An emergency department social medicine team improves care for complex patients and supports emergency room clinical staff.
An emergency department social medicine (EDSM) team at a San Francisco-based hospital has improved the care of patients with psychosocial needs.
Treating patients with behavioral health issues such as substance abuse and social challenges such as homelessness pose several difficulties in emergency departments. For example, ED clinicians are under time pressure to treat patients with acute medical conditions and ED staff typically have limited links to community-based organizations.
The EDSM team at Zuckerberg San Francisco General Hospital and Trauma Center was detailed recently in an article published by the Journal of the American Medical Association. The EDSM team at the hospital includes a patient navigator, social workers, care coordination nurses, a pharmacist, physician consultants, and specialists in transitional care, substance use, and quality improvement.
The journal article features four key data points:
From October 2017 to March 2020, the EDSM team conducted nearly 4,000 consultations to assess and coordinate care for patients, which prevented 567 admissions and 127 readmissions
More than 1,100 patients were given discharge medications at no charge and received pharmacist education about their medications before discharge
For patients treated by the EDSM team, mean ED length of stay was 345.8 minutes, which was just slightly higher than the 344-minute length of stay of all other ED patients
60-day ED utilization decreased 5.8% for patients treated by the EDSM team
Medications were provided free of charge to ED patients with barriers to medication access to promote safer discharge to the community.
The EDSM team worked closely with the ED staff, the journal article's co-authors wrote.
"At a standard time daily, the EDSM team rounded in the ED to elicit referrals from clinicians for patients experiencing homelessness, substance use, mental illness, food insecurity, intimate partner violence, and gaps in medication access, health insurance coverage, ambulatory care, and home-based services. Throughout the day, the EDSM team reviewed the electronic health records for ED patients with psychosocial needs. Additionally, ED clinicians and nurses proactively discussed psychosocially complex patients with the EDSM patient navigator by phone or in person. Once a patient referral was identified, the EDSM team integrated the psychosocial and medical aspects of care in consultation with the ED clinical team prior to patient ED discharge or admission."
Connecting patients with services
The EDSM team works with patients and ED clinicians to connect patients with services after discharge, the lead author of the journal article told HealthLeaders.
"The EDSM multidisciplinary team starts by meeting with the patient to understand his or her self-identified needs. In parallel, the team solicits input from the ED clinician on the medical issues and clinician concerns. Once a plan is created in partnership with the patient and ED clinician, EDSM team members call community-based partners including substance use treatment programs, social workers, case managers, food programs, emergency housing programs, and other community-based social services to facilitate enrollment and service delivery after discharge from the ED," said Jack Chase, MD, co-director of social medicine at Zuckerberg San Francisco General Hospital and Trauma Center.
The EDSM team works closely with staff in the San Francisco Department of Public Health and other city agencies to make community social service connections, he said.
EDSM team members also connect patients with ambulatory care providers, Chase said. These providers include primary and specialty medical care, mental health care, and substance-abuse treatment providers. These connections are made through the electronic medical record and by email to provide ongoing support, to arrange case conferences to discuss complicated patient care situations, and to facilitate referrals after discharge, he said.
Role of social medicine consultants
The EDSM teams social medicine consultants play a crucial role for patients and ED clinical staff, Chase said.
"Our social medicine consultants, soon to include a nurse practitioner in addition to physicians, employ a service-based mindset to meet the patient's self-identified needs while also providing clinical guidance, reassurance, and extra work capacity to our ED clinical colleagues. We recognize that our ED clinical colleagues are managing acute medical emergencies such as stroke, respiratory failure, cardiac arrest, and trauma while simultaneously managing behavioral health and social emergencies, including substance use relapse, psychosis, homelessness, starvation, extreme poverty, and social isolation," he said.
The EDSM team focuses on the care of patients with less acute medical issues and more prominent behavioral and social needs, Chase said.
"Our goal is to meet the patient's self-identified needs in the most efficient and successful way possible while also providing our ED clinical colleagues with a preferable alternative to admission for social needs or discharge without adequate support. To integrate a bio-psycho-social plan, key elements of this work include direct EDSM clinician to ED clinician communication and consultation, augmenting community-based services to meet a patient's needs, and care coordination with community-based clinicians to support comprehensive outpatient care."
