Scout by Sutter Health combines downloadable information with human nonclinical guides to help young people with anxiety, depression, and stress.
Sutter Health has launched a digitally driven tool matched with nonclinical guides to support youth and young adults who are struggling with anxiety, depression, and stress.
Access to behavioral health services is a challenge for many people afflicted with mental illness. In 2016, about 16.5% of school-aged children had been diagnosed with a mental health disorder. During the coronavirus pandemic, a larger than average share (56%) of people between 18 and 24 have reported symptoms of anxiety and/or depressive disorder.
Scout by Sutter Health was launched as a pilot program in July 2020. The program was launched at scale in April 2021. Scout is a 12-week, nonclinical program targeted at youth and young adults aged 12 to 26.
"Scout is a nonclinical tool—it is not a substitute for treatment. Rather, Scout is a tool to build youth and caregiver resilience. It helps youth manage their symptoms and helps them in their everyday lives in managing a variety of life challenges while they are having depression, anxiety, or stress," says Larry Marx, MD, director of integrated care for the mental health and addiction team at Sutter Health.
Pediatricians or clinicians working with young people and/or their families can refer patients or caregivers to Scout if there are concerns around stress, anxiety, or depression.
Scout has four primary elements:
1. Weekly virtual screenings
After young people enroll in Scout, they are screened weekly for anxiety and depression, says Vandana Pant, MA, director of strategic initiatives for the health design and innovation team at Sutter Health. "For a young person who uses Scout, they sign up, then they receive weekly screeners. Those weekly screeners are based on evidence-based tools that measure both anxiety and depression—the GAD-7 and PHQ-9. Based on the young person's responses to the screeners every week, they receive personalized content."
The screeners rate a young person's symptoms from mild, to moderate, to severe. When a rating reaches the moderate level, the young person automatically gets outreach from a nonclinical guide. Reaching out to a clinician is recommended for additional support, she says. "We are very conscious of directing young people back into care if their scores are showing that they are at a level that may require clinical care. That provides a safety net."
2. Digital modules of educational and supportive materials
Downloadable information that Scout provides falls into two categories: young people received personalized information based on responses to the screeners, and young people and their caregivers receive standard digital information modules on a weekly basis.
The standard digital information modules can be educational about anxiety and depression or address other topics such as communication skills, Pant says.
"When a caregiver signs up for Scout, the main difference is that the young person has a highly personalized experience with the screeners. If you sign up as a caregiver such as a parent, modules are sent out on a weekly basis that parallel the modules that the young people receive. For example, if a young person receives an educational module on anxiety, their caregiver will receive the same module of content. For the caregiver, the goal is to build resilience through building knowledge," she says.
An example of personalized information is making it age-specific, Pant says.
"A lot of people in their early 20s are in the workforce, and we have tools that are valid for that age group like isolation at work, communication with peers, living successfully with roommates, managing finances, and the stress of dating. So, there is a host of content that is not necessarily clinical but addresses things that form the basis of people's everyday anxieties. On the younger end of the spectrum, we have content modules that address things like talking with friends about mental health, having a healthy diet, tips for getting to bed on time, and tips for settling the mind," she says.
3. Exercises
Scout has been designed to not be directive or prescriptive. For example, exercises linked to the information modules provide options for young people, Marx says.
"As the youth or the young adult goes through the different modules, there is a variety of different exercises that they can choose to participate in. There are no dictates or prescribing in the tool—there are just helpful suggestions. If someone decides to do one of the exercises, Scout checks on how they feel after the exercise to give some insight into whether a particular practice improves overall well-being. Because Scout is not a clinical tool, youth can pick and choose exercises or material that are going to be meaningful to them. There is no monitoring of what material or exercise has been used, so young people are completely autonomous," he says.
4. Nonclinical guides
A unique aspect of Scout is the use of nonclinical guides provided by Boston-based Docent Health to engage young people, Pant says.
"The core of the program and what really differentiates it is that we support the experience that young people go through for 12 weeks with nonclinical guides. Docent Health provides the nonclinical guides—they essentially guide the experience. For example, in addition to my weekly screener, I can text additional concerns. In that case, a Docent guide will step in and give a personalized response. That boosts the support because young people know that they can reach out if they want to," she says.
The nonclinical guides play a key role in Scout, Pant says. "Once you are enrolled in the program, you receive the screeners in an automated way, but you are welcomed into the program by a nonclinical guide. That nonclinical guide also keeps checking in with you through the course of the program. The nonclinical guide is also available via text as a source of support and engagement."
Sutter Health decided to include a human touch in Scout because of design-stage feedback from young people and the project's youth advisory group, she says. "Across the board, from age 12 to 26 and in the youth advisory group, we heard that one of the key challenges that young people face when they are feeling depressed or anxious is that they feel isolated. We responded to that need for human connection by creating a program that had an opportunity for nonclinical, human guide support."
Measuring Scout's impact
Sutter Health and Docent Health created a dashboard for Scout that has metrics on the population health and individual level.
On the population health level, week-over-week aggregate scores on the anxiety and depression screeners measure whether participants are trending in a positive or negative direction.
Engagement level is also measured week over week. Engagement is measured by how many people are completing the screeners and how many people are texting the nonclinical guides.
So far, the numbers look good, Pant says. "We have had about 510 users over the past three months: 40% of them are caregivers and 60% of them are young people. On an aggregate basis, we have seen a 1.7% improvement in anxiety scores; so, week-over-week, we are seeing improvement in anxiety at the population health level. About 95% of the users say they are finding the modules meaningful."
More faculty at a Texas academic medical center are considering quitting or scaling back to part-time employment during the pandemic.
Faculty at an urban academic medical center are more likely to quit or move to part-time employment during the coronavirus pandemic, a recent research article found.
Clinician burnout was already at high levels before the coronavirus pandemic began in spring 2020. It is widely believed that work-life integration and burnout have worsened during the pandemic.
The recent research article, which was published by JAMA Network Open, features survey data collected from more than 1,000 medical, graduate, and health professional school faculty at the University of Texas Southwestern in Dallas. The survey was conducted in September 2020.
The study includes several key data points.
After the coronavirus pandemic began, faculty were more likely to consider quitting or scaling back to part-time employment than before the pandemic (quitting 23% versus 14% and scaling back to part time 29% versus 22%)
After the coronavirus pandemic began, female faculty were more likely to consider quitting or scaling back to part-time employment compared to male faculty than before the pandemic (quitting 28% versus 15% and scaling back to part time 40% versus 13%)
After the coronavirus pandemic began, faculty with children were more likely to consider quitting or scaling back to part-time employment than before the pandemic (quitting 29% versus 17% and scaling back to part time 40% versus 24%)
After the coronavirus pandemic began, female faculty with children were more likely to consider quitting than female faculty without children than before the pandemic (quitting 35% versus 17%)
"In this survey study, the perceived stressors associated with work-life integration were higher in women than men, were highest in women with children, and have been exacerbated by the COVID-19 pandemic. The association of both gender and parenting with increased perceived work-life stress may disproportionately decrease the long-term retention and promotion of junior and midcareer women faculty," the research article's co-authors wrote.
