Spectrum Health West Michigan's new senior vice president of quality, safety, and patient experience shares his insights.
There are golden opportunities to improve patient safety and patient experience at healthcare organizations, a new top executive at Grand Rapids, Michigan-based Spectrum Health says.
Spectrum Health has hired James Moses, MD, MPH, to serve as senior vice president of quality, safety, and patient experience at Spectrum Health West Michigan, which is one of two healthcare delivery divisions at the health system. He is set to begin working in his new role in April.
Moses comes to Spectrum Health from Boston Medical Center, where he has served as chief quality officer and vice president of quality and safety. The board-certified pediatrician and pediatric hospitalist earned his medical degree at the University of Chicago Pritzker School of Medicine.
HealthLeaders recently discussed issues related to safety and patient experience with Moses. The following is a lightly edited transcript of that conversation.
HealthLeaders: What are the primary elements of patient experience?
James Moses: Patient experience is extremely important. The main elements are patient-centeredness and thinking through how care is personalized for every patient. Patient experience is more than just patient satisfaction. Patient experience is about the experience we are providing to patients and whether they walk away feeling like the experience was something they felt positive about.
The patient experience is also about respect. When you do not tailor care to individuals, it is a form of disrespect. If providers are not doing their homework prior to clinical visits to really understand the patients who are in front of them and the active issues, that can be perceived as a sign of disrespect. If patients do not feel that their concerns are being heard, that is not achieving the patient-centeredness and the personalization aspect that you want in the patient experience.
Eventually, what we are seeing in telemedicine and digital health will help facilitate and accelerate the personalization of healthcare. That is something to be excited about.
HL: Where do you see the opportunities to improve patient experience?
Moses: One area of opportunity is continuity of care. The team of providers needs to act as a team.
Sometimes, you go to one provider, and they act completely independent of other the providers and specialists. You have a one-off experience instead of continuity and a sense that your caregivers know you. Too often, I see providers asking patients for an update on what the other doctors have said, which is not patient-centered and not the right patient experience. There needs to be much better effort around systems of healthcare and ensuring that they are functioning in a coordinated way across multiple services, so that care can be tailored across the care continuum in a way that makes the patient feel respected and their physicians are all on the same page.
Patients need to know that the right thing is going to be done in clinical decision-making as well as the coordination of evaluations, diagnostic workups, and treatments. In healthcare, patients fend for themselves quite a lot, and we have to remove those types of barriers and remove discoordination in their care.
HL: Patient safety has been a top goal in healthcare since the publication of To Err Is Human two decades ago. Which patient safety areas remain problematic?
Moses: One of the continuous areas of opportunity is around diagnostic errors. There has been a lot of discussion around why providers and clinicians make the wrong diagnosis and what is happening around their decision-making process that is getting them to head down the wrong path. We need to make sure that clinicians can step back and take a nuanced view to ensure that they are making the right diagnosis and to confirm that the diagnoses they are making are in line with what they are seeing clinically.
Another area is related to growth of procedures happening in the ambulatory space. Historically, we have had a lot of surgical procedures and other types of invasive interventions in the hospital-based environment, which is a very controlled setting. One of the areas that has presented new risk is a push toward having ambulatory procedures and not necessarily having the same safeguards in place as we had in the hospital-based operative arena.
Another area is communication among teams and across transitions. We still have work to do to ensure that we have robust communication around transitions and ensuring robust continuity of care between teams. That is going to be a continued area of priority and focus for all of healthcare for the foreseeable future.
HL: Where are the opportunities to improve communication?
Moses: Handoffs and transitions of care continue to be an opportunity.
When the emergency department is admitting patients to the inpatient area or there are surgical patients coming up from the operating room to a surgical ICU, there continues to be opportunity to ensure that teams are using standardized communication tools to help with the adequacy of handoffs and to make sure that everybody understands the key areas of care that need to be handed off.
In the transitions of care between providers and the ambulatory space, you are not in such an acute situation. But often, we see providers side-step direct communication between specialists and primary care doctors—they often communicate through their medical documentation, which is not the same as having huddles around complex patients with specialized needs. Patients would benefit if there were more planned communications.
HL: In healthcare, how far away are we from seeing the degree of safety that we see in the aviation industry?
Moses: Unfortunately, we are pretty far away from that level of safety. Healthcare is not like flying one airplane at a time. It is like flying hundreds of thousands of planes every day all at the same time. So, there is a high level of complexity that we deal with in healthcare. We do not have the safeguards we need to have in place to the extent that they should be in place.
It is going to be a long journey, but it does not need to be a forever journey. What I would like to see is a national focus on safety events and harm from safety events. That would help organizations to understand the true north of keeping patients safe. Having a national priority on patient safety would make the journey quicker as well as more robust and transformative.
It also would be beneficial for organizations to be more transparent about the frequency of harm events. When you look at the measures that we report, they are preventable harm measures and patient experience measures. But we do not have a national framework for reporting serious safety events in a way that allows folks to come together to learn best practices and to objectively understand how one organization may be doing a better job or worse job.
New policies are needed to close hospital patient safety gap between Black and White patients, researchers say.
Differences in the quality of hospitals that Black and White patients access are a driver of patient safety disparities between Black and White patients, a new report says.
Racial care disparities have been a concern in U.S. healthcare for decades. These disparities have drawn heightened attention during the coronavirus pandemic because Black, Hispanic, American Indian, and Alaska Native COVID-19 patients have experienced disproportionately high rates of negative outcomes including mortality.
The new report, which was conducted by researchers at the Urban Institute with funding from the Robert Wood Johnson Foundation, examines 2017 hospital discharge data from the Agency for Healthcare Research and Quality's Cost and Utilization Project. The researchers also used AHRQ software to focus on 11 patient safety indicators.
