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.'"
A 40% decline in emergency department visits for emergent, nonpreventable conditions indicates that many patients with serious health problems avoided emergency rooms during the first phase of the pandemic, researchers find.
An examination of emergency department visits before and during the coronavirus pandemic at a St. Louis-based health system found an overall 35% reduction in ED visits, according to a new research article.
Declines in ED visits during the pandemic have been widely reported across the country. Reasons for ED avoidance include fear of contracting the coronavirus in healthcare settings, stay-at-home orders, and increased childcare linked to school closures.
The new research article, which was published today by Health Affairs, examined data from more than 1.2 million ED visits for non-COVID-19 conditions at BJC HealthCare from January 2018 to June 2020. The research included assessing whether decreases in ED visits were associated with insurance status or race.
"Understanding whether ED avoidance differed in association with race or insurance status is imperative to ensuring that already vulnerable populations do not suffer from worse outcomes from non-COVID-19 conditions as the pandemic continues to wax and wane across the country," the research article's co-authors wrote.
The research includes several key data points:
The number of non-COVID-19 ED visits decreased 35% after St. Louis city and county stay-at-home orders.
Non-COVID-19 ED visits decreased across all acuity levels in the first phase of the pandemic. Nonemergent visits fell 52%; primary care-treatable visits fell 47%; emergent, preventable visits fell 46%; and emergent, nonpreventable visits fell 40%.
Visits for mental health conditions fell 32%. Visits for alcohol and drug use did not experience a statistically significant decline.
There were large decreases in ED visits based on insurance status. ED visits by privately insured patients fell 46%. ED visits by Medicaid patients fell 44%. ED visits by uninsured patients fell about 40%. ED visits by Medicare patients fell 31%.
There were no significant differences in the decline of ED visits by race. The vast majority of the patients in the study were either White or Black.
"The COVID-19 pandemic was associated with a large drop in non-COVID-19 ED visits across all acuity levels, a smaller decrease in visits due to mental health, and no decrease in visits due to substance use issues. These findings suggest a need to inform the public of health conditions that require timely ED care and to improve access to alternative, lower-risk settings of care, especially for populations with social or medical risk factors," the research article's co-authors wrote.
Interpreting the data
It is likely that many patients with serious health problems avoided the ED during the first phase of the pandemic, the co-authors wrote. "The 40 percent decline in ED visits of the highest acuity suggests that there were many 'missing' patients who should have sought ED care for conditions such as heart attacks and strokes. Fear of contracting COVID-19 may have overshadowed even serious symptoms for many."
The behavioral health characteristics of the pandemic likely explain why there was a relatively modest decline in ED visits for mental health conditions and no decline in ED visits for substance abuse, the co-authors wrote.
"As a result of the high levels of anxiety and stress associated with the pandemic and its disruption of daily life, mental health and substance use issues may have been exacerbated to the point of offsetting decreases in these visits that might have otherwise occurred as a result of ED aversion. It is also possible that decreased access to outpatient care for these health issues precluded significant decreases in related ED visits," they wrote.
The relatively high frailty of Medicare patients likely explains why they experienced the smallest decline of ED visits classified by insurance coverage, the co-authors wrote. "This may be explained by the relatively high prevalence of chronic conditions among Medicare patients and the lower threshold for primary care or telehealth clinicians to refer older patients for ED evaluation."
Overall health also is a likely explanation for why privately insured patients experienced the biggest decline of ED visits classified by insurance coverage, the co-authors wrote. "Although the privately insured population is a diverse group in terms of age, income, and medical risk factors, they are younger and have fewer comorbidities than Medicare patients, on average."
The finding that decreases in ED visits were not associated with race was unexpected, the co-authors wrote.
"National survey data have found that fears of contracting COVID-19 are high among Black patients and that Black patients reported a higher likelihood of avoiding emergency care even for serious medical conditions compared with White patients. However, in our particular sample, we did not find differences by race in terms of ED use patterns. Whether these findings are related to the unique characteristics of our patient population is unclear; further study using other databases is warranted."