Interpreting the data
Raising children is a major stressor for female faculty regardless of the pandemic, the research article's co-authors wrote. "In our study, faculty who were mothers were more likely to consider leaving or already had or were considering reducing their employment to part time both before and since the pandemic compared with faculty women without children, highlighting the universal stress of caregiving independent of the pandemic."
Working part time can exacerbate existing gender gaps at academic medical centers, the research article's co-authors wrote. "In our study, women were 3 times more likely than men to consider or already be employed part time both before and since the pandemic. Part-time faculty perceive that they perform more unpaid work, have fewer research opportunities, a slower career trajectory, and may be less likely to take on leadership appointments."
Academic medical centers should take actions to improve work-life integration, particularly for female faculty, the research article's co-authors wrote.
"Better support of working parents, specifically working mothers, through flexible work policies, improved childcare and parental leave programs, more equitable sharing of unpaid care hours between women and men, and active acknowledgment of the effects of work-life conflict on academic productivity and fulfillment are paramount to ensuring academic medicine does not lose talented faculty and proactively combats gender inequity and gender-based advancement regression," they wrote.
Although verbal threats were the most common kind of workplace abuse reported by survey respondents, 34% of the ED healthcare workers also reported physical assaults by patients.
Violence toward emergency department healthcare workers is prevalent and underreported, and victimized ED healthcare workers experience emotional injury during and after assaults, a new research article found.
Earlier research has shown that EDs are a hotbed for workplace violence. A New York City study found that 97% of emergency medicine resident physicians had experienced verbal harassment in an ED. A study published in 2016 found that 78% of ED healthcare workers had reported a violent assault in the prior year.
The new research article, which was published by Annals of Emergency Medicine, is based on survey data collected from 123 ED healthcare workers at an academic medical center in North Carolina. The survey respondents included 27 resident physicians, who were hypothesized to be at greater risk of workplace violence than their older colleagues.
"Residents are in training, are often young, and frequently have minimal experience with such encounters. They may lack the skills or training needed to prevent, manage, or process incidents of abuse," the research article's co-authors wrote.
The research article includes several key data points.
Among all survey respondents, 80% reported at least one verbal assault in the prior year. Among residents, 89% reported at least one verbal assault in the prior year.
Among all survey respondents, 70% reported experiencing verbal assault multiple times. Among residents, 74% reported experiencing verbal assault multiple times.
Among all survey respondents, 34% reported one incident of physical assault. Among residents, 22% reported one incident of physical assault.
Among all survey respondents, 9% reported multiple physical assaults. No residents reported multiple physical assaults, which the researchers said was likely due to the clinicians working in the ED for less than 2.5 years.
Among all survey respondents, 63% reported feeling unsafe in the workplace. Among residents, 67% reported feeling unsafe in the workplace.
Among residents, 96% discussed workplace abuse only with a colleague or no one at all. None of the residents filed formal incident or police reports.
The healthcare workers were asked whether there were specific reasons that led perpetrators to commit acts of violence or abuse. Among healthcare workers who experienced assault, 22% said they believed the incident was motivated by race or ethnicity, 21% said they believed the incident was related to their sex or gender identity, and 21% said they believed the incident was related to their age.
"Although verbal assault is most common, 34% of healthcare workers in this academic ED also reported incidents of physical assault by patients. Consistent with prior studies, only 20% of respondents filed formal incident reports or police reports, and when looking specifically at resident responses, there were no formal reports filed," the research article's co-authors wrote.
The survey responses generated 24 narratives about workplace violence and abuse. The narratives featured four themes: comments on assaults and threats, feeling unsafe, resignation, and influence on care. The following are examples of comments that fell into these four themes.
Assaults and threats: "A patient was verbally assaulting. After many minutes of being yelled at, the patient hit me and swung at another nurse demanding IV pain medicine, then proceeding to scream that this was our fault, and threatening to kill us and our families."
Feeling unsafe: "I was punched in the eye by a psych patient, did not file a police report because the officer made me feel like I contributed to the incident. I missed three days of work. Now I always feel unsafe on my job."
Resignation: "Workplace violence is unfortunately part of the job. It's concerning that charges can be filed against a healthcare professional for too much force but nothing can be done when a patient punches, kicks, bites, scratches, pulls hair, or generally assaults you. I'm not here to get beaten up. This culture needs to change before a nurse gets killed by a patient."
Influence on care: "I've experienced multiple encounters with intoxicated patients being verbally abusive and threatening. It has definitely impacted my ability to provide care."
Research insights
Verbal and physical abuse of healthcare workers takes an emotional toll, one of the research article's co-authors told HealthLeaders.
"The experience of abuse in the workplace can certainly contribute to burnout, lower job satisfaction, stress, and disengagement. In the worst cases, when there are physical threats, it can even lead to fear and a change in behavior such as canceling social media accounts or not driving directly home," said Christina Shenvi, MD, PhD, an associate professor of emergency medicine at the University of North Carolina School of Medicine in Chapel Hill, North Carolina.
An effective incident reporting system is crucial to addressing workplace violence in healthcare settings, she said. "It is important that healthcare workers know that if they report concerns, that action will be taken to help keep them safe and prevent future incidents."
Healthcare organizations should have a set of essential interventions and responses in place to address workplace violence, Shenvi said. "Institutions should have a process for assessing the reports and events, provide legal support when needed, and create policies and procedures to prevent future abusive episodes. In addition, institutions should have a means of providing emotional and personal support to healthcare workers to facilitate emotional recovery."
MercyOne's new chief medical executive says he is positioned to be a primary leader in the health system's efforts to achieve health equity.
A chief medical executive has a key role to play in addressing health equity, the new chief medical executive at Clive, Iowa—based MercyOne says.
Hijinio Carreon, DO, was recently named to the newly created position of chief medical executive at the MercyOne health system. An emergency medicine physician, Carreon previously served as chief medical officer of MercyOne Des Moines Medical Center.
Carreon recently talked with HealthLeaders about a range of issues, including health equity, physician engagement, and his vision for telehealth after the coronavirus pandemic has passed. The following is a lightly edited transcript of that discussion.
HealthLeaders: What is the role of the chief medical executive in addressing health equity?
Hijinio Carreon: As the chief medical executive, I should promote and ensure responsibility across all disciplines in terms of health equity. I should be in the forefront in addressing health disparities. In this role, I find myself as an essential leader of the hospitals and need to make sure that I create an equitable environment for our diverse population.
COVID-19 has resulted in a lot of changes and identified many weaknesses in our healthcare delivery system—whether those are related to social determinants or how we manage chronic illnesses. From my perspective, it is extremely vital to address health equity. I must ensure that I am implementing effective education programs for our clinicians to address their unconscious biases and to garner patient trust.
My immediate objectives related to health equity and personalized care are a digital strategy to create avenues to improve access to care and ensuring that we continue to move to a value-based care model. We currently utilize health coaches and community health workers to identify the social determinants that exist in our communities. We do not want to just address social determinants but also tie them into the resources that exist within the communities, so that we are addressing the fundamental reasons for why people are not seeking medical care or why people are unable to make an appointment that has been scheduled.