Four of the patient safety indicators were categorized as "general," including pressure ulcer rate and central venous catheter-related blood stream infection rate. The other seven patient safety indicators were categorized as "surgery-related," including perioperative hemorrhage or hematoma rate and postoperative sepsis rate.
The researchers also categorized hospitals as "high quality" or "low quality" based on whether a hospital was above or below the median value of each patient safety indicator.
The new report features four primary findings:
Compared to White patients, Black patients experienced worse care quality for six of the 11 patient safety indicators. The care disparity was particularly notable for surgery-related patient safety indicators, with Black patients experiencing worse care quality compared to White patients for five of the seven measures.
When the researchers focused on Medicare beneficiaries, there were similar Black-White disparities in patient safety indicators.
Black patients were less likely to be admitted to high quality hospitals for 9 of the eleven patient safety indicators. The care disparity was particularly notable for surgery-related patient safety indicators, with Black patients less likely to be admitted to high quality hospitals for six of the seven patient safety indicators. White patients were 9 percentage points more likely to be admitted to high quality hospitals on four patient safety indicators and more than 7 percentage points more likely to be admitted to high quality hospitals on six indicators.
Compared to White patients, Black patients were less likely to be admitted to high quality hospitals for two or more of the four general patient safety indicators. Compared to White patients, Black patients were 7.9 percentage points more likely to be admitted to low quality hospitals for all seven of the surgery-related patient safety indicators. Compared to White patients, Black patients were 4.9 percentage points less likely to be admitted to high quality hospitals for all of the surgery-related patient safety indicators.
"This study finds that Black and White patients face different standards of patient safety and that some of this disparity can be attributed to differences in the quality of hospitals patients access. Black-White disparities in patient safety are larger for quality measures surrounding surgical procedures, and Black patients are significantly less likely than white patients to access the hospitals best able to minimize these adverse surgery-related patient safety risks," the report says.
Interpreting the data
The propensity of Black patients to access low quality hospitals more often than White patients is a driver of quality disparities in hospital care, the lead author of the new report told HealthLeaders.
"We have known that Black and White patients experience different quality of hospital care for decades. The focus of this study was to ask whether these differences are, in part, driven by differences in the overall quality of hospitals that Black and White patients can access. The answer is, 'yes.' We find that White patients access high quality hospitals that are best able to minimize adverse safety events such as hospital-acquired illnesses or injuries," said Anuj Gangopadhyaya, PhD, a senior research associate at Urban Institute.
There have been several policies implemented in the past several decades that might have been expected to narrow differences in the quality of care, he said. "Those policies include Medicare discontinuing reimbursing hospitals for services treating specific hospital-acquired conditions as well as penalties enforced under the Affordable Care Act. Nonetheless, we continue to see persistent differences in patient safety across hospitals."
New policies are needed to close the Black-White patient safety gap, Gangopadhyaya said. "Black patients are consistently more likely to be admitted to hospitals that are on the worst end of patient safety measures. This is evidence that the current policies that are attempting to improve patient safety and narrow patient safety gaps are either sluggish or ineffective."
Disparities in surgery-related patient safety measures are "concerning to say the least," he said.
"The biggest disparities and patient safety gaps between Black and White patients are for surgery-related patient safety measures. At the population level, Black patients are far more likely than White patients to suffer from sepsis infections, pulmonary embolism, respiratory failure, and other horrible conditions that occur during or after a surgical procedure," Gangopadhyaya said.
The Affordable Care Act has not been effective in addressing this disparity, he said.
"It was well established before the Affordable Care Act that Black patients were consistently more likely to receive treatment at hospitals that were considered low quality with regard to surgery performance. In our research, we were interested in whether that story had changed at all in the post-Affordable Care Act world. The ACA was intended to improve healthcare access and affordability for vulnerable populations. Our results suggest there has been little change on this front. We continue to see patient safety gaps and differences in the quality of hospitals used by patients, particularly for surgical procedures."
COVID-19 has many parallels to earlier outbreaks including lack of preparedness, healthcare inequities, and politicization of pandemics, medical historians say.
Medical historians say there are pivotal lessens to be learned from the coronavirus pandemic and previous widespread outbreaks.
The coronavirus pandemic is the worst infectious disease outbreak in the United States since the 1918 influenza pandemic, with each virus claiming more than a half million American lives. There are instructive parallels to be drawn between the coronavirus pandemic and outbreaks such as the 1918 flu, a quartet of medical historians from Michigan Medicine's University of Michigan Medical School says.
Preparation and health equity
Howard Markel, MD, PhD, director of the Center for the History of Medicine at the medical school, says the coronavirus pandemic has illustrated the necessity to prepare for global pandemics in the future.
"We have to be on guard and fix the things that led to this pandemic. This is the worst crisis of our lives, and the biggest collective experience since the Great Depression. If this doesn't teach us once and for all to start preparing for pandemics in the modern world, where an outbreak anywhere can go everywhere, I don’t know what will," he says.
Investing in public health is like investing in public safety, Markel says. "I have a firehouse two blocks from where I live, and I have never called it. But I pay my taxes and I'm glad it's there in case we do need it. That's what we have to be doing with public health at the local, state, national and international level."
Inequity has taken a heavy toll in lives during the coronavirus pandemic and earlier outbreaks such as the typhus epidemics two centuries ago in London, he says. "The poor don't get sick because they're bad or unworthy, they get sick because they're poor, living in crowded conditions, without access to healthcare."
In terms of inequity, history is repeating itself during the coronavirus pandemic, Markel says. "Now we have a different pandemic and what a surprise, the poor are more affected than the wealthy. But what I fear is that like pandemics and epidemics past, the last act of this one will be amnesia, and going back to life like it was."