Creating and sustaining EDSM teams
The EDSM team initiative at Zuckerberg San Francisco General Hospital and Trauma Center targeted a specific goal when the program was created, Chase said.
"Our initial vision of using a multidisciplinary team to provide more comprehensive care in the ED came from using a quality improvement mindset to understand a central problem affecting our patients and our hospital: How to meet the complex medical, social, and behavioral health needs for patients in the ED while preserving acute care services and bed space within the hospital for patients with the highest level of medical acuity."
He offered advice for how other hospitals can start an EDSM team program.
"We would recommend that hospitals start by reviewing their own patient and community data and identifying what challenges they see in relation to caring for patients with complex needs. Once data on patients' health-related social needs are defined and the reasons for unmet needs are understood, we recommend using performance improvement methodology to identify initial small tests of change to make progressive enhancements. Additionally, we recommend stakeholder engagement and team-building with community partners and existing community social services."
There are crucial elements to sustain an EDSM team program, Chase said.
"One key to success in securing support and acquiring funding has been our use of data to demonstrate effectiveness of each intervention coupled with patient stories to demonstrate the human impact of this model of care. Additional elements of our model include empowering frontline staff to drive improvement based on their own daily experiences in clinical care and creating space within the program for professional development. The latter effort supports increased training and certification to allow team members to fulfill the highest level of their licensure and credentials while building new, more sophisticated skills in the process."
The goals of the CEO include addressing infection preventionist burnout and promoting coronavirus vaccination.
The new leader of the Association for Professionals in Infection Control and Epidemiology (APIC) says the coronavirus pandemic has taught the country many hard lessons about controlling deadly pathogens.
Infection preventionists have been a vital source of expertise during the pandemic. For example, they have played a pivotal role in helping healthcare organizations to prevent the spread of the coronavirus in their facilities.
Devin Jopp, EdD, MS, began working as the new CEO of APIC in December. In previous roles, he has worked with prime healthcare stakeholders, including payers, providers, and healthcare information technology professionals. For example, he served as president and CEO at the Workgroup for Electronic Data Interchange, which focuses on enhancing the exchange of healthcare information.
In a recent discussion with HealthLeaders, Jopp talked about a range of issues related to infection preventionists during the pandemic. The following is a lightly edited transcript of that conversation.
HealthLeaders: What are your top priorities in your new role at APIC?
Devin Jopp: Right now, I want to help our members identify and share best practices in the COVID-19 response. I also want to help ensure that we do not see healthcare-associated infections rise while we pay attention to COVID-19. We need to stay focused on other things like MRSA that are out there and be on guard for new infections.
I am very much worried about burnout among infection preventionists, so I want to help prevent burnout. I also want to help recruit new infection preventionists at a time when our country really needs them.
Another one of my goals is around awareness of the need to further infection prevention in all of our care settings, especially long-term care facilities. There was a real miss in long-term care facilities in terms of not having enough infection preventionists on site before the coronavirus pandemic.
Finally, vaccines are certainly going to be important to protect our healthcare workers and the general public. I want to break down the myths and be a source of truth regarding these vaccines.
HL: Where do you think we have made the greatest strides in infection control for the novel coronavirus?
Jopp: Our understanding of the virus has grown significantly since the beginning of the pandemic. We have learned much more about how the virus is spread. For example, we have learned that spread is more airborne than through contamination of surfaces.
We have learned more about the morphology of the virus. We have learned that it is a lipid-based virus, which means that it reacts to water and soap. In the early days of the pandemic, we were worried that we would need other cleaners such as bleach to help control the virus.
We have learned that personal protective equipment and social distancing works. So, if we implement these measures, they are some of the best safeguards that we have.
We have also learned that testing and contact tracing work. When testing and contact tracing are implemented properly, it is a great opportunity for us to help turn the tide on the virus.
HL: What are the primary challenges remaining in infection control of the coronavirus?
Jopp: Clearly, vaccines are going to be an issue. I am worried about resistance, so we need to get enough of our healthcare workers to actually take the vaccines. There are concerns about how quickly the vaccines were developed, but the vaccines are based on science.
The lack of affordable PPE and availability of testing is still a concern that we must address.
The whole idea of COVID-19 fatigue, resistance to wearing masks, and engaging in social gatherings is a huge challenge for us. We must be able to overcome these challenges to control the coronavirus infection rate.