HL: What are the primary elements of personalizing patient care?
Carreon: There has been a lack of personalized care for a long time. Healthcare has struggled to gather patient information necessary to tailor care because of the disparate electronic health records that exist even within some health systems. This creates a great deal of frustration for not only patients but also physicians.
When you break down personalized care, it spans multiple dimensions. There is a partnership between the clinician and the patient. At MercyOne, we want to ensure that we create adequate healthcare access points. We want to ensure that we have effective methods of communicating across the continuum of care.
In my role as chief medical executive, being that chief clinical person over both the ambulatory and inpatient sides means being able to see both sides and not just have physicians focused on the ambulatory side or the inpatient side. I need to oversee the operation from both avenues to ensure that we are fulfilling patient needs across the continuum of care. I want to ensure that patient data is accessible and viewable across the delivery models—whether that is ambulatory, subspecialty services, or the inpatient setting.
HL: What are the primary elements to success in physician engagement?
Carreon: The keys to physician engagement are transparency, alignment of our goals, physician empowerment, teamwork and collaboration, and allowing physicians to lead.
In terms of transparency, at times, the belief is that the physician is the frontline worker and may not have a vested interest in the finances and payer issues that may be occurring in healthcare industries. In reality, physicians developing an understanding of how reimbursement is done, what the current finances are, and where the opportunities exist helps create alignment. With alignment, the goal of the organization's success should align with the goals of the practicing clinicians. So, if their goals are improvement of patient care and improvement of patient access, they should align with the organization's goals.
HL: What is your vision for telehealth after the coronavirus pandemic has passed?
Carreon: I have a strong belief in telehealth. In the initial months of COVID-19, about 25% of our patient visits were performed virtually. As we continue to reopen our clinics safely, digital health still maintains a significant objective for us.
When it comes to accessibility, I cannot emphasize enough that telehealth is one of the strategies to improve accessibility, especially in a state like ours where we have a lot of rural communities. There is not a hospital in every town. There is not a clinic in every town. So, we must have different modalities for patients to access us. Versus a trip of several hours, telehealth offers an opportunity for patients to stay in their homes and access care.
If patients need a higher level of care, telehealth can direct patients to the appropriate location to get whatever additional care they may require.
There are concerns about access to broadband as well as insurance and reimbursement issues that may prevent patients from accessing virtual services. We need to make reimbursement transparent for the consumer to ensure that they know what they are going to have to pay out of pocket and what their insurance is going to cover.
From the patient's perspective, we must create a seamless telehealth experience.
HL: What are the primary measures for the performance of a chief medical executive?
Carreon: Physician and advanced practice provider engagement is extremely important. Quality outcomes—specifically around hospital-acquired conditions and mortality—are extremely important. Then there is improvement in the equity of care in the communities we serve. Health equity must be more than a nice statement that is said—it must be embedded in the belief of the frontline physicians that they believe there is an opportunity to improve equity in care. If people understand the importance and value of keeping our communities healthy, that engenders trust in the patients who we serve.
Population growth and aging are expected to be the primary drivers of demand for physicians through 2034, a healthcare workforce report says.
By 2034, there will be a shortage of physicians ranging from 37,800 to 124,000, according to a recent report prepared for the Association of American Medical Colleges.
The AAMC has published seven annual supply and demand reports on the physician workforce since 2015. Projected shortages of physicians pose several implications, including limiting access to care, stymying efforts to achieve health equity, and eroding clinician well-being.
The projected physician shortage is a complex challenge that requires urgent action, AAMC President and CEO David Skorton, MD, said in a prepared statement.
"Addressing the physician shortage requires a multipronged solution that starts with educating and training enough physicians to meet America's needs and includes improving access to care, diversifying the physician workforce, and ensuring our nation is prepared to address current and future public health crises. Now more than ever, the nation must make a long-term investment in the healthcare workforce. The time to act is now," he said.
This year's AAMC physician workforce report was prepared by the Life Science division of IHS Markit, a global information company. The analysis was conducted before the onset of the coronavirus pandemic and was updated with trends in healthcare delivery and the physician workforce such as physician work hours and retirement trends.
The report features five key findings.
1. Projected physician shortage by 2034
Demand for physicians is projected to grow faster than supply for more than a decade, with the physician shortage by 2034 set to range from 37,800 to 124,000, the workforce report says.
The shortfall of primary care physicians is projected from 17,800 to 48,000 by 2034.
The shortfall of specialty physicians is projected from 21,000 to 77,100 by 2034, including the following three categories:
Surgical specialties shortfall from 15,800 to 30,200
Medical specialties shortfall from 3,800 to 13,400
Shortage in other specialties ranging from 10,300 to 35,600
2. Demographic drivers
Population growth and aging of the U.S. population are expected to be the primary drivers of demand for physicians from 2019 to 2034, the workforce report says.
"During this period, the U.S. population is projected to grow by 10.6%, from about 328.2 million to 363.0 million. The population under age 18 is projected to grow by 5.6%, which portends low growth in demand for pediatric specialties. The population aged 65 and older is projected to grow by 42.4% — primarily due to the 74.0% growth in size of the population age 75 and older. This trend portends high growth in demand for physician specialties that predominantly care for older Americans," the report says.
3. Aging workforce
Many physicians are approaching retirement age, and trends in retirement decisions will have a significant impact on the supply of physicians, the workforce report says.
"More than two of five currently active physicians will be 65 or older within the next decade. Shifts in retirement patterns over that time could have large implications for physician supply. Growing concerns about physician burnout, documented in the literature and exacerbated by COVID-19, suggest physicians will be more likely to accelerate than delay retirement. On the other hand, economic uncertainty and any detrimental effect on physician wealth could contribute to delaying retirement," the report says.
4. Impact of increasing care access
The coronavirus pandemic has heightened concern over health equity and care access, the workforce report says. "COVID-19 has raised awareness of the disparities in health and access to care by minority populations, people living in rural communities, and people without medical insurance."
If these concerns are addressed, demand for physicians will increase significantly, the report says. "If underserved populations had healthcare use patterns like populations with fewer access barriers, demand would rise such that the nation would be short by about 102,400 (13%) to 180,400 (22%) physicians relative to the current supply. Improving access to care is a national imperative."
5. Impact of the coronavirus pandemic
COVID-19 will likely impact both supply and demand for physicians, but the effects will be hard to determine for years, the workforce report says.
"The current pandemic has demonstrated that to better ameliorate the morbidity, mortality, and economic impacts of future pandemics, we will need to train (or cross-train) more physicians to alleviate shortages in crucial specialties and settings; approach this ramp-up within a context of equity, diversity, and inclusion; focus on the well-being of the healthcare workforce so that our providers are healthy enough to provide high-quality care to patients; and improve the effectiveness and efficiency of care delivery by using promising technologies and team-based care," the report says.
The pandemic has exposed weaknesses in the healthcare system and placed a spotlight on the importance of physicians in U.S. medicine, Skorton said.