Parallels to earlier pandemics
There are several similarities between the coronavirus pandemic and the 1918 flu, says Powel Kazanjian, MD, PhD, chief of infectious diseases at the medical school and a medical historian. "A surge of infection that overwhelms capacity is similar with 1918 flu, as is the government downplaying of infection that led to a lack of concerted, centralized guidelines, and the loneliness of social isolation."
Placing personal liberty and economics ahead of public health concerns is common in the history of infectious disease outbreaks, he says. "I am not surprised by the differences in the adherence to social distancing guidelines by individual states, or the prioritization of economy over public health issues—a that has been seen before."
Public health interventions
Public health recommendations targeting behavior such as social distancing and mask wearing proved effective in both the coronavirus pandemic and the 1918 flu, J. Alexander Navarro, PhD, assistant director at the Center for the History of Medicine says.
Public health measures "had a major positive impact on the case count and death toll in those places that implemented them early, used multiple interventions, and kept them in place for as long as possible," he says.
The coronavirus pandemic and earlier outbreaks show the necessity of funding public health, Navarro says. “When budgets are tight, public health spending is low-hanging fruit. That is, until a crisis suddenly pops up and we need to call on a robust infrastructure that has been allowed to crumble."
Pandemic politics
The coronavirus pandemic is generally comparable to the 1918 flu, but the influenza pandemic is not the best prior U.S. example of politicizing an outbreak, says Joel Howell, MD, PhD, Elizabeth Farrand Professor of the History of Medicine and director of the medical school's Program in Society and Medicine.
"The obvious, and most comparable, is the 1918 flu pandemic. But there are lessons to be learned from comparisons as well to the onset of AIDS, especially in the ways that the epidemic was used to justify a set of political and moral beliefs," he says.
Political leaders including members of the Reagan administration targeted the gay community in the early phase of the HIV/AIDS outbreak in the 1980s.
History tells us that there will be more major infectious disease outbreaks, Howell says. "This will not be the last pandemic. We need to be ready for the next one, which could be a lot worse."
The new facility in Cleveland will combine a range of services, including intensive rehabilitation, skilled nursing, and a multi-specialty geriatric practice on-site.
Two Ohio-based health systems have signed a collaborative agreement to operate a comprehensive skilled nursing and rehabilitation center in the Old Brooklyn neighborhood of Cleveland.
Traditional skilled nursing facilities are often standalone institutions with limited connections to acute care hospitals and home health services. The new facility in Cleveland, which is set to open by the end of the year, is being designed to have smooth transitions of care from the hospital setting to the home setting.
The new partnership features Toledo-based ProMedica and The MetroHealth System in Cleveland. The new facility, which will be located in the former Deaconess Hospital, will be called ProMedica Skilled Nursing and Rehabilitation at MetroHealth and will serve a mainly senior population.
ProMedica Skilled Nursing and Rehabilitation at MetroHealth is envisioned as a new approach to post-acute care for seniors, says Julie Jacono, MBA, senior vice president and chief strategy and innovation officer at MetroHealth.
"Most skilled nursing facilities are a disconnected campus. The patients get transported from one place to another. Physicians from a health system may come into the facility or they may not come into the facility. What is different with our new facility is this is a fluid continuity of care from multiple stages of care. It is one team following the patients all the way through their care. We feel that continuity of care and joint accountability for how the patient does in the end is what makes this new facility very different," she says.
The new facility will have 96 beds for lengths of stay expected to be less than 30 days. It will provide medically complex and intensive rehabilitation services for patients transitioning from hospital to home as well as 24-hour skilled nursing care. The facility will offer outpatient care and convenient access to inpatient rehabilitation services, geriatricians, and geriatric specialists.
ProMedica Skilled Nursing and Rehabilitation at MetroHealth is being designed as the skilled nursing facility of the future, says Randy Oostra, DM, president and CEO of ProMedica.
"We have tapped healthcare industry experts, architects, infection preventionists, and other specialists. A lot of their features are included in this partnership such as all private rooms. The facility will have some rehab capabilities that will be enhanced. And there will be the kind of monitoring you would expect in more modern facilities. When people walk in, the facility will look, operate, and feel very different than the senior facilities that were built 20 years ago," he says.
Key elements of the partnership
ProMedica Skilled Nursing and Rehabilitation at MetroHealth will be jointly staffed by the health systems, Jacono says.
"With the exception of the physicians and the therapists, the caregivers will be ProMedica staff. They will be hired and managed by ProMedica Senior Care. That is why this is a partnership. We will be jointly staffing elements of the care team. It is why we feel very optimistic about this partnership because ProMedica has done this before, and they were open and excited to work with us collaboratively," she says.
ProMedica and MetroHealth are well-suited for this kind of partnership, Oostra says. "We are both strongly mission-based in that we are committed to addressing social determinants of health and we have a lot of focus on working in our neighborhoods. In talking with MetroHealth, we have a lot of focus on the next level of care coordination for seniors as they come out of acute care and how you integrate that better."
ProMedica Skilled Nursing and Rehabilitation at MetroHealth will be a cornerstone of the Old Brooklyn neighborhood, Jacono says.
"That entire campus is dedicated to the unique needs of seniors as they move across the continuum of care, and it is in a great neighborhood. Surrounding that campus, there are several apartment complexes that serve large numbers of seniors. At both ProMedica and MetroHealth, we see this as a community facility. So, we have worked diligently with community partners, and they see this facility as a new asset in the Old Brooklyn community. It can drive quality of life and economic development in that community. Residents in this community see this facility as a great alternative for them to remain healthy and age in place," she says.