HL: How can healthcare IT play a role in control of the coronavirus?
Jopp: National surveillance is one of the big learnings that came out of the pandemic, and we need to enhance it. Electronic health record systems need to enhance the level of their data sharing.
We really need to look at how local and state health departments as well as healthcare providers share data. Now, we realize that this kind of sharing is not working at the level that it needs to be. During the pandemic, we could have been more nimble and have more accurate data if this kind of sharing was better.
We also need standardization of public health registries and to try to normalize those registries to make sure that we have accurate data and that it is reported quickly.
All of this points to the need to have true interoperability. We need to make sure that—from the patient health record all the way through to healthcare facilities and government agencies—we can communicate in a way that is seamless. We have been working on interoperability for decades, and we still have work to do.
HL: How will the coronavirus pandemic affect infection prevention efforts after the crisis has passed?
Jopp: The pandemic is going to force many organizations to do a lot of soul searching about what they could have done better. One issue is creating strategies for managing novel pathogens.
We need to create processes for disaster preparedness using pandemics as a likely scenario. Before, when we talked about disaster preparedness, we talked about earthquakes, hurricanes, and terrorism. Pandemics were not a top priority as a likely scenario, and that is certainly going to change.
We have got to improve our infection prevention infrastructure in all aspects of healthcare and outside of healthcare. Again, long-term care facilities were a real miss and more of those facilities need to have infection preventionists on staff. It cost lives to not have more infection preventionists on staff in that setting.
When you look outside of healthcare, infection preventionists are needed in fitness centers, hospitality, and travel such as cruise ships. We need to look at infection prevention in a different light.
HL: What actions would you like to see the new Biden administration take to improve infection prevention?
Jopp: The Centers for Disease Control and Prevention is crucial. We need to try to ensure that we are providing proper investment into the CDC to be sure that they have the resources to do things such as bolstering our surveillance capability and stockpiling PPE. The National Institutes of Health is another key agency. We need to try to enhance our readiness to conduct research. Providing proper funding to these agencies is a very important step.
The researchers reviewed utilization of low-value services such as imaging for non-specific back pain and arthroscopic surgery for knee osteoarthritis.
Most primary care physicians are effective at limiting the ordering of low-value medical services, a new research article says.
Earlier research found that annual spending on low-value medical services in U.S. healthcare ranges from $75 billion to $100 billion. "Primary care physicians (PCPs) have been conceptualized as potential gatekeepers for efforts to reduce low-value spending," the co-authors of the new research article wrote.
The new research article, which was published this week in Annals of Internal Medicine, analyzed Medicare Part B claims from a random sample of beneficiaries enrolled between 2007 and 2014. Examples of low-value medical services included imaging for non-specific back pain, prostate specific antigen screening for men older than 75, and arthroscopic surgery for knee osteoarthritis.
The study includes two key data points:
For most PCPs, the medical services they performed or ordered accounted for less than 9% of their patients' low-value spending, which represented less than 0.3% of their total Medicare Part B spending.
For most PCPs, referrals accounted for less than 16% of their patients' low-value spending, which represented less than 0.5% of their total Medicare Part B spending.
The data indicates PCPs are effective gatekeepers for low-value medical services, the lead author of the study told HealthLeaders.
"Our findings suggest that PCPs generally do a good job avoiding performing, ordering, or referring their patients for low-value services. For most PCPs, spending from low-value services they performed or ordered accounted for less than 9% of their panel's total low-value spending, and services they referred their patients out for accounted for less than 16% of their panel's total low-value spending," said Aaron Baum, PhD, assistant professor, Department of Health System Design & Global Health, Icahn School of Medicine at Mount Sinai Health System, New York, New York.
Spending on low-value medical services accounts for a significant amount of wasteful healthcare spending, he said. "One trillion dollars—25%—of healthcare spending is classified as waste. Of this, low-value services, which can be measured using claims data, account for upto $100 billion per year. We need to be able to measure more of the remaining $900 billion of wasted spending using readily available data sources in order to monitor and better understand the sources of wasted healthcare spending overall."
The specialties that contributed the most to low-value spending included cardiology, ambulatory surgical centers, internal medicine, orthopedic surgery, and gastroenterology, Baum said.