"The COVID-19 pandemic has highlighted many of the deepest disparities in health and access to healthcare services and exposed vulnerabilities in the healthcare system. The pandemic also has underscored the vital role that physicians and other healthcare providers play in our nation's healthcare infrastructure and the need to ensure we have enough physicians to meet America's needs," he said.
Only 39% of survey respondents said their physician practice had taken concrete steps to address burnout in the prior 12 months.
A new sentiment survey gauges physician burnout and other challenges.
Burnout is one of the top challenges facing clinicians and other healthcare workers nationwide. In a September 2020 report published by The Physicians Foundation, 30% of more than 2,300 physicians surveyed cited feelings of hopelessness or having no purpose due to changes in their practices related to the coronavirus pandemic. Research published in September 2018 indicated that nearly half of physicians across the country were experiencing burnout symptoms.
The new sentiment survey, which was published by Watertown, Massachusetts-based athenahealth, is based on information collected from nearly 800 physicians. Most of the respondents (64%) worked at independent practices, with 22% of respondents working at hospital-affiliated practices. Most of the respondents (75%) were primary care physicians and 25% were specialty physicians.
The sentiment survey includes several key data points.
39% of respondents said their practices had taken concrete steps to address burnout in the prior 12 months
More female physicians (32%) reported feeling burned out at least once a week compared to male physicians (26%)
52% of physicians 65 years and older reported their burnout frequency was "never" or "a few times a year or less"
37% of physicians 18 to 44 years old and 37% of physicians 44 to 65 years old reported their burnout frequency was "never" or "a few times a year or less"
On average, physicians spent 64% of their weekly working hours on direct patient care, 23% of their weekly working hours on work-related activities other than direct patient care, and 14% of their weekly working hours performed at home outside business hours
50% of respondents said they had all of the information they needed to quickly come up to speed on a patient's story during a patient visit
23% of respondents said that they had difficulty focusing on patient care because of time consuming administrative tasks
Interpreting the data
The finding that only 39% of practices had taken concrete steps to address burnout in the prior 12 months is troubling, Jessica Sweeney-Platt, vice president of research and editorial strategy at athenahealth, told HealthLeaders.
"Only a little more than a third of physicians said their practices have taken concrete steps to address burnout, which means more than 60% have not taken concrete steps. That is contributing to the sense that the pace of practice is something that the physicians are struggling to maintain. One of the most troubling aspects of that finding was that if you answered that your practice has not taken concrete steps to decrease burnout, you were much more likely to report feeling rushed in your interactions with patients. It is that sense of time pressure and the out-of-control nature of the physician's schedule that we think is a big input into levels of burnout," she said.
The sentiment survey provides insight into the gender gap in physician burnout, Sweeney-Platt said. "There were some very clear differences between female physicians and male physicians. Female physicians are feeling much more burned out than their male counterparts. They also report spending more time working outside of normal work hours. There is a connection between those two findings."
The relationship between age and physician burnout points to a potential way to help address burnout, she said. "It is interesting that older physicians are reporting burnout less frequently in our survey. There may be some insights that older physicians can share with their younger colleagues in terms of how they have learned to manage and balance the conflicting requirements on their time."
More research is needed to assess the impact of hours spent on work-related activities other than direct patient care and weekly working hours performed at home outside business hours, Sweeney-Platt said.
"It depends a lot on what they are doing. For example, if a physician is spending two hours at home every night diving deep into the journals and thinking hard about the clinical conditions for specific patients that they have seen during the day and using their training and their intellect trying to get to better answers, then that would feel satisfying. However, if that two hours is spent finishing up paperwork or finishing up the documentation burden, that is not going to feel optimal," she said.
Physician practices should make it easier for clinicians to come up to speed on a patient's story, Sweeney-Platt said. "We can do better for the physicians who do not have all the information they need to quickly come up to speed on a patient's story during a patient visit. Even if you end up feeling that you have all of the information you need to come up to speed on a patient's story, sometimes the work required to get to that information is too much."
Burdensome administrative tasks are a serious problem for many physicians, she said. "The administrative tasks that take physicians' focus away from their direct patient care is the most concerning element of the distribution of their work effort. Most physicians I have talked with would say that they did not get into the practice of medicine to get on the phone with insurance companies, for example. That is a deeply unsatisfying."
Physician practices that are successful at shifting administrative work away from their clinicians have focused on creating clear roles and responsibilities for the members of the care team, Sweeney-Platt said. "They have carefully thought about the way that they want work to flow across the care team so that the physicians and the clinical team members are doing the work that only they can do. As much as possible, these practices ensure that non-clinical team members are enabled and capable of taking on administrative tasks.
The coronavirus pandemic has improved reimbursement for hospital at home services and opened up opportunities for virtual hospital at home programs.
Editor's note: This article appears in the May/June 2021 issue of HealthLeaders magazine.
After modest uptake for nearly three decades, hospital at home programs are now growing faster across the country due to the coronavirus pandemic.
Johns Hopkins Medicine launched the country's first hospital at home program in 1994. Largely because of inadequate financing mechanisms such as lack of reimbursement from Medicare, adoption of hospital at home programs was slow in the United States. The pandemic has changed that.
The biggest shift came in November 2020, with the Centers for Medicare & Medicaid Services (CMS) implementing the Acute Hospital Care at Home waiver program, which cleared the way for Medicare to pay for hospital at home services during the COVID-19 public health emergency. Six healthcare organizations were designated as the first participants in the waiver program, including two health systems that participated in this story: Mount Sinai Health System in New York City and UnityPoint Health in West Des Moines, Iowa.
The Mount Sinai Hospitalization at Home program is expected to grow significantly with the new Medicare reimbursement, says Linda DeCherrie, MD, clinical director of Mount Sinai at Home as well as professor of geriatrics and palliative medicine at the Icahn School of Medicine at Mount Sinai. Before the CMS waiver program, Mount Sinai Hospitalization at Home served 15–20 patients per month, she says. Now, she expects that census to double.
Many hospital at home programs are enrolling in the Acute Hospital Care at Home waiver program, DeCherrie says. "There is tremendous interest in the waiver. As of early February, there were 100 programs that had applied for the waiver and had received it."
Medicare reimbursement for hospital at home services will likely continue after the pandemic passes, says Albert Siu, MD, MSPH, chair emeritus at the Brookdale Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine.
"My crystal ball tells me that when the public health emergency ends, there will probably be an interruption of the payment model. My hope is that we will have gained enough momentum during this pandemic that the genie will be out of the bottle. We will have to find a permanent Medicare payment model, even if it requires statutory change," he says.
In addition to the Acute Hospital Care at Home waiver program, another driver of hospital at home growth during the pandemic has been the launch of virtual programs to monitor coronavirus patients outside the hospital setting. Denver Health has served more than 1,000 patients in its Virtual Hospital at Home program.
HealthLeaders spoke with three healthcare systems about how they are growing successful hospital at home programs amid the pandemic.
UnityPoint Health Hospital to Home
UnityPoint Health launched its Hospital to Home program in September 2018.
"By providing hospital-level care in the home, not only are we taking care of the patient's healthcare needs, but we are also able to evaluate their living conditions and determine what support they need to stay at home. It allows us to work with their family members or friends and keep them in the home," says Mag VanOosten, RN, president and chief clinical officer of UnityPoint at Home.
