Nashville General Hospital is addressing patient food insecurity and working with faith-based organizations to boost education attainment, health literacy, and healthcare access.
Nashville General Hospital in Nashville, Tennessee, is committed to addressing social determinants of health and health equity.
Social determinants of health such as food security and housing have a greater impact on health outcomes than clinical care. Health equity has become a hot topic in healthcare during the coronavirus pandemic, with the disproportionate impact on vulnerable populations such as African Americans highlighting health inequities in the United States.
The national health inequities during the pandemic have played out in the Nashville area, says Joseph Webb, DSc, MS, chief executive officer of Nashville General Hospital. "We have a marginalized population. We have the disproportionate impact that occurs on certain populations—which has been pronounced during the COVID-19 pandemic. Health disparities seem to surface with any type of epidemic or pandemic particularly as it relates to the marginalized population."
Nashville General Hospital has several programs targeting social determinants of health and health equity, including a "food pharmacy" that addresses food insecurity and an initiative featuring faith-based organizations that focuses on education attainment, health literacy, and healthcare access.
Addressing food insecurity
The Food Pharmacy at Nashville General Hospital provides free food for patients who screen positive for food insecurity. "We realized there were several individuals whose food insecurity conditions were exacerbating their health outcomes," Webb says.
All hospital patients are eligible to receive assistance from The Food Pharmacy, he says. "For each patient that encounters our hospital—whether that contact point is in our emergency room or one of our clinics—a food insecurity questionnaire is administered. If someone indicates that they are struggling with food insecurity based on the questionnaire, then that individual is referred to The Food Pharmacy by their physician. Initially, 12 weeks of free food are provided, then we reassess them for that food need."
The program has improved the survival rate of the hospital's cancer patients, Webb says. "We have a cancer care program here and cancer patients rely heavily on maintaining a certain weight so they can tolerate chemotherapy. Any time cancer patients struggle with food insecurity, it puts them at greater risk of mortality. So, by having this program in place, we have a section of The Food Pharmacy with high-calorie food to keep our cancer care patients healthy and at a certain weight level."
The hospital's director of food services plays a leading role in selecting and supplying the food. The major food bank in Nashville—Second Harvest—also allows the hospital to purchase food at a reduced price. There are several sources of funding that go into purchasing the food, including donations to the hospital's foundation and employee contributions that are earmarked for The Food Pharmacy.
Faith-based initiative
Nashville General Hospital, which is a safety net hospital with 150 inpatient beds, has launched a faith-based initiative to address social determinants of health and health equity called the Congregational Health and Education Network (CHEN). More than 100 congregations are members of CHEN. The hospital's chaplain plays a leadership role in the nonprofit organization and a manager runs the program.
There are three pillars at CHEN, Webb says. "Number One is education attainment because we believe that there is a strong correlation between education and all of the other social determinants of health. If you can impact education, you can typically impact income, housing, and other social determinants of health. The other two pillars are health literacy and access to healthcare."
CHEN has multiple approaches to boosting education attainment, he says. "CHEN has aligned with our health sciences program here at the hospital. We have several educational programs that produce graduates. For example, we have radiology technologists and certified nursing assistants. We teamed up with CHEN and the state in a workforce development program. In addition, CHEN has gotten awards for scholarships that are distributed to congregation members."
The hospital has held health literacy forums for CHEN members and there are materials that go out to the church networks for addressing health literacy. Webb calls health literacy a "silent giant" in health disparities.
"Health literacy is the ability to take the information that is being provided to you by a healthcare provider, interpret that information, and apply that information to your condition. If you can do that, you are health literate. If you cannot do that, then there is a risk that when you go home you will do almost none of what you were instructed to do. If you are not carrying out what you were instructed to do, that is a disparity," he says.
Within the healthcare access pillar, CHEN is making sure that individuals understand that they have access to healthcare and that healthcare is available to them regardless of their ability to pay, Webb says.
"For us, it is much more cost-effective and effective in terms of health outcomes if we can get you into our ambulatory division and start providing care to you before you get into crisis and must come into the emergency room or go to the ICU, which is where the cost in healthcare starts to spiral. We see providing care access as a way of controlling costs; and as a safety net hospital, it is cost avoidance. Any time we can engage in cost avoidance, those are dollars we can use for other efforts," he says.
The hospital provides financial counseling to patients. For patients who are uninsured, the hospital tries to enroll them in health plans such as Medicaid. "After we exhaust all opportunities to get them under some kind of coverage, then we will put them into our charity program."
The health equity challenge
Health equity poses a daunting challenge for U.S. healthcare, Webb says.
"We are not going to cure health inequities until there is a more equitable distribution of the social determinants of health. Social determinants of health are the drivers of health inequities and health disparities. If we cannot address this maldistribution of social determinants of health, how then are we going to ever address health equity?" he says.
It is going to be hard to address health equity without universal health coverage, Webb says.
"There is no magic wand that you can wave so that everyone is going to have equity in healthcare. That is not going to happen because the national, state, and local policies are never politically going to get to the point where they create a completely equitable healthcare system. The issue is that healthcare in this country is not a right. That creates the framework for how we execute healthcare delivery in this country. There is no mandate that everyone has healthcare. So, we have that disparity and inequity to begin with at a national level."
To eliminate health disparities, health systems must be able to capture how patients self-identify and how they are experiencing health outcomes differently.
To address health equity, health systems need to improve the collection, storage, and processing of patient data, according to Kedar Mate, MD, president and CEO of the Institute for Healthcare Improvement.
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.
