types of codes. So, we have worked over the past eight years to dive deeply into revenue cycle. We have decreased our inpatient denials and outpatient denials by huge percentages. We have focused heavily on how we can make sure that we are correctly sending out our bills and making sure that we appropriately advocate and fight for all inappropriate denials. The revenue cycle work has been tremendously helpful for us not only to increase our bottom line but also to think about how we do work and how we do work more efficiently," she says.
Behavioral health programs can also address financial losses by cobbling together sources of financial support, Henry says.
"As administrators, we hustle hard to braid public and private financing. This includes grants from the federal government, grants from the counties, and grants from the state. We combine these grants with private funding, which includes foundation funding such as private foundations that support programs in the schools. We braid these funds with third-party insurance revenue in ways that allow us to build sustainable programs," he says.
Philanthropy is a significant source of financial support for behavioral health services at Denver Health, Thurstone says. "We have gotten several private foundation grants recently to expand services related to infant mental health and substance treatment. Everybody seems to be talking about behavioral health. It is a hot topic, and that has created some philanthropy dollars that have helped us expand as well as cover some of the financial gaps. These grants have been about $2 million over the past two years."
Grant funding and philanthropy have bolstered the finances of Atrium Health's behavioral health services, Sparks says.
"Financially, we have been able to leverage our ability to get some innovative programs started with grant funding. There has been a snowball effect with one of our funding sources—The Duke Endowment. It seems that once you get a good program going, they want to hear more. This is how we got a virtual patient navigation program started. When we get programs started with grant funding, we can share our data with our overall organization, show benefits, and get the support to continue. We also rely on philanthropy. Our foundation has been successful getting donations from the community. We recently got a $350,000 donation from a former patient's family because of their experience and how well the patient did," he says.
Financial losses at behavioral health programs need to be viewed through a broad lens, says Ruth Benca, MD, PhD, professor and chair of the Department of Psychiatry at Atrium Health Wake Forest Baptist.
"The big picture is about the overall medical spend. It is not just about what psychiatry can do to make money. It should be about how we can provide cost-effective mental healthcare that is going to improve the overall health of our population. We know that poor mental health contributes to poor physical health and disability, and that is what is costing us billions and billions of dollars," she says.
Behavioral health programs reduce the total cost of care at health systems, Sparks says.
"As an organization and as a service line, rather than focusing on the revenue bottom line we have tried to focus on how the behavioral health program fits into the larger health system. In an organization like ours, we have been focusing as much as we can in moving toward a population health model and value-based model. We know that you really cannot do a population health model without significant behavioral healthcare. We have tried to look at finances in that way—not looking at how much behavioral health is bringing in but how much we are able to lower the overall cost of care for patients," he says.
Improve patient access
A primary strategy for addressing patient access is integrating behavioral health into specialty practices—particularly primary care, Henry says.
"We put behavioral health professionals and psychiatrists into primary care practices and other medical subspecialties. We began doing that in 2019 and have just completed our 75th integrated practice. So, just in the past couple of years, we have added 75 new access points for behavioral health services in Western Pennsylvania. Fifty of those sites are primary care practices, and 25 are other medical subspecialties such as pain, neurology, endocrinology, gastrointestinal, orthopedics, and oncology," he says.
Integrated behavioral health can be achieved by utilizing social workers, says James Kimball, MD, a psychiatrist at Atrium Health Wake Forest Baptist. "Essentially, we are reaching out to primary care practices through a social worker. The social worker is doing some basic counseling with patients and doing depression and anxiety ratings scales. A psychiatrist will supervise them and advise the primary care clinician on possible medication options for the patient in a way that can better manage depression and anxiety."
Atrium Health has established a virtual behavioral health integration program, which operates in about 60 of the health system's 200 primary care practices, Sparks says.
"The primary care provider can connect with our team virtually, and a licensed clinician will evaluate a patient in the office at the time of the primary care visit. Then patients can connect with services through our program. The primary care clinician can connect on the spot with a provider such as a psychiatrist or an advanced practice provider to get recommendations for any medications or any revisions of medications," he says.
The virtual behavioral health integration program has performed well on key metrics, Sparks says. "We have had a significant decrease in patients coming to our emergency department and going into the hospital because of this program. It has been about a 25% reduction in avoidable inpatient stays and about a 13% reduction in emergency care."