Patients are enrolled in the Hospital to Home program from UnityPoint Health hospital inpatient floors and emergency departments, says Dianne Schultz, DNP, MSN, RN, vice president of operations for UnityPoint at Home.
"Clinical coordination team members support Hospital to Home screening, and they signal further medical screenings to the providers. Hospitalists as well as emergency department providers actively refer patients to Hospital to Home. The Hospital to Home providers then engage in educational rounding with the care coordination team as well as ED and hospitalist providers to support their awareness and informed decision-making regarding Hospital to Home qualifications. If a patient is identified and anticipated to qualify for the Hospital to Home services, the referral is made and the Hospital to Home provider engages to assume that transition of care," Schultz says.
Patients with several medical conditions are well suited for Hospital to Home care, she says. "Basically, we look at patients who have specific medical conditions such as cellulitis, chronic obstructive pulmonary disease, heart failure, pneumonia, dehydration, urinary tract infection, deep vein thrombosis, pulmonary embolism, and acute viral illnesses. That tends to be the core of patients who do very well at home under this model of care."
Acuity is pivotal in determining whether a patient is appropriate for the Hospital to Home program, Schultz says. "These patients are the healthiest of our hospitalized patients. These are not patients who are medically at risk to escalate to the ICU while hospitalized. These are patients who require hospitalization; however, with having services and a model in place, we can safely provide their care in the home."
Hospital to Home model of care
The primary elements of the Hospital to Home care model are daily in-person visits, remote monitoring, and a 30-day ambulatory care bundle.
"At our core, we have one daily provider in-person visit and twice daily nursing visits in-person as well. In-person ancillary services are provided as medically necessary. In addition to those in-person visits, we do perform video visits as needed. We also have telephonic visits. We use a complement of all of those methods to urgently and interventionally act on behalf of our patients' medical needs," Schultz says.
Remote monitoring is a "huge component" of the Hospital to Home program, she says.
"The remote clinical monitoring provides basic clinical monitoring such as heart rate, respiration, pulse oximetry, and patient weight. This data allows our clinicians to monitor the patient, then engage with the patient. For example, a clinician could notice that the patient's oxygen saturation has gone down, and they can contact the patient right away and go through an assessment telephonically. If the clinician wants to see what the patient looks like, they can get on a video visit. If there is further concern, they could immediately deploy an in-person visit."
The remote monitoring provides immediacy in care, VanOosten says. "Remote clinical monitoring has been a bonus to our program. It allows for immediate intervention. Our clinicians get notified on their phone if there is any unexpected variance."
After a patient's acute care period, which generally lasts three to five days, Hospital to Home patients are transitioned to a 30-day ambulatory bundle. "We continue to manage the patient in an ambulatory model with clinician engagement and the remote clinical monitoring. With the ambulatory bundle, we can still urgently and interventionally manage patients to avoid the need to go to the ED or hospital," Schultz says.
The 30-day ambulatory bundle was launched in October 2019. The initiative had a dramatic impact on ED and hospital escalation rates, which are the number of Hospital to Home patients who had to seek care at an ED or be hospitalized. The following data compares escalation rates in September 2019 and November 2020:
• The seven-day ED escalation rate fell from 8.5% to zero
• The seven-day hospital escalation rate fell from 6.8% to 3.8%
• The 30-day ED escalation rate fell from 27.1% to 2.9%
• The 30-day hospital escalation rate fell from 22.0% to 5.9%
Operating via the Acute Hospital Care at Home model
UnityPoint Health served its first patient under the Acute Hospital Care at Home waiver on February 1. "The impact of the Acute Hospital Care at Home waiver has been profound in our program. It opens eligibility to even more patients, allowing us to care for more patients in their home aligned with traditional Medicare," Schultz says.
Operationally, the Hospital to Home program is largely compatible with the Acute Hospital Care at Home waiver. Enrollment of Medicare patients for hospital at home services under the waiver follows the same procedures as the Hospital to Home program. And the Hospital to Home daily visits by clinicians and nurses comply with the requirements of the waiver.
The key changes to adapt to the waiver operationally have been related to Acute Hospital Care at Home being an inpatient rather than an outpatient program, Schultz says. "We worked to meld together the workflows that we had established in the ambulatory space with our inpatient services."
For example, inpatient services typically do not schedule clinicians, who round on patients as a normal part of their activities. Scheduling clinicians in the electronic health record is essential in hospital at home programs, she says. "It is very important that the activities of clinicians are scheduled, so we understand where all of the clinicians are at and are able to help navigate them through various home environments. We worked closely with Epic and our UnityPoint Health Epic build team to get that functionality in place for the Epic inpatient platform."
Financially, there is a stark difference between the Hospital to Home and Acute Hospital Care at Home programs, Schultz says. "The Acute Hospital Care at Home waiver provides inpatient hospital reimbursement for qualified program billing. Our Hospital to Home ambulatory model utilizes outpatient visit encounters for professional billing. The waiver program certainly offers us a revenue stream that helps to cover the costs of the new program."
Achieving success in the Hospital to Home program
In addition to achieving low ED and hospital escalation rates, the Hospital to Home program has achieved high patient experience scores and cost savings, Schultz says. About 99% of patients give the quality of care they receive a score of 10 on a scale of 1 to 10. When comparing Hospital to Home and traditional hospitalization, the average cost reduction is about $6,000 per patient.
The ability of UnityPoint Health to provide all Hospital to Home services in-house has been crucial to the program's success, VanOosten says.
"Having all the services under UnityPoint Health is our secret sauce. It allows us to keep our patients within our system so we can integrate between our service lines. We do not have to rely on third-party partnerships, which allows us to provide better care for our patients and better continuity of care across the continuum," VanOosten says.
Mount Sinai Hospitalization at Home
The New York City–based Mount Sinai Health System expects its Hospitalization at Home program to improve financially and grow significantly with participation in the Acute Hospital Care at Home waiver program.
"We will probably double the number of patients coming through our hospital at home program because of the waiver. That will help us financially. In a program like ours, you need a minimum staff to operate. Having more patients coming through helps financially on the standard baseline operating costs," DeCherrie says.
Prior to being accepted for the Acute Hospital Care at Home waiver, the Mount Sinai Hospitalization at Home program admitted 15–20 patients per month, she says.
The Hospitalization at Home program's financial model has evolved over time.
The program launched in 2014 under a CMS Innovation grant, which allowed Hospitalization at Home to serve Medicare fee-for-service patients. When the grant ended in 2017, the program had to adopt a new financial model, DeCherrie says. "We formed a joint venture with Contessa Health. We then started to get contracts with Medicare and Medicaid managed care plans. And we had to stop taking care of Medicare fee-for-service patients."
The joint venture contracts are 30-day bundles that include acute care in the home and active monitoring of patients after the acute phase of their condition.
How the Hospitalization at Home program works
The patients in the Hospitalization at Home program primarily come from the four emergency departments that the Mount Sinai Health System operates in Manhattan, DeCherrie says.