Using telehealth poses risks for healthcare providers including misdiagnosis.
There are three primary risks associated with telehealth, a risk management expert says.
Telehealth has expanded significantly since the start of the coronavirus pandemic last spring. The expansion of telehealth has included growth in specialties such as oncology that previously experienced modest adoption of telemedicine.
The main risks that generate potential liability for healthcare providers are related to misdiagnosis, data security, and privacy protection, says Peter Reilly, MS, North American healthcare practice leader and chief sales officer for Chicago-based HUB International.
1. Misdiagnosis risk
Misdiagnosis is the biggest malpractice risk in telehealth, Reilly says.
"The biggest malpractice risk is misdiagnosis simply because what the medical professional heard or saw during the interaction was incomplete, resulting in a misdiagnosis. There could also be the failure to diagnose a condition. For example, a dermatologist could fail to diagnose a skin lesion that could be more serious than just a rash. The other malpractice risk is if the doctor recommends a treatment plan that is not accurate. A doctor could get a treatment plan wrong because they are not skilled in telehealth visits. Very few physicians were trained to treat patients virtually," he says.
Technology failures can lead to a misdiagnosis, Reilly says. "There can be a short glitch that occurs in the visual or audio interaction that leads to the doctor hearing the wrong thing or missing something important."
He suggests two strategies to mitigate the risk of misdiagnosis in telehealth.
"In most instances, if the provider has any sense that there was not a very clear picture or robust opportunity to examine the patient, they need to recommend that the patient seek medical care in person. That may be challenging during the pandemic, but if there is any sense from the medical professional that something is not right, they should refer the patient to an outpatient facility or emergency room," Reilly says.
"While more costly, another option is to have another medical professional such as a nurse or physician assistant present during a telehealth visit. If that other medical professional gets a sense that something has gone wrong, it provides another level of risk mitigation. For some of the more complex specialties, this is a strategy that we have seen where medical providers can protect themselves," he says.
2. Data security risk
Healthcare providers face three primary risks in the realm of telehealth data security, Reilly says.
"Number One, you are relying on a data technology platform, which may be good, but it does not compare to the privacy of sitting with a patient in an exam room. The technology platform can be subject to an attack. Number Two, the physician must rely on the technology platform to not only examine the patient but also make a diagnosis or recommendation for treatment. That data can be hacked. Number Three, a patient's data could be stored incorrectly. If a physician relies on that data for future treatment plans, there is potential exposure to a medical malpractice claim," he says.
Mitigating the risks associated with data security include having protection built into the technology platform, Reilly says.
"The technology platform needs to be robust and well protected with firewalls. The technology platform also needs to be maintained. One of the biggest issues in healthcare cyber-liability is that patches are not utilized and are not kept up to date. The technology platform should be in the most current state possible," he says.
In addition, healthcare providers should be cognizant of patient information custody and rules around patient information—who has access to it and how it can be utilized, Reilly says. "There are checklists and other services that can help outline best practices in data security. There also needs to be training of staff to understand how to mitigate data security risks and to know when there has been a breach."
3. Privacy protection risk
Healthcare providers using telehealth should be familiar with rules and regulations for privacy protection, he says. "Privacy protection starts with an understanding and knowledge of state and federal rules and regulations for privacy protection that have to be offered or maintained if you house personal health information. The same applies to housing debit or credit card information."
Telehealth providers need to have robust procedures, protocols, and protections in place to make sure that third parties cannot accidentally or intentionally take data, Reilly says.
If data is taken, it is important for physician practices, hospitals, and other healthcare facilities to have a breach response in place, he says. "The breach response is important to comply with local, state, and potentially federal rules for notification of a breach. Having a breach response plan can avoid compliance penalties and/or potential liability."