Opening new facilities is another strategy to address patient access.
Mount Sinai is planning to open a new comprehensive behavioral health center in Lower Manhattan next year, Lim says. "We basically are creating a wide continuum of behavioral healthcare in one building. We will have inpatient services, intensive outpatient services such as partial hospitalization, and crisis and respite beds where people can stay seven days a week if they are experiencing a behavioral health crisis."
Mount Sinai is also set to open a new behavioral health ambulatory center in Uptown Manhattan that will include adult and child psychiatry clinical services as well as a partial hospitalization outpatient program, she says.
The metrics for evaluating the new facilities will include the impact on psychiatric hospitalizations and quality-based measures such as suicide prevention, Lim says. "It is extremely difficult, but we are always aiming for zero suicides. We will also be looking for decreased no-shows and increased visits."
AHN is opening several community mental health centers, says Henry.
"Our approach is neighborhood-centric. That is harmonious with Allegheny Health Network's overall strategy of serving neighborhoods instead of building large medical centers in urban areas. We heat-mapped the points of most frequent origination for more acute psychiatric needs. We did this by ZIP code, and we dropped outpatient and intensive outpatient behavioral health clinics into regions that had the highest frequency of need. We have opened three clinics in the past year using that methodology. We will open three more clinics next year, and we will open three more in 2023," he says.
Shore up workforce shortages
Compensation is a primary strategy to address workforce shortages, Henry says.
"Several years ago, we designed a new compensation plan that set a productivity target for our physicians. Beyond that productivity target, physicians can keep 100% of the average net revenue that we bring in for their efforts. For example, if somebody has a large student loan burden, they can work a little extra and it absolutely gives them an opportunity to make more money," he says.
Allegheny Health Network has also raised base compensation for psychiatrists, says Anthony Mannarino, PhD, vice chair of the AHN Psychiatry and Behavioral Health Institute. "Our base compensation for psychiatrists has risen over the past five to six years. Ten years ago, it was much lower than it is now. We have tried very hard to look at the benchmarking standards to make sure that our base salary is as competitive as possible to recruit and retain physicians."
At AHN, a base salary is about $225,000 for an outpatient psychiatrist and $240,000 for an inpatient psychiatrist, Henry says.
Denver Health is looking for ways to decrease pressure on nursing resources, Thurstone says. "I have asked my team about whether anyone has seen other staffing models that utilize licensed practical nurses or behavioral health technicians to the maximum of their potential. I also have asked whether there is a way to protocolize care on our inpatient units so that we could utilize behavioral health technicians more. I am looking for staffing models that are not as heavily dependent on registered nurses."
Atrium Health Wake Forest Baptist has adopted a team approach to behavioral healthcare to address staffing shortages, Benca says. "One of the ways that we are addressing not having enough psychiatrists is developing treatment teams. The idea is to have several mental health providers all working up to the highest level of their license. By having teams that include nurses, mental health workers, psychologists, social workers, and psychiatrists, we can start to provide different levels of care to patients and move them up the ladder as needed. It also allows us to provide more cost-effective care to patients."
Atrium Health is trying to boost its number of clinicians through internal training, Sparks says.
"Five years ago, we started a residency program, so we are trying to build our own pipeline of residents. We also have built an advanced practice provider fellowship. This is for nurse practitioners and physician assistants who have finished their training but have decided that they want to focus on behavioral health and psychiatry. They come for a year with us as a fellow. They are employees, so they see patients with guidance similar to a residency program. Over the eight years of the program, we have retained 75% of the fellows to be a part of our workforce," he says.
There is a key metric for staffing success, Sparks says. "It is mainly the ability to keep our programs going. If we can keep our programs fully staffed and move to a point where we can expand services, then we feel we have been successful."
In 2020, the primary feelings healthcare professionals reported about the coronavirus pandemic shifted from fear to fatigue.
A new research article shows healthcare professionals (HPs) on the frontlines of the coronavirus pandemic in 2020 experienced significant levels of moral injury.
"Moral injury is emotional distress resulting from events or transgressive acts that create dissonance within one's very being due to a disruption or violation of their existential orientation and values system," the co-authors of the research article wrote. Moral injury has been associated with clinician burnout, medical errors, and suicidal thoughts.