Mate has made addressing health inequities a top priority at the Boston-based Institute for Healthcare Improvement (IHI). He recently discussed the importance of data in the effort to ameliorate health inequities with HealthLeaders. The following is a lightly edited transcript of that conversation.
HealthLeaders: Why is data a key component of addressing health equity?
Kedar Mate, MD: In any kind of improvement work, it is difficult to improve what you cannot measure. That holds as much for equity concerns as it does for other areas of quality. Local data on disparity and inequity is often gathered poorly.
For example, there is a recent Government Accountability Office report about the understanding that we have about the race and ethnicity of the people who are affected by COVID and those who have received a single dose of the vaccine. We only have the data on about 47% for each of those two measures—the data on the race and ethnicity of the individuals who have been infected or received a single dose of the vaccine. For the majority of the records that we have around this incredible public health emergency, we still only have less than half of the available information about how this pandemic has been affecting our communities and how we have been responding to them.
HL: What kind of data is critical for addressing health equity?
Mate: The data that are important are the characteristics that people self-identify that matter to the health concern that we are talking about. In certain circumstances, the race of a patient might matter. There may be Black versus White differences or Hispanic versus White differences that matter. In other circumstances, rural versus urban residence of the patient might matter. In other circumstances, whether the patient has a disability might matter.
HL: Why do health systems need a data infrastructure to address health inequity?
Mate: Health systems need a data infrastructure to address health equity, but it is a broader consideration than that. Health systems need data infrastructure to create improvements in health and health outcomes. Health systems have known this for a long time, and they have been operationalizing a data infrastructure to help improve health, healthcare, and healthcare quality for many years. We are adding to that a layer of understanding of the individual that is deeper and richer than we have had historically.
We have often taken in information and understanding about the system itself and the system properties and outcomes. We are adding to that an understanding of how people experience their care differently and how people are experiencing health outcomes differently. We are not seeking wholesale changes of the data infrastructure, nor I am suggesting that we must add a tremendous amount of change at a time when health systems are incredibly stressed. But we must leverage the existing data infrastructure and coach it to collect more information to help understand who is affected and how they are affected differentially by our healthcare and our health systems.
HL: How can health systems go about creating this new layer of data infrastructure?
Mate: A lot of what IHI has learned in our Pursuing Equity program is there is a tremendous amount of work that health systems can do to improve their information technology data collection systems to help guide them to capture the necessary information. A big part of this is prioritization. Healthcare informatics teams are probably some of the most stressed teams inside of a health system. They are constantly being asked to attend to myriad concerns and considerations.
If a health system makes health equity a strategic priority, then we must ensure that healthcare informatics teams are rating the work on health equity appropriately on the long list of the things that they face. If the health system makes it a priority, it should be a priority for the data teams. We must give our data teams and clinicians the tools to ask patients how they self-identify such as race, ethnicity, language, and gender identity. We must give our clinicians and the other people who are meeting patients the necessary tools to ask patients how they self-identify.
We must have a place for clinicians to easily report the answer to these questions. So, when someone is asked a question about how they self-identify, it must be placed in a prominent location in the record, so that people can see it, understand it, and use that information.
Lastly, we must have teams within the organization that are prepared to use the data to take action. One of the observations that we made in our Pursuing Equity work is that the teams that tended to respond to the information the best were either the quality improvement team or the population health team. They are responsible to take action. They need to look at the data, process the data, pick some priorities, then take some action.
The new behavioral health unit is designed to meet both the medical needs and the mental health needs of patients.
A Shreveport, Louisiana-based behavioral health hospital has opened a 30-bed unit for coronavirus-positive patients who need immediate behavioral health care.
Most acute care hospitals are not equipped to treat behavioral health patients who also have a COVID-19 diagnosis. With the coronavirus pandemic's Delta variant surge and Hurricane Ida's aftermath, acute care hospitals in Louisiana are struggling to find enough inpatient beds to treat patients.
In January, a joint venture between Plano, Texas-based Oceans Healthcare and Ochsner LSU Health Shreveport opened a new 89 bed behavioral health hospital—Louisiana Behavioral Health. Oceans Healthcare operates several behavioral health hospitals in Louisiana, Texas, and Mississippi.
Early this month, Louisiana Behavioral Health established a 30-bed unit for behavioral health patients who also have a COVID-19 diagnosis. The new behavioral health unit meets a critical need, says Stuart Archer, MBA, CEO of Oceans Healthcare.
"When you take a behavioral health patient who has a unique set of needs and on top of that has an active COVID diagnosis, you have a patient who needs a special inpatient unit. Historically, these patients would be stuck in an emergency room for days or weeks. Or they could take a bed in an inpatient medical unit. There really wasn't anywhere to move that patient," he says.
The new behavioral health unit gives patients access to both mental health care and COVID-19 care, Archer says.
"Most behavioral health hospitals in Louisiana and nationally are designed with semi-private settings to improve socialization and help people as they go through their treatment. So, most behavioral health hospitals are a very hard place for a patient with an active COVID diagnosis simply because of the precautions that must be taken. You do not want to make other patients sick. It has been tough to take an active COVID psych patient on a behavioral health unit. By opening this specialized unit, we can address both needs of the patient. We can address their COVID diagnosis in a way that does not make others sick, and not delay treatment for their behavioral health condition," he says.
The new behavioral health unit is equipped to treat patients with a COVID diagnosis, Archer says.
"All of the infectious disease protocols and standards are followed on the unit, and they are similar to what you would see on any other active COVID unit. The nurses and other caregivers have the appropriate personal protective equipment. So, we have a strong behavioral health component on the unit along with a strong medical component. Patients are seen by both a medical physician and a psychiatrist during their stay. Their medical condition is monitored closely," he says.