The leader of America's Physician Groups pushes for acceleration of the shift from the fee-for-service care model to value-based care.
The leader of a physician association focused on the transition to value-based care has written a letter to the incoming Biden administration urging adoption of three approaches to improve the U.S. healthcare system.
Led by innovations adopted by the Centers for Medicare & Medicaid Services, the country has been shifting away from the fee-for-service (FFS) care model to value-based care models such as Medicare Advantage health plans. The goal of this movement is transitioning from the FFS care model's emphasis on reimbursing medical services based on the volume of services provided to value-based care models that emphasize lowering costs and increasing quality.
The letter to the Biden administration is from Donald Crane, JD, president and CEO of America's Physician Groups. APG represents more than 300 physician groups that employ or contract with about 195,000 physicians who provide care to nearly 45 million patients.
Crane told HealthLeaders that the FFS care model is not serving the country well. "Fee-for-service is a barrier to quality improvement and is ruinously wasteful. Our citizens deserve better," he said.
Crane's letter calls on the Biden administration to take three approaches to strengthening the U.S. healthcare system.
1. Hasten shift from fee-for-service reimbursement to value-based care
The Biden administration should support adoption of budget-based prospective payment models, Crane says in his letter. "As providers and organizations continue to make investments in accepting risk and providing high quality care at a low cost for patients, supporting the movement to budget-based prospective payment models at the physician group level will provide them with the proper incentives to encourage the acceptance of risk."
Value-based care models represent a step forward in addressing social determinants of health, Crane says. "These models also play an integral role in addressing social determinants of health through initiatives centered around behavioral health, increased screening of patients for risk factors of these determinants, and other proactive methods of care. The social determinants of health-focused care that physicians in value-based models offer provide a level of financial value that must be supported moving forward."
If Joe Biden follows through on his campaign pledge to create a public option health plan, it should feature a value-based payment model, Crane says. "We are aware that a public healthcare option will be one of the avenues examined as a possibility in extending the best care possible. Should a plan for a public healthcare option be drafted, we would recommend that for physician groups a budget-based prospective payment system be utilized."
2. Bolstering Medicare Advantage
Medicare Advantage is playing a crucial role in the shift from FFS to value-based care, and the program should be actively supported, Crane says. "An integral part of the move from volume to value is supporting Medicare Advantage (MA) and the role it plays in shifting healthcare in this direction. Providers and health plans who engage in high-value, risk-based MA contracts are working diligently to improve overall quality in the MA program and should be rewarded for those efforts."
Medicare Advantage health plans should embrace budget-based prospective payment, he says. "Congress, the Centers for Medicare & Medicaid Services, and stakeholders must work together to put in place incentives that further drive the value evolution in MA just as they are working to do so in traditional Medicare. These incentives should offer both positive and negative reinforcement that will motivate MA plans to push budget-based prospective payment downstream to the physician group level."
3. Decreasing healthcare costs
To lower healthcare costs, the Biden administration should encourage the ongoing shift of care from high-cost settings such as hospitals to low-cost settings such as the home and ambulatory care, Crane says.
"Transferring more patient care to ambulatory or home settings is making life changing strides in offering increased convenience and care options for patients while lowering costs and delivering improved outcomes. Technology has also progressed to the point where virtual visits offer even more convenience for patients while still allowing providers to effectively treat those suffering from chronic conditions while monitoring their health and creating effective care plans for treatment. The advantages that telehealth services represent for those patients with issues surrounding access to care, individuals with disabilities, and the elderly have been evident during the ongoing pandemic."
Lowering drug prices is another essential element of decreasing healthcare cost, he says.
"Rising prices have had a great effect on access to much needed medicines for those suffering from chronic conditions. The effects of high prescription drug costs also have systemic consequences, with patient non-compliance because of decreased access or the inability to afford medication leading to increased costs for the healthcare system in general through unnecessary hospitalizations, emergency services, and physician visits."
Efforts to decrease drug prices should include drug importation reform, value-based purchasing, and international pricing models, Crane says.
Safety protocols for ED patients with psychiatric illness require balancing the creation of a safe space with maintaining a therapeutic and humane environment.
An emergency department safety protocol detailed in a new journal article is designed to keep patients with psychiatric illness from suffering self-harm.