Preparing patients for success
For seniors, the new facility will serve as a bridge between the hospital setting and the home setting, Oostra says.
"Patients coming out of a hospital are often not prepared to go about their normal lives. With penalties for rehospitalizations, what we have been seeing at health systems is the need to link hospitals more closely with senior facilities to prevent rehospitalization or declines in health. One of the services this new facility will be providing is intensive rehabilitation to set up patients to thrive at home," he says.
A comprehensive approach to care will be a crucial aspect of ProMedica Skilled Nursing and Rehabilitation at MetroHealth, Jacono says.
"It is innovative because it is part of a larger system of care. In one campus, we are having some of the top physical medicine and rehabilitation doctors and our geriatric doctors working together. What we envision is a physical representation of a patient-centered medical home. We have the physical asset to be able to bring patient-centered care around our seniors," she says.
A wide array of services will be available in the new facility, Jacono says.
"Over the past five years, we have made a series of investments to make the Old Brooklyn Campus our primary hub for acute rehabilitation, spinal cord injury, and bringing the rest of our assets around geriatrics. On this campus, you are going to have a comprehensive personality for outpatient geriatric care, skilled nursing geriatric care, acute rehab, and research related to rehabilitation. McGregor PACE is a partner in that building—they have a great day program for seniors who are trying to avoid going to a nursing home," she says.
The new facility will help seniors make the transition to their homes, Jacono says.
"Our teams will work collaboratively, so that when a senior is ready to be discharged from the skilled nursing facility back into their home, we will have the right home care set up to be successful. We will assess social determinants of health, so if what a patient needs to be successful at home are additional services, we have the McGregor PACE program and a strong relationship with our local agency on aging to make sure that discharge is not just a checked box. We will not be saying, 'You are done with your rehab—good luck!' We will be taking responsibility for a patient's success and outcomes as they transition home," she says.
ProMedica Skilled Nursing and Rehabilitation at MetroHealth will provide a model of care that should be attractive to other health systems, Oostra says.
"We think these kinds of partnerships will start to evolve across the country, and that more and more health systems that may not have traditionally focused on senior care will look at this as a model for what they can do not only for patients leaving their hospitals but also what they can do to address aging in neighborhoods," he says.
Health system executives surveyed early this year are optimistic about service volumes despite ongoing uncertainty linked to the coronavirus pandemic.
Although hospital service volumes decreased significantly in 2020, health system leaders expect most service volumes to rebound by 2022, a new survey found.
Particularly during the early phase of the coronavirus pandemic, healthcare providers experienced sharp declines in service utilization. The drivers of reduced utilization included state restrictions on elective surgery to accommodate coronavirus patient surges and patients deferring care because they feared exposure to the virus in healthcare settings.
The new survey, which was conducted by New York-based McKinsey & Company from Jan. 17 to Feb. 5, collected information from 30 of the largest nonprofit and for-profit health systems in the country.
A surprising finding of the survey was significant optimism about the future despite continuing uncertainty linked to the pandemic, says Kyle Gibler, MD, MBA, a partner at McKinsey & Company.
"When we talk with clients, many are concerned about a slow recovery of volumes to pre-COVID levels. But in our survey, most health systems predicted a near-return to historical levels by the middle of 2021 for most clinical areas. Even emergency department volumes, which many health systems have publicly talked about potentially never returning to pre-COVID levels, were projected to fully return by 2022," he says.
The survey includes several key data points:
Inpatient admissions: On average, hospitals surveyed experienced a more than 20% decrease in inpatient admissions from March to June 2020. Survey respondents reported that inpatient admissions rebounded by the end of 2020, ending the year at about 7% below 2019 levels. Survey respondents expected inpatient admissions to remain at 2019 baseline levels in early 2021, but they forecasted an increase of 7% to 8% in 2022 and 2023.
ED visits: Hospitals surveyed experience about a 14% decrease in ED visits in 2020, and they expected to remain below pre-pandemic levels this year. Survey respondents expected ED visits to return to baseline by 2022 and to increase about 5% over 2019 baseline levels by 2023.
Outpatient visits: Health systems surveyed experienced a more than 15% decrease in outpatient visits in 2020. They expect outpatient visits to rebound to baseline by the second quarter of this year and to increase about 7% above 2019 baseline levels by the end of this year.
Surgical volume: On average, health systems surveyed experienced about a 14% decrease in operating room procedures in 2020, and they expect surgical volume to return to baseline by the third quarter of this year. Survey respondents expect OR procedures to increase about 8% above 2019 levels by 2022.
Interpreting the data
Last year's decrease in inpatient admissions was partially offset by higher acuity among hospitalized patients, says David Bueno, PhD, a partner at McKinsey & Company.
"What we saw was that the number of patients hospitalized over that period certainly decreased, but what we also saw was an increase in acuity. So, while there were fewer patients in the hospitals, the patients who were in the hospitals were sicker. If we look more recently in the last quarterly report, we see revenue per adjusted admission up in the range of 15% year-over-year. So, there was smaller volume but sicker volume. That certainly helped hospitals sustain themselves from a financial perspective," he says.
Lower ED volumes could be a long-term trend, Gibler says.
"While ED volumes are starting to recover in the most recent quarter, many health systems expect ED volumes to remain below historical baselines for a while if not indefinitely as lower acuity patients seek other channels of care such as urgent care, primary care offices, and virtual care visits. What we expect is for hospitals to change their channel strategy. They will likely decrease the size of their ED footprint and increase in-person access points in the community such as urgent care and primary care as well as adopt digital offerings to make care more convenient," he says.
In EDs, patient acuity has had a similar effect on emergency room visits as inpatient admissions, Gibler says. "While ED volumes have been down, the average acuity has been above historical levels over the past 12 months. So, there has been some natural offset of the decreased volume by seeing sicker patients coming through the ED."