Most hospital are not equipped for these kinds of patients, Archer says.
"When you add a COVID diagnosis on top of a behavioral health diagnosis, historically there have been very few beds for those types of patients. These patients have been stuck in an ER or they were put on a medical unit where their COVID diagnosis could be monitored but there were few resources for their behavioral health diagnosis. Under those conditions, the patients' behavioral health condition worsened while they were inpatients receiving treatment for COVID. Our unit is equipped to address both issues simultaneously," he says.
The benefits of Cleveland Clinic's internal coaching programs include professional development, employee retention, and reduction of burnout.
Cleveland Clinic has robust coaching programs for the Cleveland-based health system's physicians.
Coaching programs can help health systems address physician wellbeing and retention. The coaching programs at Cleveland Clinic are credited with helping the health system avoid $84 million in physician turnover costs over the past decade.
Cleveland Clinic has two programs that provide coaching services to physicians. The Center for Excellence in Coaching and Mentoring provides physician peer-based coaching. The Mandel Global Leadership and Learning Institute (GLLI) provides non-physician coaches for physicians.
"We have two core components. The Center for Excellence in Coaching and Mentoring is physician-led peer physician coaching. The Mandel Global Leadership and Learning Institute features coaches who are not physicians; however, 60% to 70% of the people we coach are physicians," says Ashley Villani, MBA, senior organization development consultant at GLLI.
The programs work in concert, she says. "The intentionality around it is that the programs collaborate with one another. I collaborate with the Center for Excellence in Coaching and Mentoring to complement and align our coaching initiatives. We align our training for both our physician coaches and non-physician coaches, with the idea to not compete with one another because we are here for the same reason—to provide coaching for all caregivers and physicians."
Villani says GLLI has 42 non-physician coaches, which are drawn from two sources. About half of the coaches are leaders in the institute or organization development consultants at the institute. The other half of the coaches are "enterprise coaches," she says. "Those are formal or informal leaders in the enterprise who went through the same training as all of our other coaches. Examples are chief nursing officers, executive directors, chief operating officers, and human resources senior directors."
Coaching benefits
Physicians and physician coaches generate several benefits from being involved in the coaching programs, Villani says.
"Physicians benefit from coaching by having dedicated time to pause and focus on their own development with a confidential thought-partner. An example of a benefit is increased resilience during times of change. Additionally, participants have reported increased leadership role consideration and attainment as a result of their participation, as well as increased academic output, including grants, publications, and presentations," she says.
The coaching programs also reduce physician burnout, Villani says. "Our coaching programing drives fulfillment and satisfaction as well as increasing resilience and a sense of relationship for participants. These are components of wellbeing that can mitigate burnout."
The coaching has been linked to increased physician engagement, which helps address burnout, she says. "When engagement increases, wellbeing often increases, and burnout likely decreases."
Physician coaches benefit from their coaching, Villani says.
"It's been found that the physicians who coach other physicians get as much value from the experience as those they are coaching. Additionally, they report using the skills across contexts outside of the formal coaching with colleagues, patients, and at home. Coach training surveys in 2019 showed a 62% increase from pre-to-post training in their ability to apply coaching skills in daily interactions with colleagues, a 58% increase with patients, and a 55% increase in their personal lives," she says.
Physicians have cited the coaching programs as part of the reasons why they decided to stay at Cleveland Clinic, which helped the health system avoid millions of dollars in turnover costs over the past decade, Villani says. The avoided costs include recruitment costs, onboarding costs, and training costs, she says.
Boosting physician retention also avoids the opportunity costs associated with filling a physician position, Villani says. "It takes time to recruit a new physician. Especially with the nature of our academic medical center, there are unique medical specialties, and it can take a long time to replace a physician."
Advice for establishing internal coaching programs at health systems
Establishing internal coaching programs at health systems requires an intentional effort, Villani says. "Implementing an internal coaching program and a coaching culture is a journey. It is important to understand the organization's perception of coaching prior to implementing a formal coaching program, to identify what you want the coaching program to be known for, and to use this information to inform the creation of a realistic implementation plan unique to the organization."
She says health systems should be mindful of several other considerations when establishing internal coaching programs.
Obtain support from the highest levels of leadership that coaching is valuable
Provide recognition for those who serve as coaches to maintain engagement of the coaches and to drive acknowledgment from the organization that coaching is a valuable offering
Understand the needs of your employees with a needs assessment and recognize that needs may vary based on roles within the organization
Promote a coaching culture where coaching is seen as a positive way to support personal and professional development
Make sure employees know that coaching is available and know how to request a coach
Ensure that employees know the difference between coaching and mentoring—coaching includes focusing on reflection and building upon an employee's personal assets, whereas mentors can offer employees advice
Telediagnosis on the grand scale experienced since the beginning of the coronavirus pandemic is an evolving science, researchers find.
More research is necessary to ensure diagnostic quality and safety in telemedicine, a new report published by the Society to Improve Diagnosis in Medicine (SIDM) says.
Telemedicine utilization has expanded exponentially since the beginning of the coronavirus pandemic. As noted in the new report, most research on telemedicine has focused on the maintenance health, but the use of telemedicine for telediagnosis at a grand scale is not as well understood.
The new report, which is based on information collected from healthcare organizations, clinicians, vendors, and patients, includes several key findings.
Remote patient monitoring is "an important enabler of continuity of care and patient support" in telemedicine that can facilitate diagnostic quality and safety.
Many clinicians interviewed for the report said that the skillset necessary for a good diagnosis in an in-person visit is similar to the skillset necessary to make a good telediagnosis.