The research article, which was published by JAMA Network Open, is based on survey data collected from more than 1,300 healthcare professionals in 2020 before vaccinations for COVID-19 were available. The surveys were conducted in two phases from April 24 to May 30, 2020, and Oct. 24 to Nov. 30, 2020. The surveys included a half-dozen open-ended questions such as, "What has been your greatest source of fear during the pandemic?" Survey respondents included nurses, physicians, advanced practice practitioners, and chaplains.
The research article features several key findings.
Stressors during the first year of the pandemic included fear of contagion, stigmatization, short-staffing, and inadequate personal protective equipment
Fear was the primary emotion experienced in phase 1 of the study
Fatigue was the primary emotion experienced in phase 2 of the study
Survey respondents reported feeling isolated from non-healthcare professionals
Survey respondents reported feeling alienated from patients
Survey respondents reported feeling betrayed by coworkers, administrators, and the public
"These findings suggest that HPs experienced moral injury during the COVID-19 pandemic. Moral injury was not only experienced after a single moral dilemma but also from working in morally injurious environments. These experiences can serve as potential starting points for organizations to engender and enhance organizational and individual recovery, team building, and trust. System-level solutions that address shortages in staffing and personal protective equipment are needed to promote HP well-being," the research article's co-authors wrote.
Shifting from fear to fatigue
The primary emotions that HPs experienced shifted from phase 1 to phase 2 of the study.
"In phase 1, most participants expressed fear and uncertainty about the virus itself and its societal consequences. Fears were predominantly associated with 'catching the virus' and becoming ill and/or 'spreading it' to friends, family, and patients. Some referenced fear of COVID-19 transmission to higher risk people, such as pregnant people, older people, and/or those with other medical comorbidities," the co-authors wrote.
The availability and effectiveness of personal protective equipment (PPE) was another source of fear during phase 1 of the study. "We just all assume that we will get sick or have asymptomatic COVID at some point," one survey respondent wrote.
Fatigue supplanted fear in phase 2 of the study.
"In phase 2, most participants stated that as there was more knowledge about COVID-19, there was a decrease in fear: they were 'over it' and experiencing 'COVID fatigue.' There was also resignation around adapting to 'the new normal,'" the co-authors wrote.
By phase 2 of the study, fear associated with PPE dissipated, the co-authors wrote. "In phase 2, many respondents stated that as their PPE became more available with better protocols in place, their fear is gone and replaced with exhaustion."
Isolation and alienation
In both phases of the study, survey respondents reported feeling distrustful and afraid of others such as patients and coworkers. "I don't know that others are taking it as seriously as I am," one survey respondent wrote.
Some survey respondents wrote that family, friends, and community members had become afraid of healthcare workers, with one survey respondent writing that conducting errands while wearing scrubs had to be avoided because of the stigma associated with being a healthcare worker.
Isolation and withdrawal were reported by several survey respondents. "Some people isolated and withdrew physically from others 'for fear of infecting them or exposing them to this as every day I feel that I am a carrier' (respondent 8). They also withdrew emotionally, often assuming other people did not know what they were going through. People felt isolated from their community due to politicized discourses circulating on social media on social distancing protocols, such as wearing masks, especially after having 'dealt with death or even just the difficulty of caring for these patients' (respondent 9)," the co-authors wrote.
Survey respondents reported feeling isolated from patients. "The use of PPE and social distancing measures in patient care contributed to isolation from patients, with HPs feeling as if they were providing suboptimal care. As essentialized by one respondent, 'We can't build a connection with our patients because we can't spend the time to really care for them the way they deserve to be cared for' at the bedside (respondent 14). Many lamented the use of telehealth in clinics and loss of 'the true connection,' finding telehealth to be 'dehumanizing and disjointed' (respondent 15)," the co-authors wrote.
Feelings of betrayal
In phase 1 of the study, the lack of PPE fed a sense of betrayal among some survey respondents. "I felt like our lives were more disposable than our PPE was," one survey respondent wrote.
Some survey respondents still felt betrayed over PPE in phase 2 of the study. "We've just gotten better at protecting ourselves. Our hospital doesn't do a lot for us," one survey respondent wrote.