Patients with psychiatric illness can spend lengthy periods of time in emergency departments waiting for psychiatric evaluation or transfer to an inpatient psychiatric facility. Earlier research found that the mean length of stay (LOS) for psychiatric patients in emergency departments awaiting an inpatient bed was 16.5 hours and LOS for psychiatric patients in EDs awaiting transfer to another facility was 21.5 hours. Other research has found that busy and crowded EDs are not well-suited to boarding psychiatric patients for lengthy periods of time.
The new journal article, which was published by The Joint Commission Journal on Quality and Patient Safety, includes two key data points.
In the year before the safety protocol was put in place at Massachusetts General Hospital in Boston, there were 13 episodes of attempted self-harm by 4,408 at-risk psychiatric patients, with six of those episodes resulting in actual self-harm
In the year after the safety protocol was put in place at the hospital, there were six episodes of attempted self-harm by 4,523 at-risk psychiatric patients, with one of those episodes resulting in actual self-harm
Although the safety protocol did not result in a statistically significant reduction in the number of attempted self-harm events and number of actual self-harm events, the safety protocol had a clinically significant impact, the journal article's co-authors wrote.
"With a very small number of events, it is challenging to demonstrate statistically significant changes; however, these reductions do have substantial clinical significance. With thousands of at-risk patients receiving ED care each year, the impact of improving their safety is substantial. These patients are among the most vulnerable in our healthcare system, and preventing even one episode of self-harm is a critical patient care goal," they wrote.
How the safety protocol works
Earlier research has shown that hanging is the most common form of attempted suicide in hospitals, and EDs have several lanyards such as sheets and call cords as well as anchor points such as bars and IV poles. In addition, emergency room patients or visitors may have dangerous items such as prescription drugs and sharp objects.
To reduce the danger of self-harm in EDs among patients with psychiatric illness, a multidisciplinary task force at Massachusetts General Hospital crafted four primary elements in the safety protocol.
1. Safe bathrooms: Several episodes of self-harm had been attempted in bathrooms, so the safety protocol called for the creation of "safe bathrooms." Characteristics of safe bathrooms included shatterproof fixtures and mirrors, paper wastebasket liners, and minimal lanyard risks.
2. Patient observers: After conducting research, the task force concluded that one observer with adequate visibility could monitor as many as three patients. The task force also recommended hiring dedicated ED patient observers rather than using observers who were hospitalwide.
Patient observers received a significant level of training that featured a mandatory three-week orientation and annual retraining. The patient observers learned about safety issues such as suicide risk, possession of dangerous items, and risk of harm to others.
The task force also created a check list tool for patient observers. The check list included safety concerns such as elopement risk and observation goals such as constant vigilance, safe bathroom usage, and making sure there were no dangerous objects in the environment.
3. Personal belongings: The task force determined patient belongings should be removed and stored securely. Possession of cell phones was only allowed if the case was removed to ensure dangerous items could not be hidden inside. Patient requests to keep personal belongings were allowed on an individual basis under review by nursing staff.
4. Clothing search or removal: Patients at risk for self-harm were encouraged to change into safe clothing.
Forcible disrobing of a patient was determined to be appropriate in cases of extreme risk and was based on an individual risk assessment conducted by the ED physician with the option of consultation with psychiatry staff. Forcible disrobing is inherently risky, the journal article's co-authors wrote. "Forcibly changing a patient is considered a physical restraint, and, practically, to change an unwilling patient, physical restraint is often used. Therefore, patients who are forcibly disrobed must meet restraint criteria, specifically that there is risk to the immediate physical safety of the patient or others."
The lead author of the journal article, Abigail Donovan, MD, an associate psychiatrist at Massachusetts General Hospital and assistant professor of psychiatry at Harvard Medical School in Boston, told HealthLeaders that forcible disrobing is a complex issue.
"The risk of self-harm compared to the risk of forcible changing is based upon an individual assessment at the time of presentation. That assessment must include an understanding of current suicidality, a thorough history of prior suicide attempts, a current mental status exam, and a review of additional risk factors, including substance use, current intoxication, impulsivity, prior behavior in healthcare settings, and an understanding of the individual's trauma history. To forcibly change an individual, the risk of imminent self-harm must outweigh the risks of forcible changing, which can be substantial," she said.