Clinicians reported that a primary barrier in telediagnosis is the inability to perform a physical exam.
A crucial area for more research is in determining when a virtual visit is appropriate and when an in-person visit is necessary.
Many patients interviewed for the report had developed their own triage framework for determining when a telemedicine visit is appropriate. For example, patients said they would be comfortable with a telemedicine visit to assess familiar symptoms such as a recurring earache.
Insights from the report
Remote patient monitoring has significant potential to improve telediagnosis quality and safety, Suzanne Schrandt, JD, a co-author of the report and senior patient engagement advisor at SIDM, told HealthLeaders.
"We talked with a number of folks involved in remote patient monitoring, including vendors and clinicians who use those services. It seems to have a great deal of promise, particularly for early detection in an otherwise healthy person who has new symptomology or in a person with an underlying health condition who starts to see some worrisome changes," she said.
Remote patient monitoring can also boost patient engagement, Schrandt said. "One of the things that jumped out to me is there seems to be some value from remote patient monitoring in keeping the patient engaged and active in their own care. Patients can be aware of their own symptomology, vital signs, and any other measurements that are captured."
The inability to conduct a physical exam can be problematic in telediagnosis, she said. "What we heard from the 50 listening sessions is that the most important thing is the presenting symptoms. Clearly, there are some symptoms that do not require a physical exam; and in that case, most clinicians and patients felt comfortable with the virtual care. But there are trickier, more amorphous symptoms that require a physical exam such as abdominal pain and swelling that are difficult to perceive over a camera."
Clinicians interviewed for the report said they had found innovative ways to avoid the need to conduct a physical exam, Schrandt said. "We heard many great examples from the clinicians we talked to about things that they figured out in the moment. One was assessing strength over the camera by asking the patient to pick up increasingly heavy objects as opposed to assessing strength in a physical exam by pressing down on limbs. Clinicians can also ask patients to do their own self-exam while the doctor is watching, so they could isolate an area of pain or an area of discomfort."
Equipping patients with simple diagnostic instruments can also obviate the need to conduct a physical exam, she said. "There are some great opportunities to figure out how instruments such as oximeters and blood pressure cuffs can be used by patients to supplement when a clinician cannot do a physical exam."
When asked about the skillsets needed to conduct telediagnosis versus diagnosis in person, clinicians interviewed for the report had two opposing responses, Mark Graber, MD, report co-author and SIDM president emeritus, told HealthLeaders.
"One was that the same skills you use to be effective in person would help you be effective virtually. The opposing view was that telediagnosis was a whole new ballgame, with new rules, new tools, and new everything. Those with the opposing view said that virtual care did not come naturally, that there was a learning curve, and that instruction and practice and feedback were valuable. Someone even mentioned having done simulated sessions to get up to speed, and that this experience was valuable," he said.
Conducting a virtual visit and a physical exam are different in many ways, Graber said.
"A simple example is the ongoing debate on how to evaluate someone who is short of breath. This is a piece of cake in person—you see how fast the patient is walking, whether they are pale or blue, how fast and how heavy they are breathing, and you probably already have a set of vital signs taken that include the respiratory rate, the heart rate, and even a pulse oximeter reading if you are lucky. Contrast that to the virtual encounter, where you may get the same short-of-breath complaint, but there is ongoing debate about how you evaluate this," he said.
In-person visits versus virtual visits
The report found there are five decision factors when deciding whether a patient should have an in-person visit or a telemedicine visit, Schrandt said.
"The first decision factor is the urgency of symptoms. There are some symptoms that warrant immediate, in-person attention such as chest pain. There are some symptoms that are clearly nonurgent such as a rash. However, what about the gray area? A patient could have a symptom that is unusual, but it is hard to determine the urgency. We need more research on methods for making those sorts of determinations. We need to know from the clinical perspective and the patient perspective what constitutes urgency."
"The second decision factor is the underlying health of the patient. Is this a chronic disease patient with very specific risk factors at play, or is this an otherwise healthy person? We need research to determine whether there are conditions that are going to require in-person assessment."
"The third decision factor is the familiarity of the symptoms. Is this the same earache you have had five times or is this a new symptom you have never experienced? We might be able to develop an algorithm tool that could flag when there is a symptom that calls for an in-person visit and when it is probably OK to do virtual care. We need much more research on that."
"The fourth decision factor is the relationship between the patient and the provider. This can get complicated. If there is a well-established relationship, there could be more comfort with virtual care, or at least a virtual-first approach. On the flip side, a patient can be matched with a clinician in telemedicine who the patient does not know, and we need research to know whether there are situations where that model works well or whether there are certain scenarios when that is not the right approach."
"The fifth decision factor is the quality of the virtual care. Is the visit being done over the phone? If the visit is being conducted via video, is the quality of the video clear? The concern over inequity and access to broadband came up repeatedly during the project. You cannot make decisions about whether to have in-person visits or virtual visits unless the virtual is an option."
Spreading coronavirus misinformation could cost physicians their medical licenses and medical board certifications.
The Federation of State Medical Boards (FSMB) and several medical certification organizations are calling for disciplinary action against physicians who spread misinformation about coronavirus vaccines.
The spreading of misinformation about coronavirus vaccines is widely viewed as playing a role in vaccination hesitancy across the country. Joseph Mercola, an osteopathic physician in Cape Coral, Florida, is one of the most influential spreaders of coronavirus vaccine misinformation in the country, according to The New York Times.
The FSMB, which represents medical licensing boards across the country, recently released a statement that seeks to discourage coronavirus vaccines misinformation by physicians.