The feeling of betrayal came from several sources, the co-authors wrote. "HPs felt betrayed and unsupported by management, administrators, institutions, the healthcare system more broadly, and the government. Many pointed to a disconnect between leadership and 'those of us in there doing the hard work.'"
The combination of fentanyl and the coronavirus pandemic have become primary drivers of overdose deaths in the United States.
With overdose deaths reaching a historic level, the co-founder and CEO of a substance abuse treatment organization says medical interventions must be the top priority.
Earlier this month, the Centers for Disease Control and Prevention reported that provisional data show 100,306 overdose deaths occurred in the country in the 12-month period ending in April, representing a 28.5% increase over the overdose deaths that occurred during the same period the year before. The data show opioid overdose deaths increased by nearly 20,000.
Under the circumstances, medical interventions to reverse overdoses are crucial, says Nicholas Mathews, co-founder and CEO of Agoura Hills, California-based Stillwater Behavioral Health.
"This might get into a taboo conversation, but we are at a place, with the deaths of more than 100,000 people in 12 months, where I'm not too concerned about hurting people's feelings. The harm reduction conversation is one that we need to have as a society. What that means is making sure that when, not if, people overdose by using narcotics, we as a society are prepared to help them," he says.
Medications are available to reverse opioid overdoses, and individuals should be prepared to administer them, Mathews says. "Treatment is a long-term proposition. When someone is overdosing, that is a medical emergency, and there are life-saving drugs on the market. There are nasal sprays that can reverse an opioid overdose immediately and save someone's life. I constantly encourage people, if you are in a community where overdoses are happening more and more frequently, get certified on the administration of Narcan—have Narcan readily accessible and available."
Hospitals have a key role to play in the overdose crisis, he says. "Case management departments in hospitals can have resources available for somebody post-overdose if they make it to the emergency room. Hospitals can make sure that all emergency room staff and emergency medical technicians are trained on the administration of Narcan. They can make sure that Narcan is available at all times in the ambulance and at the hospital, so that they can bring somebody back from an overdose."
After patients have been medically stabilized following an overdose, hospitals should be prepared to refer them for follow-up services, Mathews says. "There should be referrals to an addictionologist, to methadone clinics, to intensive outpatient programs, to residential detox programs, and to something as basic as an Alcoholics Anonymous meeting. An AA meeting can show these people that there is light at the end of the tunnel and there are resources to get help."
Why overdose deaths are soaring
Although the cause of the spike in overdose deaths is multifactorial, Mathews says two primary factors stand out.
1. Increased abuse of fentanyl: "The first and most obvious factor is we have a meteoric rise of the new opioid fentanyl, which is 100 times more powerful than morphine. There are many instances of accidental overdose—even by people who did not know they were taking fentanyl. They think that they are taking something else, but it is fentanyl disguised. It is insidious," he says.
The increased abuse of fentanyl is the result of a "logical progression" in the human body's ability to build tolerance to opioids, Mathews says.
"For individuals who have a physical addiction to opioids, tolerance starts with taking more and more of the drugs. Then it moves to taking opioids in a different way such as crushing pills and snorting them. There is always a point where that particular substance stops giving the addict the desired effect. So, people find the next best thing. For a long time, that process ended with intravenous heroin abuse—that was the most powerful opioid that was readily available. Now, there is fentanyl, which makes traditional heroin seem safe," he says.
2. Strain of the coronavirus pandemic: "The pandemic has been very depressing and anxiety inducing. For many people, their livelihood has been at risk, and they did not know what their future was going to look like. People had anxiety just going to the grocery store—they feared catching COVID-19 and giving it to their family," Mathews says.
For many people, the temptation to self-medicate during the pandemic has been overwhelming, he says.
"Anxiety is a powerful motivator when it comes to a desire to escape, whether that is a beer, or a pill, or smoking a drug. Whatever it is, these drugs will do exactly what they are supposed to do and alleviate anxiety. With the coronavirus pandemic, I have never seen such a clear-cut example of society-induced anxiety. All at once, everybody walked into a new environment. We did not have the tools to cope. We did not know what was safe. There has been misinformation and the lack of information. On top of those factors, everything was closed down. So, you take people who are riddled with fear, and they are stuck in their homes. They could not even get out and see family. They could not engage in healthy coping skills that could alleviate anxiety such as physical exercise. Once positive coping skills were stripped away, anxiety reached levels higher than we have ever seen before," Mathews says.