Safety protocol tips
A multidisciplinary team acting on solid research should be involved in the creation of a safety protocol for ED patients with psychiatric illness, Donovan said. "The varied perspectives of members from different disciplines are critical for developing a comprehensive and thoughtful initiative. We also advise using a root cause analysis of self-harm events to identify high-risk areas specific to the individual hospital or care setting as the starting point for a safety protocol."
It is extremely challenging to balance the creation of a safe space with maintaining a therapeutic and humane environment that also maintains the dignity of patients, she said. "At each step, we tried to ask ourselves, 'What would I want care to look like for my mother? For my child? For myself?' We felt that if we designed a protocol that we could feel good about for our loved ones' care, then we were on the right track."
'The secret sauce is having the right people with the right training,' Lifespan executive says.
At health systems and hospitals, adopting a crisis command culture has operational benefits during the coronavirus pandemic, a pair of experts say.
Across the country, health systems and hospitals have established incident command centers to manage the challenges of the pandemic. At Northwell Health last spring, incident command leadership was a key element in the health system's response to the hottest hot spot in the first coronavirus patient surge.
The crucial aspect of crisis command culture is the ability to make good decisions quickly, says Stephanie Mercado, CEO and executive director of the National Association for Healthcare Quality in Chicago.
"Decisions in healthcare—especially those related to any type of policy or procedure—have often been decided by committee and consensus with long timelines. Before the pandemic, it could take months or years to change a policy. The pandemic has shown everyone in healthcare that they need to be more flexible. They need to be more agile. Good decisions can be made on a much shorter timeline than what was previously thought," she says.
With a crisis command culture, it is possible to make good decisions on policies without putting them through a lengthy process of review and editing by multiple committees, says Nidia Williams, PhD, vice president of quality and safety at Providence, Rhode Island–based Lifespan. The health system operates several hospitals including an academic medical center and has about 17,000 employees.
"We cannot give people editing power after most people who are the key stakeholders have already said a policy is ready to go. We must streamline the decision-making process for policies. Now, we have policies that would have taken weeks if not months to approve that can be approved in hours. It is possible to approve policies in hours and still do it well. We can get more done faster—that is the lesson from crisis command culture," Williams says.
Rapid cycle improvement is an important aspect of crisis command culture decision-making, Mercado says. "We must make a decision at a point in time, but it does not have to be something decided upon forever more. Rapid cycle improvement tells us that we can go back and reevaluate decisions that were made when we have new information or circumstantial change, so we can improve decisions."
Trust and attitude are indispensable ingredients in rapid decision-making, Williams says. "A lot of it comes from trust that you have the right people playing the right roles in making decisions. It is also attitudinal. We tell ourselves we do not have the luxury of time. We do have the luxury of having everyone's talent. … We have learned that we can do the best that we can, and it can be enough so that you are not waiting for perfect before you do what you have to do."
Capitalizing on talent
In addition to rapid decision-making, a pivotal part of crisis command culture is elevating talent over hierarchy in filling key roles in incident command centers, Williams says. "The secret sauce is having the right people with the right training."
At Lifespan and other health systems, quality and safety staff are well-suited for leadership positions in incident command centers, she says.
"I am the patient safety officer at the health system. I started out as the incident commander and planning section chief at the health system–level incident command center in March. My direct superior, who is the executive vice president of quality and safety, is the person who co-led the opening of our alternative hospital site at the Rhode Island Convention Center. Now, the planning section chief at our academic medical center—Rhode Island Hospital—is my quality and safety director. We are playing important roles," Williams says.
Quality and patient safety staff have the appropriate training and experience to succeed in incident command centers, she says. "We have to document and archive our decisions over time. In addition, some of our analysts for quality and safety are most uniquely suited for not only documentation and archiving but also the analysis and reporting of our COVID-19 data both internally and externally."
The skill sets of quality and patient safety staff are an excellent fit in incident command centers, Mercado says. "The skills and competencies that those individuals have are very well-suited to provide systems, processes, and structure and order to an otherwise chaotic situation. Quality professionals do this kind of work all day, every day in their ordinary jobs; but when it comes to the pandemic, they are contributing on an order of magnitude."
Assigning quality and patient safety staff to top incident command center roles is an example of elevating skill sets over hierarchy in a crisis command culture, Williams says.