Preventive care is likely to be a primary driver of increased demand for outpatient services, Bueno says.
"We have certainly seen an outpatient visit drop-off. One of the things that we are looking for in the future is as an increasing percentage of the population becomes vaccinated for COVID hopefully health systems will see the number of preventative care visits increase, which would increase the total number of outpatient visits," he says.
Health systems are taking three approaches to the decrease in surgical volumes, Gibler says.
Some health systems are operating business as usual, with below historic volumes because they are taking whatever demand that they get. But they are not changing operations to accommodate any of the expected backlog of procedures such as knee replacements.
Some health systems are changing their bread-and-butter clinical operations and making improvements such as fixing their turnover times and making other improvements that are known levers to improve operational performance.
The bold approach is using the down time in 2020 and 2021 to completely rethink how health systems are running their ORs to accommodate volume increases after the pandemic passes, Gibler says. "They are redesigning their OR operations by using new digital tools to automate parts of the process and increase reliability. They are engaging patients in new ways to make sure that patients are not artificially deferring care longer than they need to. They are using analytics to better and more agilely match supply to demand. So, the health systems that are redesigning their OR operations will capture an outsized share of the backlog."
Historical influenza trends illuminate how to roll out coronavirus vaccines to underserved racial, ethnic, and socioeconomic groups.
Influenza vaccination trends provide valuable insight into the equitable rollout of coronavirus vaccines, a new report says.
The coronavirus pandemic has exposed inequities in the U.S. healthcare system, particularly for racial and ethnic groups, according to the Centers for Disease Control and Prevention. Research published by JAMA Network Open shows Americans with low incomes are also suffering disproportionate coronavirus infection and death burdens.
The new report, which was published by Urban Institute researchers with funding from the Robert Wood Johnson Foundation, examines historical trends for flu vaccination that indicate ways to address racial, ethnic, and economic inequities in the rollout of coronavirus vaccines. The report is based on data from the 2016 to 2018 National Health Interview Survey.
The Urban Institute report focuses on three risk groups: Nonelderly adults from 19 to 64 who are a low risk of severe COVID-19 illness, nonelderly adults from 19 to 64 who are at high risk of severe COVID-19 illness, and elderly adults 65 and over who are at high risk of severe COVID-19 illness due to their age. The report includes several key data points.
Low- and high-risk nonelderly Black and Hispanic adults had lower flu vaccination rates than their White counterparts. For example, among low-risk nonelderly adults, the flu vaccination rate for Black adults was 26.2% and the vaccination rate for White adults was 40.6%.
Risk was associated with likelihood to receive a flu vaccine among nonelderly adults with public forms of health coverage. High-risk nonelderly adults with Medicaid (34.2%) and Medicare or other public coverage (51.2%) had a higher likelihood of getting a flu vaccine than their lower risk counterparts with the same coverage (29.5% and 42.9%, respectively).
American Indians and Alaska Natives had flu vaccination rates that compared favorably with Whites. For example, among low-risk, nonelderly adults, the AI/AN vaccination rate was 45.2% and the White vaccination rate was 40.6%.
For all three COVID-19 risk groups, the presence or absence of a usual source of care was highly associated with flu vaccination rates. For example, among elderly adults, those with a usual source of care had a 69.2% flu vaccination rate compared to a 33.4% flu vaccination rate for those with no usual source of care.
Uninsured nonelderly adults had the lowest flu vaccination rates: 15.4% for low-risk nonelderly adults and 16.9% high-risk nonelderly adults.
"These findings emphasize the need to explicitly consider racial and socioeconomic equity in prioritizing rollout of the COVID‑19 vaccine. This will involve addressing access issues by expanding delivery site options and providing assistance with appointment scheduling and other logistics," the Urban Institute researchers wrote.
Four coronavirus vaccine insights from flu vaccination trends
The historical flu vaccination trends have four primary implications for the equitable rollout of coronavirus vaccines, the researchers wrote.
1. Risk has a significant impact on ethnic, racial, and socioeconomic likelihood to get vaccinated. "Among the nonelderly Black, Hispanic, Medicaid/CHIP and lower income adult populations, the higher risk group was more likely to receive their flu vaccine than their lower risk counterparts, and this pattern was particularly pronounced among lower income Black and Hispanic adults. The health conditions that put individuals at higher risk may also increase their contact with and trust in their healthcare providers and thereby increase vaccine uptake," the researchers wrote.
2. The relatively high flu vaccination rates of the American Indian and Alaskan Native populations provides insights for rolling out coronavirus vaccines to other groups that have historically experienced healthcare disparities. "Early evidence suggests that the COVID‑19 vaccine rollout among Native Americans has been very successful, with many tribes using call centers rather than online systems to schedule appointments and taking advantage of a variety of existing outreach media including newsletters, radio announcements and direct mail," the researchers wrote.
There is a lesson to be learned in avoiding reliance on the Internet to engage and enroll people for vaccination, they wrote. "Some of these strategies, especially less reliance on Internet‑based scheduling and extremely targeted outreach to the most vulnerable, could improve access for other older, less tech savvy populations."
3. It will be crucial to address low vaccination rates among uninsured adults and adults without a usual source of care. "Low vaccination rates in the South may also be related to lower rates of insurance coverage, and in the absence of progress on Medicaid or other coverage expansions, it will be important to focus on community health centers and other delivery sites that serve the uninsured," the researchers wrote.
Adults without a usual source of care would be well-served by nontraditional vaccine delivery sites, they wrote. "These may include retail pharmacies, which have also started receiving direct shipments of COVID‑19 vaccines in an effort to improve equity of vaccine distribution, and mass vaccination sites such as stadiums and convention centers."