Coupling fentanyl with the pandemic has had cataclysmic consequences, he says. "You take people, you stick them at home, you remove their jobs, you increase their anxiety, and you give them the most powerful drug we have ever had. You have a recipe for disaster."
Dartmouth-Hitchcock Health's cancer center has scored at or above the 95th percentile for patient experience by Press Ganey.
For the second year in a row, Dartmouth and Dartmouth-Hitchcock's Norris Cotton Cancer Center has received a national award for exceptional patient experience.
Patient experience is a crucial element in patient-centered care. Key components of patient experience include timely appointments, easy access to information, and good communication with healthcare providers, according to the Agency for Healthcare Research and Quality.
Norris Cotton Cancer Center, which has its main campus in Lebanon, New Hampshire, and five satellite facilities in New Hampshire and Vermont, has earned the Press Ganey Pinnacle of Excellence Award for patient experience for the second year in a row. "To earn that recognition, we had to compete with healthcare institutions nationally—not just cancer centers. Winning the Press Ganey Pinnacle of Excellence Award means that over a three-year period our cancer center scored at or above the 95th percentile in patient experience," says Steven Leach, director of the cancer center.
Norris Cotton Cancer Center excels in several facets of patient experience, he says. "One of the big things we stress is responsiveness—responding to patients as quickly as we can. We let them know that we have their information, that we have them in our electronic health record system, and that we are in the process of scheduling their appointment. Access is important. We have a target to see patients as quickly as possible after diagnosis."
Effective communication with patients is a top priority at the cancer center, Leach says.
"It is important to give our patients an opportunity to communicate. We have several tools that we provide to our patients to help them tell us what matters most to them. For example, we are in the process of rolling out a new digital app called Patient Wisdom, where our patients can pre-populate information about them before a visit. They can share who they are, who their loved ones are, what they do for a living, and what they do for fun. They can share what matters most to them and what they want their visit to focus on. With Patient Wisdom, our physicians and nurses have access to this information, when they walk into the exam room, on a tablet. They literally have in their hands what the patient wants them to know," he says.
The cancer center provides patients with easy access to care, Leach says.
"Another way that we generate a good patient experience at the Norris Cotton Cancer Center is we provide care close to where patients live at one of our six cancer center sites in New Hampshire and Vermont. For many patients, the patient experience also involves having convenient access to multidisciplinary teams. They don't have to drive to one office to see a medical oncologist then drive to another office to see a surgical oncologist. We offer one-stop shopping under one roof," he says.
The cancer center offers many support services, Leach says.
"We also provide extensive patient and family support services that range from disease-specific support groups, to art therapy, to music therapy, to massage therapy, to a whole host of classes, including meditation and cooking. We offer classes in creative writing to help our patients express their ideas and help find their own meaning in what they are going through. In the disease-specific support groups, patients can tap into the collective experience of both fellow patients currently being treated and cancer survivors," he says.
Patients are deeply involved in their care at the Norris Cotton Cancer Center, Leach says.
"We pride ourselves in co-producing a patient's care with the patient and their family. This idea of co-production is that an optimal clinical experience does not involve a unidirectional transfer of information from a physician or a nurse to a patient. Rather, the transfer of information is bidirectional. The real expert in the room regarding the patient's needs and best interest is the patient. So, we listen to our patients," he says.
Measuring patient experience
The cancer center monitors patient experience, Leach says. "We track several metrics for patient experience. Some of them are just simple questions. 'How satisfied are you with your care?' 'Would you recommend our cancer center to a friend or family member?' 'Were you treated as an individual?' Those are the kind of questions that populate our patient experience questionnaires."
Patient experience at the cancer center is also reflected in demand for services and assessments by national organizations, he says. "Part of patient experience is measured in ongoing demand for our services. Reputationally, we rank very high in measures such as the US News & World Report survey. We recently were accredited by the American College of Surgeons Commission on Cancer. Those national surveys and accreditations are based on objective metrics that include patient outcomes and delivery of safe care."
Impact of coronavirus pandemic on patient experience
The pandemic has had significant impacts on patient experience at the cancer center, Leach says.