"Physicians who generate and spread COVID-19 vaccine misinformation or disinformation are risking disciplinary action by state medical boards, including the suspension or revocation of their medical license. Due to their specialized knowledge and training, licensed physicians possess a high degree of public trust and therefore have a powerful platform in society, whether they recognize it or not. They also have an ethical and professional responsibility to practice medicine in the best interests of their patients and must share information that is factual, scientifically grounded, and consensus-driven for the betterment of public health. Spreading inaccurate COVID-19 vaccine information contradicts that responsibility, threatens to further erode public trust in the medical profession and puts all patients at risk," the statement says.
On Sept. 9, the leaders of the American Board of Family Medicine, American Board of Internal Medicine, and American Board of Pediatrics issued a joint statement on the dissemination of misinformation about COVID-19 by board certified physicians.
"We at the American Board of Family Medicine (ABFM), the American Board of Internal Medicine (ABIM), and the American Board of Pediatrics (ABP) support FSMB's position. We also want all physicians certified by our boards to know that such unethical or unprofessional conduct may prompt their respective board to take action that could put their certification at risk," the joint statement says.
Taking a stand against misinformation
Physicians who engage in coronavirus vaccine misinformation are violating hallowed obligations, Richard Baron, MD, president and CEO of the ABIM, told HealthLeaders.
"Physicians have a professional and ethical obligation to advise patients on the current state of scientific knowledge and in their field. That is what patients are relying on physicians to do. Physicians occupy a position of considerable authority and considerable trust—there are a lot of things that you get to do if you are a physician that you cannot do if you are not a physician. Part of why physicians have that privilege is the extent to which they can be counted on to be faithful to a scientific community that defines what good care looks like," he said.
Physicians have a duty to provide accurate information about coronavirus vaccines, Baron said.
"The information physicians should be giving is that vaccines are safe and effective. The number of medical contraindications from getting the vaccine are extremely small—it is mainly people who can have allergic reactions to the vaccines. This is something that has been given to hundreds of millions of people, and the number of complications is tiny. At the same time, we have more than 650,000 people in the United States who have died from a disease that the vaccines seem to prevent successfully. So, physicians should be encouraging their patients to get COVID vaccine because they are at much higher risk of dying of COVID if they do not get vaccinated than they are of any bad outcome from the vaccines," he said.
Coronavirus vaccine misinformation from physicians takes a toll, Baron said. "It is hugely damaging because it provides support for things that are just not true, and that support moves around fast. We know that misinformation moves faster on Twitter than true information. So, when physicians use their position of trust and authority to put out misinformation, the impact ripples far beyond the people who hear it because it gets repeated and disseminated. When misinformation is attributed to a physician, it has more than casual authority."
Coronavirus vaccine misinformation degrades the medical profession, he said.
"Lots of people rely on and trust what physicians tell them, and misinformation is damaging not only for the patients who hear it but also damaging to the profession because it undermines trust in physicians. Frankly, one of the biggest reasons that we put out the statement we did was to provide clear support for the doctors who are trying to do the right thing and feel beleaguered and undercut by other doctors who are putting out information that is terrible, dangerous, and wrong."
Executives who participated in the HealthLeaders CMO Exchange say their organizations are experiencing varying levels of workforce shortages.
Healthcare workforce shortages were one of the key pain points identified at the recent HealthLeaders Chief Medical Officer Exchange.
The coronavirus pandemic has highlighted workforce shortages at health systems and hospitals across the country. On Sept. 1, the American Nurses Association urged the federal Department of Health & Human Services to declare a nurse staffing crisis and to take immediate steps to implement solutions. Last week, Dartmouth-Hitchcock Health announced that the Lebanon, New Hampshire-based health system had raised its minimum rate of pay for all positions from $14 per hour to $17 per hour to address workforce shortages.
Chief Medical Officer Exchange participant Erik Summers, MD, CMO and vice chair of internal medicine at Wake Forest Baptist Medical Center, in Winston-Salem, North Carolina, recently told HealthLeaders that his organization is experiencing widespread workforce shortages.
"We are experiencing significant nursing shortages and that is impacting the hospital, but it's more than that. We are experiencing workforce shortages in care coordination, social work, nursing assistants, and respiratory therapists. We are not seeing as many shortages among physicians and physician assistants, but we are having some challenges in our staff in general," he said.
The workforce shortages are affecting operating capacity at the medical center, he said. "The biggest impact is that if you do not have the staff that you need, you cannot keep your beds open. We have had some closure of beds. We realize that we need all of our staff, especially at the time of a pandemic, to help as many patients as we can. That is the biggest impact—the inability to put patients in beds."
Chief Medical Officer Exchange participant Donald Whiting, MD, MS, CMO of Allegheny Health Network and president of Allegheny Clinic in Pittsburgh recently told HealthLeaders that AHN is also experiencing significant workforce shortages.
"Nursing shortages are the most notable because that's what keeps us from opening available beds for patients. We have bed availability, but we just don't have enough nurses to cover those beds. However, we have workforce shortages across the board. In nursing, we are competing against other healthcare providers. But across dietary roles, environmental services, ward clerks, and other non-professional roles, we are competing with McDonald's, Target, PNC Bank, and others because they are all increasing their starting pay rates, too. That is a big workforce toll," he said.
Whiting estimates that 15% of AHN's inpatient beds are closed because of workforce shortages.
Chief Medical Officer Exchange participant David Battinelli, MD, senior vice president and CMO of Northwell Health, recently told HealthLeaders that the New Hyde Park, New York-based health system is facing more limited workforce shortages.