Accounting for patient perspectives adds value to safety and quality improvement initiatives.
Patient experience is a valuable element of addressing patient safety incidents and conducting quality improvement initiatives.
After decades of operating with provider-centric care, healthcare organizations are becoming increasingly patient-centric. Evaluating and improving patient experience is a core component of patient-centric care.
"When you are defining patient experience, the most important factor is the patient perspective. There are many different levels. There is the one-on-one encounter that generates patient experience. There may be a sampling tool or survey tool to understand at a broader level the experience of the patients," says Pat Merryweather-Arges, MA, executive director of Chicago-based Project Patient Care.
Patient experience can play an essential role when there are patient safety incidents, she says. "The patient experience is extremely valuable when there has been harm because patients can comment on a missed diagnosis, on not being listened to, or other factors. You can answer important 'what if' questions. 'What if the clinician had acted differently?' 'What if the clinician had listened to me?' 'What if the clinician had taken me seriously?' 'What if the pain that I was feeling was addressed?' "
Patient experience can motivate care teams and other healthcare organization stakeholders when there are patient safety incidents, says Stephanie Mercado, CEO and executive director of the Chicago-based National Association of Healthcare Quality.
"Bringing in the patient experience humanizes a safety event. A safety event can be approached without the patient experience—it can be approached in a very linear way that focuses on the process and how improvements can be achieved. But when you bring in the patient perspective on a serious medical error, you get emotion. That emotion can move the hearts and minds of practitioners and other stakeholders toward a cause," she says.
Including patient experience in the process of addressing a patient safety incident elevates the effort, Mercado says. "The patient experience gives practitioners and other stakeholders an opportunity to reflect repeatedly in public and private settings about what went wrong and how badly they felt about it. Maybe next time they will slow down, double-check, or use the learning to make sure that the error does not happen again. The human element of involving patients makes a lasting impression."
When a patient safety incident occurs, patients and their family members often want to be involved in the response to the incident, she says. "Patients are looking to help make healthcare better. They are very motivated; and if they have had a very serious loss, they have a sense of commitment and resolve to make sure that loss does not happen to any other patient. If there has been harm, patients do not want another family to experience harm. Patients and families that have experienced harm can find themselves in a rewarding situation by partnering with a healthcare organization to make things better."
Healthcare organizations should be delicate and intentional about incorporating the patient experience in the response to a patient safety incident, Merryweather-Arges says.
"Patients who have experienced harm or family members who have experienced harm of a loved one need a span of time to heal and for the experience to be less raw. If you have had an error occur in your facility or in your care delivery as a clinician, you want to learn from that experience and the best person to teach you is the patient or the affected family. So, you integrate them into the learning process. It can be very emotional because they often relive the experience, which can be difficult. But if everyone is committed to change, the people who participate in these initiatives are very grateful. They are very forgiving of what has occurred as long as there is a commitment to change," she says.
Patient experience and quality improvement initiatives
Accounting for patient experience is a major factor in quality improvement initiatives, Merryweather-Arges says.
"When you are talking about patient experience, it is the experience of not only the outcomes of care but also the patients' experience while they are with a provider or a facility. Patient experience relates directly to quality because quality initiatives are oftentimes focused on improving health outcomes. You really cannot improve health outcomes without patient participation and engagement," she says.
Patient experience should be included in quality improvement initiatives, Mercado says. "There is patient engagement in successful quality initiatives. For example, when a hospital decides they want to improve something or a primary care practice decides they want to improve something, they engage the patients for input and to get their perspectives. That is where the patient experience is related to a quality initiative."
Surveys and patient-family advisory councils are effective tools to incorporate patient experience in quality improvement initiatives, Merryweather-Arges says.
"For example, the HCAHPS surveys ask patients about their experience in the care setting. Those experiences can help drive improvements—whether they are care improvements or improvements of the physical experience of being at a facility. Patients can be part of patient-family advisory councils, where their voice is heard," she says.