"We look almost every hour, Monday through Friday from 8 a.m. to 8 p.m., at all patients who arrive in the emergency rooms to see if they meet our insurance and geography requirements. Then, we start to follow patients with a nurse who screens out patients who are clearly not eligible for the program clinically. Then, the nurse will discuss with a hospitalist whether it is indeed the case that we can take care of a patient at home. Finally, we approach the patient to see whether they are interested in the program."
If a clinically eligible patient is interested in the program, the patient is admitted to the Hospitalization at Home program and transported home via ambulance, she says. A nurse meets the patient at home within two hours of emergency room discharge.
The primary clinical criterion for Hospitalization at Home patient eligibility is whether patients can be treated safely and effectively at home, DeCherrie says. Prior to this determination, "the emergency room physician has designated that there needs to be inpatient-level care. Then the criteria turn to whether we can treat the patient in the home."
Patient eligibility is not based on a diagnosis because patients are often not immediately diagnosed in the emergency room, she says. "We look to see whether we can operationalize the treatment plan in the home. What we do very well is taking care of patients who need IV antibiotics, IV fluids, labs monitored, and fluid diuresis for congestive heart failure. In the end, a diagnosis is coded such as congestive heart failure, cellulitis, chronic obstructive pulmonary disease, pneumonia, or dehydration. These are our bread-and-butter diagnoses."
During the acute phase of their condition, Hospitalization at Home patients receive two daily visits from a nurse and one daily visit from a clinician. About half of the clinician visits are conducted using telemedicine, DeCherrie says. "Our patients go home with a telehealth kit, which is how we do our video visits. A nurse can be in the home facilitating a video visit with a physician or nurse practitioner."
Physicians, nurse practitioners, social workers, and a phlebotomist are employed by Mount Sinai, she says. The nurses are employed by an agency, under a contract initiated by Contessa Health. If there is a need for physical, occupational, or speech therapy, the agency provides those services as well, she says.
There are care coordinators who are employed through the joint venture. "They are the nurses in the emergency room who identify potential patients and coordinate the process of getting a patient home such as acquiring oxygen, arranging the ambulance ride home, and providing the telehealth kit," DeCherrie says.
The Hospitalization at Home program has generated positive results, according to a JAMA Internal Medicine study published in 2018. The research article compared 295 patients who participated in the Hospitalization at Home program and 30-day postacute care bundle with a control group of 212 hospital inpatients who were eligible for the Hospitalization at Home program but declined to participate or were seen in an emergency department when a Hospitalization at Home admission could not be initiated.
Compared to the control patients, Hospitalization at Home patients experienced:
• Shorter lengths of stay (3.2 days versus 5.5 days)
• Lower hospital readmission rates (8.6% versus 15.6%)
• Fewer transfers to skilled nursing facilities (1.7% versus 10.4%)
• Higher likelihood to positively rate their medical care (67.8% versus 45.6%)
Adapting to Acute Hospital Care at Home waiver
Mount Sinai started seeing its first patients under the Acute Hospital Care at Home waiver in December. Participation in the waiver program required significant changes, Siu says.
"The Medicare waiver program operates in a very different way from the program that we had been running previously. By design, Medicare wanted to run the waiver program through hospitals. They want to use the hospital payment mechanism as the financing mechanism for this program. That is why there is not a 30-day transitional care bundle, for example. We have modified and developed parallel workflows for our patients because everything must be consistent with our hospitals' operating procedures. Whereas, before we had been operating Hospitalization at Home in many ways as a physician practice," he says.
The logistics under the waiver program are significantly different, DeCherrie says. "Previously, we would discharge a patient from an emergency room and admit them to our Hospitalization at Home program. But because an inpatient stay includes your emergency room visit under the hospital process, it is not a discharge from the emergency room anymore—it is treated as a transfer from one inpatient department to another."
Pharmacy has been another major change, she says.
"Prior to the Medicare waiver, because we operated as an outpatient practice, we could prescribe controlled medications just like you could prescribe anyone a controlled medication in an outpatient setting. But under the Medicare waiver, we cannot have the patients' medication billed to their Medicare Part D plan because we are not using an outpatient community pharmacy. Instead, we have chosen to use the Mount Sinai inpatient pharmacy for all oral medications."
Denver Health Virtual Hospital at Home
The coronavirus pandemic prompted Denver Health to launch its Virtual Hospital at Home program in April 2020.
The goals of the program were twofold, says Patrick Ryan, MD, medical director of the Hospital Transitions Clinic at the Denver-based health system.
"The first reason we developed Virtual Hospital at Home was to expedite discharges from the hospitals. That way, when patients were stable enough but still needed monitoring, they could be discharged in a safe way. The second reason was to potentially decrease the number of admissions to the hospitals through identification of COVID-positive patients in the emergency department who were doing well enough that they did not need to be in a hospital but needed monitoring," he says.
Daily phone calls from clinicians and nurses are at the heart of the Virtual Hospital at Home program, Ryan says. "The basic structure of our Virtual Hospital at Home program is two phone calls per day for each patient. They receive one registered nurse call and one clinician call. One call is made in the morning, and the other call is made in the afternoon to allow for interval assessment of the patient. During those phone calls, patients have their vital signs assessed through patient self-monitoring with blood pressure cuffs, thermometers, and pulse oximeters at home."
Using telephonic rather than video-based communication with patients has been simple and reliable, says Jeremy Long, MD, MPH, medical director of the Intensive Outpatient Clinic at Denver Health.
"We had the capacity to do video visits, but the technology piece was a challenge and would have required some patient components. So, we relied exclusively on the telephone; and on both the provider side and the patient side, it was beneficial. The video is great in theory, but there can be barriers for patients such as having to have an app on their phone and knowing how to use it. There was no doubt that the patients could do telephone visits," he says.
Using video visits also would have posed a scheduling challenge, Ryan says.
"Especially during our busiest times, we could not guarantee to our patients that they would be called at a specific time. The goal for our clinicians and nurses was just to get through their assigned patients during their shift. So, we could not tell patients to log in to the MyChart app at a particular time and be ready for a video visit."
Patient eligibility and enrollment
The kinds of patients who have been enrolled in the Virtual Hospital at Home program from emergency rooms and urgent care clinics have evolved over time, Long says.
"Initially, we took an all-comers approach for patients who needed some type of regular monitoring. As the pandemic went along, we tried to risk-stratify the patients. The Virtual Hospital at Home ended up being a higher-acuity monitoring program. Some of the lower-acuity patients who did not need the frequent calls that we offered in the Virtual Hospital at Home program could be monitored by their medical home clinic, with just a few calls per week," he says.
A research article published by Infection Control & Hospital Epidemiology includes data from more than 200 patients who were enrolled in the Virtual Hospital at Home program in April and May 2020. The article features three data points:
•81.5% of the patients in the program were successfully
discharged
•13.3% of the patients in the program required a higher
level of care, with 38.7% of those patients admitted for hospitalization
•The majority of the program's patients were either uninsured (28.3%) or covered by Colorado Medicaid (38.2%)
Through February, more than 1,000 patients had been enrolled in the Virtual Hospital at Home program.