"There have been workforce shortages evolving in specialty-specific competency areas for a long time that we will always have because we are constantly innovating and changing technology. It falls largely in all the types of technical workers that we need. For example, we have workforce shortages in information technology because of competing industries vying for the same people. We have workforce shortages in specialty-specific areas from radiology and imaging technicians to ultrasound technicians to laboratory workers. These are all specialty-specific technological areas," he said.
With the exception of coronavirus patient surges, Northwell has been spared nursing shortages, Battinelli said. "In the nursing area, we have workforce shortages during pandemic surges, but we do have adequate numbers of nursing applicants."
Rising to the challenge
Wake Forest Medical Center has been trying to boost recruitment and employee retention in response to workforce shortages, Summers said.
"We have looked at our salary structure—we want to be competitive in the market. Then we looked at supporting our nurses with appropriate nurse-patient ratios in the hospital. It is easy to tell nurses to see more patients, but we need to hold to not only what is going to keep our patients safe, but also what is going to keep our staff from burning out. We have been hesitant to increase our ratios on the floors or in the ICU," he said.
AHN has made a concerted effort to address workforce shortages, Whiting said. "We have tried every trick in the book. We have raised pay rates. We have given retention bonuses. We have given hero bonuses for working through COVID. We have added bonuses if an employee refers workers to us. We are giving sign-on bonuses. We have worked on making childcare available or covering childcare costs. We are looking at redesigning what nurses do to use others to do some of that work."
Employee retention is a priority at AHN, he said. "We celebrate every single event—we make people feel appreciated in every possible way. We have pizza parties. We acknowledge people with events on the nursing floors and elsewhere in the hospitals. We are doing things to create camaraderie. We are focusing on wellness—we have serenity rooms in each of the hospitals. We want people to feel appreciated and to have a sense of belonging as well as focusing on their wellness."
Northwell is focusing on culture to address workforce shortages, Battinelli said. "We want to be able to give people not only the job that they want but also the environment where they want to work. We want to have an adequate amount of respect, collegiality, and engagement. We spend an enormous amount of time on employee engagement. During the pandemic, we have enjoyed the highest employee engagement scores that we ever have had—up over the 90th percentile. We have been recognized as being one of the Top 100 places to work for by Forbes."
Workforce outlook
Workforce shortages at health systems and hospitals are likely to linger for many years, Summers and Battinelli said.
"I always tend to see light at the end of the tunnel—I believe that we can improve our employment efforts through recruiting and having people stay because I believe in the organization. But I also cannot deny that these workforce shortages are going to go beyond the COVID pandemic and will be around for a while. So, I do expect workforce shortages to persist long after the COVID patients go away," Summers said.
"As you emerge with new technical competencies, you will always be faced with workforce shortages. If you cannot retrain and refocus certain jobs that are going to become less prevalent, you will end up with more shortages. It takes an investment in people. When you do the financial analysis of this process, even though it is an investment, it does pay to educate and train staff rather than to find new people, which invariably does cost more money," Battinelli said.
Major increases were found in 2020 compared to 2019 in four serious infection types: central line-associated bloodstream infections, catheter-associated urinary tract infections, ventilator-associated events, and antibiotic resistant staph infections.
There has been a significant increase in healthcare-associated infections (HAIs) during the coronavirus pandemic, a recent research article found.
From 2015 to 2019, there were decreases in the prevalence of central-line-associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), and Clostridiodes difficile infections (CDIs). Since 2010, there have been significant year-to-year decreases in methicillin-resistant Staphylococcus aureus (MRSA).
The recent research article, which was published by Infection Control & Hospital Epidemiology, examined national- and state-level standardized infection ratios (SIRs) for each quarter in 2020 compared to each quarter in 2019. SIRs were determined for each HAI by dividing the number of reported infections by the number of predicted infections, calculated using 2015 national baseline data.
The study includes several key data points.
CLABSI: SIRs were significantly higher in the second, third and fourth quarters of 2020 compared to 2019. The largest increased SIRs occurred in the third and fourth quarters (46% to 47%).
CAUTI: The national CAUTI SIR increased steadily throughout 2020. In the fourth quarter of 2020, the CAUTI SIR increased 19%.
Ventilator-associated events (VAEs): The national VAE SIR increased throughout 2020, with the largest increase occurring in the fourth quarter (45%).
MRSA bacteremia: In the second quarter of 2020, the national MRSA bacteremia SIR increased 12% compared to the second quarter of 2019.
"This report provides a national view of the increases in HAI incidence in 2020. These data highlight the need to return to conventional infection prevention and control practices and build resiliency in these programs to withstand future pandemics," the research article's co-authors wrote.
Interpreting the data
The characteristics of the coronavirus pandemic that drove increases in CLABSIs, CAUTIs, VAEs and antibiotic resistant staph infections were "clearly multifactorial," says Arjun Srinivasan, MD, associate director for healthcare-associated infection programs at the Centers for Disease Control and Prevention (CDC).
"There are issues that drove the increases both with respect to the patients themselves and the healthcare delivery system, which were both put under enormous stress. When we look at the patients who were most likely to be hospitalized with COVID, they tended to be patients who were older with significant comorbidities. So, those were the patients who were at the highest risk to have healthcare-associated infections because they have underlying, predisposing factors," he says.
The healthcare system was under unprecedented strain, Srinivasan says.
"There were large numbers of patients presenting for care. There was very high acuity of illness. There were shortages of staffing—we had staffing problems because staff themselves were getting COVID or they were exposed and unable to work. So, we didn't have enough people to take care of the patients. Then, we also had some significant shortages of personal protective equipment—the things that we need to deliver and provide safe care. You had a perfect storm of very high-risk patients meeting a healthcare system under unprecedented pressure. Those are the factors that resulted in what we saw," he says.