4. Employers and community groups need to be enlisted to distribute coronavirus vaccines, the researchers wrote.
"Given that most nonelderly adults who did not receive a flu vaccine were working, employers could potentially play an important role in outreach and as delivery sites as the economy continues to reopen and vaccine supply increases. Similarly, leveraging the communication networks of places of worship, schools, sports leagues, and other trusted community organizations to promote vaccination will be critical in reaching individuals who may not regularly interact with the healthcare system."
HCCI is one of the country's leading advocacy and education organizations for home-based primary care. Julie Sacks, MSW, was recently promoted from chief operating officer of HCCI to president and chief operating officer.
Sacks joined HCCI in 2015 as vice president of operations and advancement.Previously, she was senior director of programs and services as well as director of the National Young Onset Center for the American Parkinson Disease Association.
Sacks is succeeding founder and CEO Thomas Cornwell, MD, who transitioned to executive chairman effective March 9. He also took on a new role as senior medical director of VillageMD's Village@Home.
HealthLeaders recently had a conversation with Sacks about the present status of home-based primary care and prospects for the future. The following is a lightly edited transcript of that conversation.
HealthLeaders: What are the main elements of home-based primary care?
Julie Sacks: The most basic definition of home-based primary care is that it is a way of providing primary care to the most at-risk and vulnerable people in our society. Generally, home-based primary care is provided to homebound and frail people who oftentimes are not getting primary care because it is too difficult for them to leave home.
The services you get through home-based primary care include annual wellness visits, vaccinations for patients and their caregivers, remote patient monitoring, telehealth, and care coordination. The home-based primary care doctor is often the quarterback of a patient's care team. They provide primary care, but they also know when to bring in palliative care, hospice, and home health services.
HL: How does a house call add value to a patient's healthcare?
Sacks: There is a strong relationship that gets developed between the clinicians and the patients. I went on house calls when I first started working at HCCI, and there was a gentleman who told the physician that he would not be alive without his care. This patient was homebound. He was depressed. He was really struggling. Having a physician come into his home to check on him was like a life preserver.
HL: How is home-based primary care financed?
Sacks: Generally, home-based primary care is financed in the same way that office visits to primary care practices are financed. Medicare reimburses the practice based on the coding that is submitted—so it is a fee-for-service model.
Initially, home-based primary care tends to be more expensive than office-based care largely because clinicians' transportation time is not reimbursed by Medicare. And because of clinician transportation, healthcare providers cannot see as many patients as an office-based clinician can see. In the long run, though, research shows that a practice or health system will benefit significantly from creating a house call program. That is because this model of care has been shown to reduce costly emergency department visits and hospital readmissions. It also improves the quality of patient care and offers people an alternative to expensive nursing home placements.
In addition, there are ways to manage the transportation challenge. For example, assisted living facilities are considered homes because they are a residential setting. When a clinician sees multiple patients in an assisted living facility, there is obviously less travel time involved. So, by including a mix of assisted living facilities, skilled nursing facilities, and individual homes, you can address the transportation challenge.
Beyond the fee-for-service model, there are also new payment models being launched by the Centers for Medicare & Medicaid Services and the Center for Medicare & Medicaid Innovation. These models are either capitated models where clinicians get a per-member-per-month fee to take care of patients or total-cost-of-care models where a practice takes on the risk of care.
HL: Are commercial payers financing home-based primary care?
Sacks: The commercial payers are definitely contracting with home-based primary care practices. They see the value of home-based primary care for their members—particularly for members who are the most seriously ill.
Some commercial payers are contracting with practices directly to provide services, but some of them such as Humana are creating their own home-based primary care programs because they see the value of this model of care.
HL: How are home-based primary care services offered at the practice level?
Sacks: Historically, there have been more practices that only provide home-based primary care, but we are seeing it move to office-based primary care practices.
During the pandemic, one of the last places you want a frail senior is in a hospital. So, we are seeing more of the office-based practices realizing the value of treating people in the home. We see this as a big area of growth.
Historically, there have been more small- to mid-sized home-based primary care practices. But now, we are seeing both models. An office-based practice can start small by hiring a nurse practitioner and sending that clinician to patients' homes.
Another trend we have seen over the past year and half is venture capital and private equity coming into the home-based primary care space. Venture capital is seeing the value of this care model, and they can invest significant capital in home-based primary care and participate in the new payment models that often require an upfront investment. There are venture capital-backed companies that are doing strictly home-based primary care.
HL: How can health systems launch home-based primary care services?
Sacks: One thing we have found is that home-based primary care at health systems must have C-suite support. There must be buy-in from the top levels of the organization.
Health systems also must understand which patients are appropriate for home-based primary care. Not every health system patient is appropriate for this model of care—it is too expensive. You want to use home-based primary care for the right patients, so you must train your whole health system on how to identify those patients. You want to have your emergency department physicians, discharge managers, and social workers aware of a home-based primary care program. You want your office-based primary care doctors aware, so they can identify high-risk patients who have not been in for a visit in a year or two.
It takes a system-wide effort to make home-based primary care successful at a health system.
HL: After the coronavirus pandemic has passed, what is your forecast for home-based primary care?
Sacks: Not every visit has to be in-person, so telemedicine will continue to benefit home-based primary care practices. It is unlikely that we will go back to seeing as little telemedicine as we saw before the pandemic.
The increased recognition by the public that home-based primary care is needed will have an impact on the market for these services after the pandemic. What I hope will happen is that patients and caregivers will start to demand this type of care now that they know that it exists. We plan to help mobilize that grassroots pressure, so that more and more health systems will adopt home-based primary care.