Keys to success
Several factors have been critical to the Virtual Hospital at Home program's success, Long and Ryan say.
A team of medical assistants played a crucial role in the program, Ryan says. "The medical assistants were particularly helpful in training patients on how to use their blood pressure cuffs and pulse oximeters. They told patients how to install batteries into those devices and how to operate them independently. The medical assistants were also important in arranging timely follow-up for our patients when they were discharged from the program."
Collaboration has also been pivotal, says Ryan.
"When we started the Virtual Hospital at Home program, we had representatives from outpatient primary care, internal medicine, family medicine, inpatient hospitalist medicine, and the emergency department. There was also collaboration at the micro level among our team. For example, there have been open lines of communication between our nursing team and our clinician team. Many times, we think of inpatient medicine and hierarchal struggles between nursing and physicians about what to do with patients. But our nursing and clinician teams trusted each other."
The Virtual Hospital at Home program stayed within the bounds of financial and other resources, Long says. "We used internal resources and did what we do best. We stayed within what we are good at rather than trying to stretch beyond what we are good at. The video visits are a good example. That would have stretched us—it was not something we were already doing. Whereas, with the telephone, it played to our strengths."
Linda DeCherrie, MD, is the clinical director of Mount Sinai at Home, professor of geriatrics and palliative medicine at Icahn School of Medicine at Mount Sinai in New York City. Photo by Chris Lane/Getty Images.
The pandemic has significantly decreased physician trust in healthcare leaders, the healthcare system as a whole, and insurance companies.
The coronavirus pandemic decreased physician trust in several healthcare institutions and sectors, according to a recent national survey.
Physicians are essential players in the healthcare system. When physicians lack trust in institutions, sectors, and colleagues, it erodes healthcare's fundamental grounding in a series of human relationships.
The recent national survey, which was conducted by NORC at the University of Chicago for the Philadelphia-based ABIM Foundation, is based on information collected from 600 physicians nationwide.
The national survey features several key data points on how the pandemic has impacted physician trust in the following institutions, sectors, and colleagues:
The healthcare system as a whole: increased trust (17%), decreased trust (30%), trust remained the same (53%)
Hospitals: increased trust (23%), decreased trust (19%), trust remained the same (58%)
Healthcare organization leadership: increased trust (18%), decreased trust (30%), trust remained the same (52%)
Pharmaceutical companies: increased trust (21%), decreased trust (13%), trust remained the same (66%)
Health insurance companies: increased trust (6%), decreased trust (31%), trust remained the same (63%)
The erosion of physician trust during the pandemic is a serious problem, Richard Baron, MD, president and CEO of the American Board of Internal Medicine and the ABIM Foundation, told HealthLeaders.
"It is a severe problem, but it is equally well-framed as an opportunity that if we focus on trust, we can make things a lot better. That is the core effort that we are undertaking—we are saying that getting organizations to focus on getting trustworthy is something that will help them be successful as organizations," he said.
The pandemic decreased physician trust in healthcare leaders, Baron said.
"The pandemic was a stress test for the healthcare system in many ways, and institutions faced all kinds of challenges in terms of getting personal protective equipment for doctors, managing the major financial stresses associated with the pandemic, and other difficulties. How people navigated those challenges as leaders was something that physicians paid a lot of attention to. If leaders did not supply adequate personal protective equipment and expected doctors to show up, it breached trust. Doctors remember those circumstances."
Healthcare leaders can pursue several strategies to restore physician trust that has been decreased during the pandemic, he said. "Healthcare leaders cannot take the trust of physicians for granted. They need to strategize as leaders in an intentional way on how they can rebuild trust. There are several strategies available to them. Transparency is a trust-building strategy. Engagement is a trust-building strategy. Sitting down with physicians when decisions need to be made is a trust-building strategy. Admitting mistakes is a trust-building strategy."
Other dimensions of physician trust
The national survey also measured broader measures of physician trust independent of the pandemic. These measures included physician trust in the following areas:
Health insurance companies: completely trust (1%), somewhat trust (19%), neither trust or distrust (23%), slightly distrust (36%), completely distrust (22%)
Other doctors within your practice: completely trust (63%), somewhat trust (31%), neither trust or distrust (5%), slightly distrust (1%), completely distrust (0%)
Other doctors outside your practice: completely trust (20%), somewhat trust (66%), neither trust or distrust (11%), slightly distrust (4%), completely distrust (0%)
The relatively high level of physician mistrust of insurance companies is concerning, Baron said. "Insurers understand that the stronger their collaboration with physicians the better their relationships are with their beneficiaries and their corporate customers. No human resources benefits manager wants to hear complaints from employees about physicians disparaging insurance companies. So, the relationship between physicians and insurers is important and needs sustaining."
Insurance companies can take several actions to gain a higher degree of trust among physicians, he said.
"It requires relationship building, engagement, transparency, and honesty. Insurers need to acknowledge or admit mistakes, they need to explain policies in ways that are accessible, and they need to create effective working processes. If an insurer has processes that are full of bureaucratic hurdles and doctors are stumbling over poorly designed systems, that does not build trust. If you give doctors a clear pathway to get through whatever you want them to get through, that can be a trust-building strategy."
The relatively high level of physician mistrust of doctors outside their medical practices also is concerning, Baron said. "It is a problem. For example, when people look at root causes of malpractice cases, it is common for litigants to hear a clinician say terrible things about the care provided by another clinician. The idea of a physician not trusting another physician puts everyone in a difficult position. The patient does not know which physician to believe. It puts the physicians in a difficult position because it leads to litigation and anxiety."
There are ways to build trust between physicians and clinicians outside of their practices, he said. "It is a lot about relationship building, responsiveness, and reliability. Every interaction is an opportunity to build trust and trust gets built by a set of behaviors—by empathy, by connection, by competence, and by compassion. Those behaviors either come across in a consulting letter or they don't. Those behaviors either come across in a phone call or they don't."
Consulting physicians need to be intentional in their efforts to establish trusting relationships with referring clinicians, Baron said. "The consultant who thinks that what they are responsible for is knowing the literature in their discipline and as long as they get that right their referring doctors will love them are missing the point. A physician expects a consultant to be competent and current, but trust is not going to come from just your competency and whether you are current with the literature. Trust comes from a real effort to create a relationship."
An imbalance between work needs and personal needs is common in the medical profession.
Physicians who experience lower work-life integration tend to be women, single, 35 or older, and work more hours and call nights, a recent research article indicates.
Work-life integration—specifically an imbalance between work needs and personal needs—is associated with physician burnout. Physicians reported high levels of burnout before the coronavirus pandemic, and physician burnout has likely worsened during the pandemic.
"Work-life integration is strongly related to burnout—even more so than a lot of the typical demographic factors that are commonly considered drivers of burnout such as gender and age. In contrast to demographic factors, work-life integration directly impacts whether individuals are putting their work needs ahead of their personal needs," Daniel Tawfik, MD, MS, lead author of the recent research article and an instructor in the Department of Pediatrics at Stanford University School of Medicine in Stanford, California, told HealthLeaders.