When including patient experience in quality improvement initiatives, patient contributions must be meaningful, Merryweather-Arges says. "Most importantly, patients do not want to be just a sounding board or a rubber stamp. They want a commitment to change. They are investing their time and their experience, which can be very emotional, to see change."
A new Declaration of Principles by 10 healthcare organizations calls for actions to safeguard the emotional, psychological, and physical safety of staff.
A group of healthcare organization CEOs recently adopted a Declaration of Principles to improve the safety of healthcare workers.
Healthcare settings pose several safety concerns for caregivers and other staff members. The dangers include emotional and psychological harm, hazards such as contaminated sharp objects, and workplace violence.
The CEO Coalition's Declaration of Principles focuses on three areas of healthcare worker safety. The CEO Coalition features the top executives at 10 healthcare organizations, including Cleveland Clinic, Henry Ford Health System, SSM Health, and UCLA Hospital System.
1. Safeguarding psychological and emotional safety:
Investing in processes and technologies that reduce emotional and cognitive burdens on team members and restore human connection to the healthcare experience.
Creating practices and policies that advance open communication between team members and leaders, so people feel safe to speak up and bring their full selves to work.
Providing resources to assess and support team members' emotional, social, and spiritual health, and alleviating the stigma and deterrents to seek support.
2. Promoting health justice:
Declaring equity and anti-racism core components of safety, and requiring explicit organizational and health equity-focused policies and practices to advance diversity, inclusion, and belonging.
3. Ensuring physical safety:
Implementing a zero-harm program for care team members to eliminate workplace violence, both physical and verbal, whether from colleagues, patients, families, or community members.
Ensuring that all healthcare organizations can procure and provide evidence-based personal protective equipment, technology, tools, and processes that healthcare team members need to do their jobs safely and care for patients.
Committed to healthcare worker safety
CEO Coalition member A. Marc Harrison, MD, president and CEO of Salt Lake City, Utah-based Intermountain Healthcare, says the Declaration of Principles elevates healthcare worker safety to the same plain as patient safety.
"We have talked about patient safety for a long time. But it seemed like we were not putting the safety of these amazing, heroic people who deliver healthcare on equal footing. One is not better than another; but healthcare workers are all human beings, and they deserve to be safe as well," he says.
The coronavirus pandemic spurred the CEO Coalition to action, Harrison says. "Intermountain has had five staff members die of COVID—not all of them got the virus at work. But I have never seen such a focus on caregiver safety out of necessity based on the challenges posed by the pandemic, particularly in the phase when we did not understand much about the virus. The Declaration of Principles is a natural offshoot of the concern that we felt about the pandemic."
Harrison, who is a pediatric ICU physician, cited a personal experience related to psychological and emotional safety.
"I am still haunted by a day in Syracuse, New York, when I was a young ICU attending physician and I attempted to resuscitate four little African American girls in an emergency department who all had died from smoke inhalation. We were unsuccessful at resuscitating every single one of them. I heard their mother's screams. If that does not affect your psychological wellbeing, I do not know what would. These kinds of experiences happen thousands of times a day across the United States. Historically, healthcare workers have been asked just to buck up. Now, we are smarter," he says.
Equity and racism are linked to healthcare worker safety, Harrison says. "We know there are huge inequities for the people we serve, and we know there are inequities for the people who are doing the serving."
He cited an example of how a racist incident at Intermountain impacted the physical and emotional safety of a nurse. "We had a Black nurse called the N-word by a gang member in one of our emergency departments. First, she felt physically unsafe. Second, she was emotionally traumatized by the experience. So, there are both physical and emotional parts to this puzzle," he says.
Workplace violence is a primary healthcare worker safety concern, Harrison says.