Deferment of elective care and uncertainty over safety procedures were among drivers of decreased utilization, analyst says.
A recent Avalere Health report shows decreased Medicare utilization in the early phase of the coronavirus pandemic.
The early phase of the pandemic had a negative impact on healthcare utilization and healthcare provider finances. For example, a poll conducted in March 2020 found that only 33% of clinicians had confidence that their practices had enough cash on hand to function for four weeks.
The Avalere Health report, which is based on Medicare fee-for-service claims data from a random sample of 20% of Medicare FFS beneficiaries, compares claims volume during the first six months of 2020 and the first six months of 2019. The report features several key data points.
Compared to 2019, Medicare FFS claims dropped in March, April, and May 2020:
March 2020: Inpatient claims increased 4%, professional claims decreased 13%, outpatient claims decreased 18%, and overall claims decreased 14%
April 2020: Inpatient claims decreased 23%, professional claims decreased 42%, outpatient claims decreased 51%, and overall claims decreased 44%
May 2020: Inpatient claims decreased 12%, professional claims decreased 25%, outpatient claims decreased 32%, and overall claims decreased 26%
Compared to 2019, Medicare FFS claims started to rebound in June 2020:
June 2020: Inpatient claims increased 4%, professional claims increased 3%, outpatient claims decreased 1%, and overall claims increased 3%
Interpreting the data
A combination of factors drove the precipitous drop in Medicare services utilization in April 2020, says Thomas Kornfield, MPP, a senior consultant at Washington, DC-based Avalere Health. "April 2020 is when the lockdowns were most severe. At that time, there was also a lot of uncertainty about what was safe and what was not safe in healthcare facilities, which reduced utilization."
Two factors were likely responsible for the steep decline in Medicare outpatient services during the early phase of the pandemic, he says. "My theory is that these decreased outpatient services were likely elective activities that Medicare beneficiaries felt could be delayed. In addition, many elective procedures were not being provided in the early phase of the pandemic."
There were a pair of primary drivers for the rebound in Medicare services, Kornfield says.
"In June 2020, that is when states started to relax lockdown restrictions. There was also less uncertainty about safety measures such as wearing masks. Healthcare providers had been able to figure out how to treat patients in a way that was safe. So, it was a combination of understanding ways in which services can be provided in a safe environment as well as more states moving toward reopening."
Healthcare providers and researchers should try to monitor and address the impact of deferred care, he says. "It is going to be important to look at what the deferred care means in terms of higher healthcare costs down the road. At this point, the impact of the deferred care is unknown."
The membership of the coalition includes many organizations that are focused on other complex chronic illnesses.
More than 50 organizations have formed the Long COVID Alliance to use their collective knowledge and resources to educate policymakers, accelerate research, and empower patients.
There are coronavirus "long haulers" among COVID-19 patients who have experience mild, moderate, and severe infections. In a recent study of COVID-19 patients hospitalized with severe acute respiratory infection, functional impairment was found in 53.8% of patients four months after hospital discharge. Long COVID symptoms include cough, shortness of breath, anxiety and depression, cardiac issues, fatigue, deconditioning, and hair loss.
The formation of the Long COVID Alliance was announced on Feb. 25. "At this point, we are more of a coalition than an organization. We are composed of both organizations and individuals. We see the need for the Long COVID Alliance as being three-fold: education, research, and advocacy," says Emily Taylor, MA, director of advocacy and community relations at The Solve ME/CFS Initiative in Glendale, California.
The Solve ME/CFS Initiative is one of the founders of the Long COVID Alliance. The organization is dedicated to research, advocacy, and patient support for myalgic encephalomyelitis, which was previously called chronic fatigue syndrome.
In addition to The Solve ME/CFS Initiative, several complex chronic illness organizations are participating in the Long COVID Alliance.
"Many patients who have complex chronic illnesses such as ME/CFS have not been taken seriously by the health system. All of a sudden, the long COVID patients have validity. COVID is real and the medical community is treating it like it is real. There are many COVID patients getting the same long-haul symptoms at the same time, and long COVID is legitimizing illnesses like ME/CFS that have fought for legitimacy for years," Taylor says.
Long COVID Alliance goals
The Long COVID Alliance wants to promote public-private partnerships, Taylor says.
"For complex chronic diseases, the most successful initiatives are public-private partnerships. For example, the National Institutes of Health has established partnerships with nonprofits and for-profit entities such as collaborative research centers. There are three collaborative research centers that the NIH has funded for ME/CFS in the past couple of years. This was a perfect example of academia, private partners such as Solve ME, other advocacy organizations, and public research centers with public dollars coming together to identify the primary research barriers and design studies that can address those barriers."
The Long COVID Alliance wants to confront systemic bias and racism in the response to long COVID, she says.
"The Long COVID Alliance can help drive health equity by being a bridge between healthcare providers, federal policy makers and funders, insurers, and the patient community. Long COVID patients mirror the disparities and systemic inadequacies that already existed before the pandemic. People of color are getting COVID and long COVID at a higher rate than other Americans. We are hoping that the Long COVID Alliance can bring issues of health equity to the forefront by being a conduit for patient voices and being a source of good peer-reviewed science."
Time is of the essence in finding effective treatments for long COVID, Taylor says.
"There is a sense of urgency to get this work started. Public-private partnerships in cancer, Alzheimer's, and autism took years to generate results. We do not have that kind of time with the long COVID patients. What we have learned from ME/CFS and other post-viral illnesses is that you have a treatment window at early onset that is usually two to three years. If patients do not receive treatment in that time, their illness can last the rest of their lives," she says.
The endgame is getting bench-to-bedside science fast enough so that coronavirus long haulers do not stay disabled for years, Taylor says. "We do not want the long haulers to become part of the permanent chronic illness community. That is why we are pushing this initiative so soon."