There is hope to reverse the increases in HAIs during the ongoing pandemic, Srinivasan says.
"The first thing is to be aware of the data. What has been wonderful to see is that hospitals have continued to monitor these infections and to report them to the CDC, even though for the first six months of 2020, they did not have to report them. The Centers for Medicare & Medicaid Services gave hospitals permission to stop reporting because they were under a lot of strain. But 80% to 90% of hospitals kept reporting. So, assessing and monitoring this information and knowing that you have this problem is absolutely the first step toward correcting it," he says.
The other part of reversing the trend is a more challenging because we are still faced with the same set of challenges, Srinivasan says. "Granted, the supplies of personal protective equipment have gotten better, but the large number of patients getting ill and the comorbidities that those patients have remains a challenge. The strain on the healthcare system remains a challenge. Fortunately, we have many healthcare workers who are vaccinated, so hopefully that helps with some of the staffing issues."
The increase in HAIs should not discourage patients from going to a hospital when they need acute care, he says.
"There have been more infections in hospitals than there were two years ago. At the same time, we know that people have needed hospital care for COVID. There is no doubt that many people have had their lives saved because they went to a hospital in a timely manner when they got sick and were able to get treatment for COVID. There are always risks associated with seeking medical care, and some of those risks are infections. Yes, there have been more infections over the past year, but when you need to be in a hospital, we want you to go to a hospital. That is a place where there are people dedicated to making you better and saving your life. So, we do not want this data to scare people away from getting the care that they need."
The CDC is hopeful that the increases in HAIs during the coronavirus pandemic will be reversed once the crisis state of the pandemic has passed, Srinivasan says.
"Our hope is that these increased infections are situational due to the unusual circumstances that arose during the pandemic. Once the pandemic has passed, we expect that as hospitals return to their normal state that we will see these infections go back down to where they were. We are going to be focusing on this area—making sure that we are doing everything to rebuild that firm foundation that we had. There were policies and procedures that were in place that resulted in the decreases in these infections."
In addition to physical symptoms such as cough and fatigue, coronavirus 'long haulers' are experiencing a range of behavioral health conditions.
Coronavirus "long haulers" are experiencing several behavioral health conditions, according to an expert at Doctor On Demand.
One of the more mysterious characteristics of COVID-19 is that a significant number of patients who are long haulers experience symptoms for weeks or months after recovering from the acute phase of the illness. Long haulers have a range of physical symptoms, including cough, shortness of breath, constitutional symptoms such as numbness and tingling, cardiac issues, hair loss, and deconditioning.
Coronavirus long haulers are also experiencing behavioral health issues, says Nikole Benders-Hadi, MD, medical director of behavioral health at Doctor On Demand.
"At Doctor On Demand, we are seeing a lot of depression and anxiety among long haulers. Particularly when you experience long-term anxiety symptoms, the condition has the opportunity to differentiate itself into other more specific anxiety disorders such as generalized anxiety disorder, panic disorders, and posttraumatic stress disorder. PTSD is defined as anxiety symptoms related to a trauma that lasts for greater than six months. Unfortunately, we are seeing an uptick in those types of diagnoses now. The impact of those kinds of symptoms are wide and varied. We are seeing people come to us talking about the impact on their relationships, on their work productivity, and on their ability to function day to day," she says.
Coronavirus long haulers are experiencing behavioral health conditions beyond anxiety and depression, Benders-Hadi says. "We are seeing increases in substance abuse disorders. We are also seeing an increase in the prevalence of obsessive-compulsive disorder in people who are overly focused on cleanliness. There was a recent Lancet study that showed increases in diagnoses of psychotic disorders, where people become very paranoid about cleanliness, and it advances to the point where they have delusions."
Addressing behavioral health issues among coronavirus long haulers
Treatments are available for coronavirus long haulers who are experiencing behavioral health conditions, she says.
"Unfortunately, there are not quick solutions to any of these symptoms—there is no magic pill that you can offer. We can provide supportive therapy and cognitive behavioral therapy. CBT has been shown to be effective because CBT specifically works to identify anxiety triggers. The work becomes practicing a different type of response when you feel anxiety rising up. It involves recognizing acute changes in your body and empowering the patient to exhibit more control over their anxiety," Benders-Hadi says.
Many people can provide emotional support to coronavirus long haulers with behavioral health issues, she says. "Being proactive about checking in with friends, loved ones, and co-workers who are experiencing long COVID symptoms is a great first step to making sure that they are getting the support they need. As a clinician, for me it comes down to early intervention being key. We need to offer practical advice on how to counter brain fog, for example. We need to encourage patients to be able to talk to their managers at work if there are work accommodations that are needed."
Increase in patient volume
During the pandemic, Doctor On Demand has seen a dramatic increase in behavioral health visits, including visits with coronavirus long haulers, Benders-Hadi says.
"In 2020, we saw a 140% year-over-year growth in behavioral health visits, and the demand for behavioral health visits remains high. We have seen the demand for medical visits come and go with different coronavirus variants and concern about acute COVID infections, but we have not seen a decrease in the need for behavioral health visits. The depression, anxiety, and other behavioral health conditions that are resulting from the long-term symptoms that patients are experiencing show that COVID is having a continuing impact," she says.