"There have been periods when we have not been able to invite family members to be in the room with their loved one during visits with the oncologists. Sometimes, that was just heartbreaking, but it was the right thing to do to keep our patients, their family members, and our clinical teams safe. We still have a limited number of visitors, which can be challenging. We also had to switch our entire program of patient and family support services to a virtual format. For more than a year, all of our offerings such as yoga classes, meditation classes, and sessions for music therapy and art therapy were converted to a virtual, Zoom format."
Workforce shortages linked to the pandemic have also affected patient experience at the cancer center, he says. "COVID has led to upheaval in the clinical workforce in healthcare. We are struggling with staffing issues. If not managed appropriately, that can have a negative impact on the patient experience."
Approach to psychotherapy encourages patients to be observant of their thought processes and to focus on values.
Acceptance and Commitment Therapy can help coronavirus "long haulers" cope with the chronic illness, a psychology professor and practicing psychologist says.
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. Coronavirus 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 can also experience several behavioral health conditions, says Joseph Trunzo, PhD, a professor in the Department of Psychology at Bryant University in Smithfield, Rhode Island, and a practicing psychologist at Providence Psychology Services in Providence, Rhode Island. Trunzo is also co-author of a book on coronavirus long haulers—Long Haul COVID: A Survivor's Guide.
"At the top of the list, in no particular order, are depression, anxiety, significant and overwhelming fatigue, and cognitive dysfunction, which is commonly referred to as brain fog. There are rare instances where the behavioral health issues become more significant and problematic, including hallucinations and psychosis, but those are relatively rare," he says.
Brain fog is one of the most common long haul COVID symptoms, Trunzo says. "People do not seem to be processing information as quickly or as easily or, sometimes, at all. They may have short-term memory problems. They are not encoding information in the way that they would normally do. Prior to their COVID infection, they might have been able to read a magazine article and remember and digest it well. After their COVID infection, that kind of comprehension becomes very hard."
Acceptance and Commitment Therapy for coronavirus long haulers
Acceptance and Commitment Therapy (ACT) can ease the burden of long haul COVID, Trunzo says. "ACT is a form of psychotherapy grounded in behavioral science that has a lot of empirical evidence in helping people with chronic illnesses to live as rich and full a life as possible, even though they may be experiencing significant symptoms."
Defusion is one of the primary skills taught to patients in ACT, he says.
"The idea is to separate yourself and be more observant of your thought processes. As human beings, we tend to take whatever we think as gospel truth. So, when the thought pops into your head, 'I'm never going to get better,' defusion is the process of rather than having that thought and accepting it as true, you take a step back and say, 'I just had a thought that I might not get better.' Putting yourself in a more observant stance as to what your thought process is then gives you an ability to make better decisions around how functional the thought really is," Trunzo says.
ACT sets aside the truthfulness of thoughts and focuses on their utility, he says.
"For example, with the thought, 'I'm never going to get better,' ACT is not interested in arguing whether that is true. The only thing that ACT cares about is whether there is any functional value or usefulness to that thought. When you can observe your own thought processes, you can ask yourself whether a thought has functional value or usefulness and decide whether it is worth engaging in those thoughts," Trunzo says.
ACT also focuses on values, he says.
"Values are the things that we find inherently meaningful and important to us. ACT encourages values to be the guideposts for all decision-making. For example, someone could have a value of being close to family and friends. But brain fog makes it hard for them to go to trivia night with friends. Their mind is just not sharp enough. The behavior—going to trivia night—is driven by the value of connecting with friends. Even though someone may not be able to engage with the specific behavior of going to trivia night, there are other ways that they can connect with that value. They can have friends come over to watch a movie or have friends over for dinner," Trunzo says.
ACT can help coronavirus long haulers deal with the loss of control from the chronic illness, he says.
"ACT is an approach to psychotherapy that helps people to deal with situations over which they do not have a lot of control. For people who have long haul COVID, they do not have a lot of control over their symptoms. We do not have a lot of treatments. ACT is a way to help people deal with this kind of a situation. ACT can help people engage in their lives in a way that is still meaningful and can provide enrichment. It can help people move forward rather than having them trapped in the thought, 'I cannot do anything in my life until I get physically better.' ACT can help people break out of that cycle."