"Most of the C-suite does not take on command center structure roles—even at the affiliate hospitals. At our academic medical center's incident command center, the section planning chief is the director of clinical excellence and patient experience. So, she is a quality and safety professional first and foremost, but she has a key crisis command center role at our biggest hospital," she says.
Incident command center metrics
During the pandemic, a primary metric for incident command centers is whether they are reporting COVID-19 data to state and federal agencies on a timely basis, Williams says.
"That data is important because if you miss a day or a series of days, your CEOs and presidents and other top executives will get an email that the reporting has not been submitted. This reporting is tied to our reimbursement from the Federal Emergency Management Agency and the Cares Act, for example," she says.
For health systems and hospitals, the reporting requirements related to the pandemic include the following data sets:
How many coronavirus-positive patients are in hospitals
How many people have tested positive for the coronavirus
How many people have been given a coronavirus test
How many coronavirus patients are in ICU beds
How many coronavirus patients are in medical beds
Critical staffing shortages in hospitals
There is significant reporting about COVID-19, the population Lifespan is serving, and the health system's resources, Williams says.
"There are personal protective equipment numbers such as how many masks you have and how many gowns you have. We must report how many beds we have available to reflect our capacity. When you turn on the news at night, and they tell you how many people tested positive that day or the positivity rate that day, that information is coming from individual organizations like ours submitting data every day," she says.
In a wide-ranging address today, the president of the American Medical Association highlighted multiple challenges posed by the coronavirus pandemic.
In an address to the National Press Club today, American Medical Association President Susan Bailey, MD, called for a coordinated and comprehensive federal response to the coronavirus pandemic.
At the beginning of her address, Bailey highlighted the epic proportions of the pandemic. She said the country is experiencing 1 million new COVID-19 cases per week and recently "reached the grim milestone" of losing 4,000 lives to the coronavirus in a single day.
"Some areas of the country are experiencing record case surges that are flooding emergency departments and intensive care units. In other areas, first responders are having to make agonizing choices about whom to treat for routine health emergencies to ease overcrowding at local hospitals. With hospitals stretched at or near their breaking point, some are even forced to treat patients in cafeterias, hallways, and conference rooms," she said.
State and local authorities are not adequately equipped to cope with the pandemic without federal help, Bailey said.
"While safe and effective vaccines are at-hand, the distribution mechanisms at state and local levels have been slow, inconsistent, and severely hampered by unrealistic expectations and a lack of coordination at the federal level. This inaction at the highest level of our government has placed yet another daunting burden on the shoulders of state and local officials who lack the resources, sufficient guidance, and the support they need to handle a health emergency of this magnitude on their own."
So far, the government response to the pandemic has been woefully fragmented, she said. "Leaving state and local officials to shoulder this burden alone without adequate support from the federal government is not going to work. Fifty different strategies across 50 states will continue to sow confusion and slow the process."
The incoming administration of President-Elect Joe Biden should focus on three areas as soon as possible, Bailey said.
1. National strategy: "I call upon the incoming Biden administration to implement a national strategy and provide states and local jurisdictions with additional resources, guidance, and support to enable rapid distribution and administration of vaccines," she said.
2. Coordination with states: "The AMA urges the Biden administration to talk with states to identify gaps in vaccine distribution and to work collaboratively to address areas of concern," she said.
3. Defense Production Act: "We call for the new administration to develop a more robust national strategy for continued COVID-19 testing and production of [personal protective equipment] by tapping into the full powers of the Defense Production Act," she said.
Pandemic big picture
Bailey said the pandemic has exposed five troubling elements of U.S. healthcare that must be addressed.
1. Importance of science: There needs to be heightened adherence to science and science-based decision making in areas related to healthcare, she said. "Whether you are a physician like me or a journalist, or whether you simply post your ideas on Facebook or Twitter, all of us share some responsibility for stopping the spread of disinformation and for creating an environment where science and evidence rule the day. We must insist that our elected officials affirm science, evidence and fact in their words and actions."
The federal government's key scientific institutions such as the Centers for Disease Control and Prevention and the Food and Drug Administration should not be subjected to political pressure, Bailey said. "Politics have no place in a pandemic; and never again should scientists, researchers, or physicians feel the weight of intimidation or have the integrity of our work questioned."
2. Access to affordable care: All Americans should have access to affordable healthcare services and health coverage, she said.