Hopeful for the future
The Long COVID Alliance is off to a good start, Taylor says.
"It is a lot of work to build an effective coalition or alliance. In my 15 years of working in this field, I have never seen a coalition come together so quickly and so organically. That reflects the urgency of treating long haulers and the decades of experience that our coalition partners have with similar post-viral chronic illnesses. We see the writing on the wall, and everyone is on the same page—we need to get these patients well as soon as possible. We all have this single-minded goal, and we are all working as hard as we can to get there."
Case managers are a pivotal element of a new program designed to improve care for behavioral health patients up to three months after hospital discharge.
A collaboration in Rhode Island between a behavioral health hospital and a payer seeks to reduce hospital readmissions and improve quality of care.
Readmissions are a significant issue in hospitalizations for behavioral health conditions. A research article published by the Agency for Healthcare Research and Quality examined data from more than 840,000 hospital stays for mood disorders and more than 380,000 hospital stays for schizophrenia. The 30-day readmission rate for mood disorders was 9.0%, and the 30-day readmission rate for schizophrenia was 15.7%.
In December, Butler Hospital in Providence, Rhode Island, launched its pilot Transitional Outpatient Program for patients who have insurance coverage from Blue Cross & Blue Shield of Rhode Island.
"The program is targeted from one month to three months after hospital discharge—that is the time that problems are more likely to develop and people need extra support. What we offer is a collection of different services depending on the needs of the patient. Those services include case management, which is what we have teamed up with Blue Cross to provide. It is short-term case management for those initial months after hospital discharge. In addition, patients often benefit from getting additional counseling, therapy, and medication management," says Brandon Gaudiano, PhD, clinical director of the Transitional Outpatient Program.
Butler Hospital can provide outpatient services on a timely basis after hospital discharge if those services cannot be set up in the community, he says. "If patients need new healthcare providers or need to be seen sooner than they can be in the community, Butler Hospital has providers who can provide those services to make sure that the time between hospital discharge and being seen by a provider is shortened."
Many patients who have a behavioral health inpatient stays are at risk of rehospitalization, Gaudiano says. "With the types of diagnoses that patients are dealing with, such as substance use disorders, risk of relapse can be very high. There are also diagnoses such as mood disorders—bipolar disorder and severe depression—where patients need a lot of extra assistance and help. There are also patients with schizophrenia and other psychotic spectrum disorders who often are dealing with chronic conditions, where even if the acute episode is over there are still many things they need assistance with."
The Transitional Outpatient Program is designed to make sure that patients receive care after their hospital discharge, he says. "We want to make sure the treatment that patients get continues after they leave the hospital. Patients go from very intensive, 24-hour monitoring and support to typical outpatient treatment, which might be meeting once per week with a clinician."
With the new program, patients get support from a team of professionals who work together to monitor the patients' situations, help them to problem-solve, and identify if there are certain needs that are not being met that can be addressed with services, Gaudiano says.
"Our approach prevents things like nonadherence to treatment—we can make sure that we are supporting the patient, make sure that they can continue with their medication, and make sure that they can continue to get to their appointments. We can make sure that patients are being followed up, monitored, and reassessed for any kind of risk factors that might be developing. It is nonadherence problems and not being able to manage stressors effectively that trigger relapse and rehospitalization."
How the Transitional Outpatient Program was implemented
The most innovative element of the new program is case management, Gaudiano says.
"Adding in case management provides an extra level of support and care that otherwise is not typical of care when patients leave the hospital. We feel that if patients have short-term case management, that extra support that patients need in a limited time can help to reduce rehospitalizations. Often, patients need help with a variety of different issues that they are dealing with in the community. There might be several social determinants of health issues that a case manager can address and help the patient problem-solve. The case manager can help the patient access services for housing, financial issues, or other problems that they might be having," he says.
Two part-time case managers are the only new hires for the Transitional Outpatient Program, Gaudiano says. "We also have the outpatient therapists and prescribers, which include psychiatrists. They are basically devoting some of their time for this new program, but they were already employed at the hospital. So, this program does not require completely new staff because we can repurpose some staff or expand their duties to include this new program."
Therapy is individualized for the patients based on their mental health needs, he says. "Typically, it is a short-term model of care that identifies the patient's goals after hospital discharge. We want to make sure patients are supported in achieving those goals. Often, there is cognitive-behavioral treatment and short-term counseling that is provided. We also make sure our therapists provide safety planning to reduce suicide risk."
Medication management is another key element of the Transitional Outpatient Program, Gaudiano says. "Patients often have medication changes done when they are in the hospital. In seeing a provider after patients leave the hospital, sometimes there are further medication adjustments as their symptoms improve or as they adapt to the medications. So, a medication provider will assess that and adjust medications as needed to make sure that medications are continuing to work for the patient."
Measuring effectiveness of the program
Readmissions are the primary metric being used to gauge the effectiveness of the Transitional Outpatient Program, says Sarah Fleury, LICSW, manager of behavioral health at Blue Cross & Blue Shield of Rhode Island.
"The main quality metric that we are looking at is readmissions—we are hoping to lower 30-day readmissions for members who go through this program by 5%. If we can achieve a 5% reduction in readmissions—taking into account the costs of the case managers—we expect to have about $118,000 worth of net savings per year. That would be about 14 fewer readmissions per year," she says.
The Transitional Outpatient Program should be a good example of a behavioral health initiative that generates a return on investment and improved clinical outcomes, Fleury says. "The cost of the case managers, which is the component that we are adding, should ultimately result in a net savings from reduced readmissions. So, the program should generate a return on investment, and it ensures that our members have access to high quality care."