"We have seen workplace violence spike with the substance abuse crisis and the behavioral health tidal wave associated with the pandemic. Those are probably our greatest correlates to physical safety issues—whether people are getting punched, kicked, scratched, or spit upon. We report on this every day in our tiered huddles, and we have made huge progress with lots of tactics. But workplace violence against healthcare workers is a fact of life across the United States in emergency departments and behavioral health units in particular."
In a study conducted at Massachusetts General Hospital, pairing community health workers with hospital inpatients reduced readmissions nearly 50%.
Pairing community health workers with adult accountable care organization-insured hospital inpatients after discharge resulted in a significant reduction in hospital readmissions, a recent research article shows.
Readmissions are a key performance indicator for hospitals. Earlier research has shown that readmissions of adult inpatients within 30 days of hospital discharge are common and about 27% of the readmissions are preventable.
The recent research, which was published by JAMA Network Open, is based on data collected from 550 adult hospital inpatients drawn from six general medicine units at Massachusetts General Hospital in Boston. There were 277 patients placed in the community health worker intervention group and 273 patients placed in a control group receiving standard care, which included routine care from primary care clinics.
The study generated several key data points:
Compared to the control group, patients in the intervention group were less likely to experience a 30-day readmission (odds ratio 0.44).
Compared to the control group, patients in the intervention group were less likely to miss clinic appointments within 30 days of hospital discharge (odd ratio 0.56). For the intervention group, 22.0% of patients missed clinic appointments. For the control group, 33.7% of patients missed clinic appointments.
Compared with control group patients, intervention group patients discharged to rehabilitation had a significant reduction in readmissions. However, intervention group patients discharged to home experienced no significant reduction in readmissions.
The three most common actions community health workers took were counseling to encourage adherence with clinical care plans (86.3% of patients), psychosocial support (82.7%), and making and confirming clinical appointments (46.2%).
The community health workers (CHWs) had a significant impact, the research article's co-authors wrote.
"In this randomized clinical trial at one academic medical center, a CHW intervention reduced 30-day hospital readmissions in adult general medicine inpatients by nearly 50%. However, subgroup analyses revealed that most of the effect occurred for participants initially discharged to short-term rehabilitation. Intervention participants also were less likely to miss clinic appointments, but no significant reductions in ED visits were noted. These results indicate that CHW interventions may help reduce hospital readmissions and improve preventive care among some clinically complex patients within an ACO," they wrote.
The co-authors speculated on why the CHW intervention achieved readmission reduction for hospital inpatients discharged to rehabilitation rather than hospital inpatients discharged to home. "Potential reasons for this effect may be that CHWs addressed unmet medical and social needs that occurred during the transition from rehabilitation to home and that CHWs improved communication among the patient, rehabilitation staff, and primary physician prior to return to home."
How the community health worker intervention worked
The CHW intervention with adult ACO-insured hospital inpatients after discharge had several primary elements:
CHWs met with hospital inpatients before discharge and worked with the patients for 30 days, including assistance with clinical access and social resources
CHWs interacted with patients through telephone calls, text messages, and field visits
CHWs provided psychosocial support and health coaching through behavioral strategies, including motivational interviewing and goal-setting to improve adherence to clinical care plans
CHWs addressed patient-identified social needs such as food, housing, and transportation
Interpreting the research
In comments to HealthLeaders, the lead author of the research article speculated on why the CHW intervention achieved fewer missed clinical appointments compared to the control group.
"For the study intervention, CHWs were trained to focus on reinforcing the patient care plan and addressing any unmet need related to social determinants of health including transportation. In these ways, CHW support may have contributed to better support and fewer missed appointments among intervention participants," said Jocelyn Carter, MD, MPH, internist, Department of Medicine, Massachusetts General Hospital.
Participants being insured by an ACO likely had an impact on the study's results, she said. "Pre-existing participant connections to primary care and the ACO network were essential for effective communication between CHWs and clinical teams and for assisting participants with access to post-discharge care. These ACO-associated factors were key to CHWs connecting participants with resources and programs when they needed them most."