Healthcare providers need to think about coronavirus long haulers in the same way they think about other chronic illness patients, Benders-Hadi says. "We need to pull together research and data. We need to bring together both behavioral health specialists as well as medical and rehabilitation specialists to help treat individuals holistically rather than in isolation. That is going to be key given the widespread impact of both the physical and behavioral health symptoms that COVID long haulers are struggling with."
Jennifer Orozco sees physician assistants as a vital part of care teams and expects continued growth of the profession.
The new president of the American Academy of PAs (AAPA) is bullish on the future of the physician assistant profession.
Jennifer Orozco, MMS, PA-C, began her AAPA presidency on July 1. She practices in vascular surgery and serves as director of advanced practice providers at Rush University Medical Center in Chicago.
Orozco spoke recently with HealthLeaders about a range of issues, including the agenda for her AAPA presidency, the role of PAs in care teams, and her vision for the future of the PA profession. The following is a lightly edited transcript of that conversation.
HealthLeaders: What are the primary elements of your agenda as president of the AAPA?
Jennifer Orozco: There are three things that are important to me and many in the PA profession.
First is patient access to care. We continue to have major patient access issues across the United States.
Second is removing barriers to PA practice. PAs cannot be part of the solution to improve patient access to care until we remove antiquated legislative and regulatory barriers.
Third is a focus on mental health, which is one of my passions. I have been knee-deep in the coronavirus pandemic for the past 18 months in Chicago. I have seen the effects not only on the patients but also on the healthcare workforce. I want to shine light on mental health and remove the stigma.
HL: Are there particular restrictions on PAs that you would like to target?
Orozco: There are only three states that remove a specific relationship with a physician for PAs to practice. In every other state, PAs must be tied legally to a physician filed with the state. There is a lot of paperwork associated with this requirement.
This requirement does not accurately reflect how we have practiced for more than 50 years, and it has been a huge barrier during the coronavirus pandemic. Our profession is flexible, and PAs are generalists, so they can move to different specialties. But we often could not move them during the pandemic because there were so many regulatory barriers. Many governors issued executive orders to remove the requirement that PAs be tied to a physician at the state level. This allowed us to move PAs who were trained to take care of critically ill patients across state lines to coronavirus hotspots.
PAs are highly trained. They have many hours of clinical training as well as administrative training. They do not have as many years of training as a physician, but they are next in line in terms of training.
Another area I would like to address is allowing PAs to govern themselves in the states and have PA boards. We would not have a physician board governing all the nurses in a state. The nurses do that for themselves. We have more than 150,000 PAs in the country, and they should be governing their profession because they know their education, training, and background.
HL: How have PAs played a role in responding to the coronavirus pandemic?
Orozco: Like all frontline providers, PAs have had a very challenging 18 months. They have not only been trying to take care of COVID-19 patients, but also trying to make sure that the basic healthcare needs of their own patients are met. But this is what we are trained for. When there is a crisis, our commitment to patients is stronger than ever.
The AAPA put out a survey in 2020 that showed three out of five PAs had tested, diagnosed, or treated COVID-19 patients. For PAs, the key during the pandemic has been our ability to be flexible.
As a healthcare administrator my life was made easier because I was able to take PAs and move them to wherever I needed to. I knew they had the education, the training, and the skillset to take care of COVID-19 patients, whether it was testing, critical care in the ICU, or care in the emergency department. Wherever there was a need, I knew there were PAs who were trained and ready to go. During the pandemic, PAs became part of the "go to" workforce.
HL: How should PAs fit into care teams at physician practices?
Orozco: The most successful clinical teams are the ones that utilize the skillsets and the abilities of each individual team member to the fullest extent. No single person cares solely for a patient. It is not just a doctor. It is not just a nurse. It is not just a respiratory therapist. Every single team member brings a skillset and an expertise. That is the way healthcare is delivered, and the PA profession was founded on the concept of collaborative practice.
PAs fit into the team-based healthcare model. We have the training to care for the patient from start to finish. Evidence has shown that the most successful teams are the ones that decide what works best for them. We need to allow teams to be flexible.
HL: What is your vision for the future of PAs?
Orozco: The PA profession was named the Number One job by U.S. News & World Report this past January. That demonstrates that patients and employers know and value the PA role. The profession is expected to continue to grow. The federal Bureau of Labor Statistics estimates that PA employment will grow 31 percent from 2020 to 2030, much faster than the average for all occupations.
As PAs continue to grow, we can help improve access to care and provide high quality care despite the gaps that we have seen during the pandemic. We have an aging population, healthcare is complex, and patients need a comprehensive approach to medicine, especially in the primary care arena, where we have challenges getting enough physicians.
Additionally, PAs are leadership trained, so I envision PAs serving in leadership roles across all medical settings and specialties. These leadership roles could be at medical centers, departments of public health, and at the state, regional, and national levels.
HL: What advice do you have to offer to new PAs?
Orozco: It is a difficult time for new PAs. We are surviving a pandemic. New PAs were in school during a global pandemic, which is unprecedented.
Given the mental health pressures of the pandemic, my advice to new PAs is you must take care of yourself first. You cannot care for other people if you are not taking care of yourself. Provider burnout among PAs, physicians, and nurses is serious and devastating. Burnout has been an issue for many years, but the pandemic has elevated the problem. PAs need to prioritize their mental health and wellbeing so they can deliver healthcare to patients.
I also encourage new PAs to look for ways they can innovate as well as lead healthcare teams. Do not be afraid—be bold. Go out and deliver the healthcare that you are trained to do. We also need to keep the patient-centered focus at the core of all that we do.
New PAs should not get lost in their administrative duties and their student loans. If you keep the patient focus at the forefront, along with your mental health and wellbeing, you are going to be a successful PA throughout your career.