The research article, which was published by JAMA Network Open, is based on information collected from more than 4,300 physicians. Work-life integration was measured with an 8-item scale, with scores ranging from 0 to 100 and higher scores signifying better work-life integration (WLI).
The study includes several key data points:
Female physicians had a worse mean WLI score than male physicians (52 versus 57)
A lower work-life integration score was associated with being 35 or older, single, working more hours, and more call nights
Medical specialties associated with low work-life integration included emergency medicine, urology, general surgery, anesthesiology, and family medicine
The largest gender disparities were observed in physicians who were 45 to 54 years old
"Poor WLI may have adverse effects on physicians and their families at multiple levels, highlighting the urgency of addressing these disparities. Women are more likely to experience burnout, which may be largely attributable to differences in professional characteristics and satisfaction with WLI," the research article's co-authors wrote.
Improving work-life integration
There are five actions that healthcare organizations can take to improve physician WLI, the research article says.
1. Increase physician control of scheduling
Although the most appropriate approach to scheduling will vary by healthcare organization, specialty, and work setting, there are some strategies that can be widely successful, Tawfik says.
"One approach is promoting a culture where any non-time-sensitive items can be addressed flexibly—either after hours if that works best for the individual or the next day if that is better for them. For outpatient specialties, there can be improved flexibility for clinic appointments while taking into account the needs of other clinic staff. One other idea is making sure there are sufficient personnel and resources, so that physicians can reduce their work hours when needed without having to worry that they are putting their colleagues under excess burden or putting their patients at risk of not having enough access to care," he says.
2. Improve practice efficiency
To boost WLI, one area that is especially promising is reducing clerical burden for physicians, Tawfik says.
"For example, over the past several years, many clinics have introduced scribes, who are individuals who are specially trained to document clinical encounters. This provides timely documentation of encounters, reduces some of the clerical workload on physicians, and may improve the billing accuracy for clinics. Overall, studies that have looked at the introduction of scribes have been promising at improving physician efficiency and quality," he says.
Electronic health records are another prime opportunity to improve practice efficiency, Tawfik says. "Physicians can customize electronic health records to make EHRs work more efficiently for them. Physicians should also be afforded the time to learn how to use their EHRs most efficiently."
3. Decrease gender disparities in compensation, retention, and promotions
It will take a concerted effort to increase compensation, retention, and promotions for female physicians, Tawfik says.
"Women physicians have an uphill battle for many reasons. The culture of medicine has been male dominated for a long time, plus there are gender disparities in the medical workforce that have existed for a long time. Although there has been some progress made recently, we are still a long way from achieving equity. So, healthcare organizations need to recognize that women physicians are coming from a position of disadvantage and recognize that they need to prioritize women when they are recruiting new physicians and when they are evaluating physicians for promotion," he says.
4. Establish gender-specific mentorship, coaching, and networking
There are interventions that healthcare organizations can implement to level the playing field for female physicians, Tawfik says.
"It will be very important for mentorship, coaching, and networking to go hand-in-hand with promoting women to leadership positions and introducing larger systemic changes. Gender specific mentorship and coaching can provide more rapid benefits than the systemic changes that will take a while to achieve. Some of the important steps will be identifying women physicians who have been successful at navigating the system and advocating for change," he says.
5. Provide childcare
Healthcare organizations can improve physician WLI by offering childcare, the research article's co-authors wrote. "On-site or other readily accessible high quality backup childcare may also reduce gender disparities among physician-parents, particularly for holidays or for prolonged school closures such as experienced during the COVID-19 pandemic in 2020."
Evidence shows that genuine apologies reduce the risk of malpractice litigation when medical errors occur.
There are best practices to follow when physicians make apologies to patients, an expert on clinician-patient communication says.
Trust is an essential component in the relationship between physicians and patients. When a medical error occurs or a physician creates a negative patient experience such as being significantly late for an appointment, an apology can repair damage to the trust in a relationship.
"I cannot think of a circumstance when a physician has created a situation that requires an apology and should not make one. Erring on the side of making the apology is better than remaining silent or not making an apology," says Richard Frankel, PhD, a professor of medicine at Indiana University School of Medicine and research scientist at the Regenstrief Institute in Indianapolis.
There are four elements of a complete and genuine apology, says Frankel, who co-authored an award-winning journal article on physician apologies last year.
Acknowledgment of a problem
Explanation of why the problem occurred
Expressing sincere remorse or regret
Some form of recompence that could be financial, psychological, and/or a commitment to change behavior
"A genuine apology incorporates all four of those elements. The best practice is to engage in all four elements," he says.
Going beyond acknowledgment and explanation is crucial to make a genuine apology, Frankel says. "A key element is sincere remorse—'I am sorry for what I did, I recognize what I did, I take responsibility for what I did, I am remorseful, and I want to do better.' The restoration of the relationship will often hinge upon making a commitment. It is committing to doing something differently rather than simply offering a mechanical response in the moment, then moving on to the next thing."
Incomplete apologies often have a negative impact on the physician-patient relationship, he says. "People do not trust a partial apology, and they do not feel it is sincere when what they want is a sincere expression of the other person's remorse and sincere expression of what they are going to do about it. A partial apology comes across as being untrustworthy, and trust is a huge part of what a genuine apology restores."
It is possible to measure the impact of apologies, Frankel says.
"The impact of apologies can be measured both directly and indirectly. Directly, when apologies occur, the rates of medical malpractice lawsuits decline. The indirect measures are things like physician resilience. Where apology does not occur, the rates of depression for physicians are greater and the rates of suicide are greater."
Apologies, malpractice litigation risk, and physician well-being
Clinicians should not avoid making apologies out of fear that apologizing to a patient will increase the odds of drawing a malpractice lawsuit, Frankel says. "The evidence is that where apologies are made the risk of malpractice lawsuits goes down. In 17 states there are laws that shield a physician from being sued for medical malpractice if they offer an apology. There is a growing recognition that apology is a good preventative for medical malpractice lawsuits."
Apologizing to patients also boosts physician well-being, he says.
"There is also research that shows that physicians who make medical errors suffer themselves disproportionately to the medical errors that they make. Like anyone who is in a skilled profession or a skilled trade, when you make a mistake, it is harmful to the other person, but it is also harmful to the professional or tradesman. It harmful to your sense of pride. It is harmful to your sense of being able to practice at a level of skill that you thought you had. Apology is one way to restore confidence and one way to restore the balance between your skills and your psychological well-being."
From the clinician's perspective, Frankel has seen the healing potential of apologizes many times. "I know from personal experience of working with hundreds of physicians that the act of making an apology—though it can sometimes be difficult and painful—almost always results in a relief of distress."
Apologies and medical errors
Making a complete and genuine apology is appropriate when a medical error has occurred, Frankel says.
"For example, a physician might say, 'We gave you the wrong medication. Fortunately, it is not a medication that is going to cause you any harm, but we take this kind of situation very seriously. We acknowledge that we made a mistake; and when this happens, we want to learn from our mistakes and learn to do a better job. We are sincerely sorry and remorseful that this occurred, and we are dedicated to making it right for you and making it right for anybody who comes after you.'"