"As certain provisions of relief packages from the beginning of the pandemic expire, many Americans are still facing tremendous difficulties and hardships—some dealing with the loss of a job or a business. … In this new year, we urge the federal government to take necessary measures to protect not only lives but livelihoods at risk—measures such as a second enrollment period for the Affordable Care Act."
3. Addressing health inequities: The pandemic has revealed widespread inequity in the U.S. healthcare system, Bailey said.
"The data from COVID-19 is painfully clear. Communities of color have been disproportionately impacted by this pandemic because of systemic inequities that are rooted in racism. Heart disease, diabetes, and other chronic conditions that have led to devastating consequences for African American, Latino, and Indigenous communities … have also made them more susceptible to the dangers of COVID-19. The road ahead demands that our health system acknowledge these inequities and work to integrate new policies to level the playing field in all communities."
4. Improving public health: The country's public health infrastructure has been "gutted," she said. "In the last 13 years, we lost 40,000 jobs at the state and local public health agencies, with the local health department workforce shrinking about a quarter. We are seeing the impact of this disinvestment play out today in the slow vaccine rollout we are witnessing. Marginalized and minority communities and people living in rural areas have also suffered the consequences of this disinvestment for too long."
5. Global nature of health: The United States needs to work with other countries to address future outbreaks of disease, Bailey said.
"We cannot act as if our country exists in isolation. We must recognize the global community of health providers and healthcare institutions—and lead these efforts as we are called to do. Global alliances in healthcare are critical in helping prevent future threats before they sweep our planet. We applaud the incoming administration's commitment to rejoin the World Health Organization."
Pandemic impact on physicians
The pandemic has taken a heavy toll on physicians, Bailey said during a question-and-answer session after her address.
"The frontline doctors who are in the emergency rooms and the specialists who work in the ICUs have been running on fumes for a long time. … But on the other side, there are doctors who are having to close their practices because they don't have enough patients to see because of local shutdowns combined with fears among patients about going out into public," she said.
Physician burnout and suicide are significant concerns during the pandemic, Bailey said. "There is burnout. Many are aware of Dr. Lorna Breen—the physician in New York who committed suicide last year. We do not have good numbers on what has happened with the suicide rate among physicians and other healthcare workers during the pandemic, but I am sure it is not going down."
Many people are reluctant to be vaccinated for reasons including misinformation and cultural barriers.
Clinicians need to take a multipronged approach to communicating with their patients about coronavirus vaccination, a Yale New Haven Health expert says.
With the COVID-19 pandemic raging across the country, vaccination is a key implement in the public health toolbox. Vaccination is widely viewed as essential to controlling the coronavirus through herd immunity, which occurs when a large proportion of a population develops resistance to an infection.
There are four best practices clinicians should follow when communicating with people to encourage them to get coronavirus vaccination, says Richard Martinello, MD, medical director of infection prevention at Yale New Haven Health in New Haven, Connecticut.
1. Cast vaccination as part of wider infection prevention strategy
"Not only with coronavirus vaccination but also with flu, sometimes we focus on the act of getting vaccinated as being the preventive effort. While vaccination is a key part of our overall public health strategy to prevent disease, it is only one part of a multifaceted approach to keep people healthy," Martinello says.
While the pandemic is wreaking havoc nationwide, clinicians should communicate that vaccination is only one of several preventive measures, he says. "Wearing a mask, social distancing, and getting vaccinated are key components for people to achieve their goals. Oftentimes, that can be a more productive conversation than one of simply saying, 'We need you to get vaccinated.'"
2. Tap into patient values and goals
It important to understand a patient's values and goals, then to communicate how vaccination is aligned with those values and goals, he says. "What do they want for themselves? What do they want for their family? Then, as physicians and others in healthcare, what we need to do is think about how to frame what we think are the right actions for the patient in the context of what their goals are."
For example, many people feel the coronavirus pandemic has constrained their independence and ability to lead a "normal life," Martinello says.
"Right now, some of us have a sense that our freedoms are being squelched. Doing what we can to decrease coronavirus transmission in our communities such as vaccination can allow us to regain those freedoms that we value—freedoms like being able to fly on a plane without having to worry about infection or the freedom to go out to a restaurant without having to worry," he says.
3. Hold open conversations
To have productive conversations about coronavirus vaccination, clinicians need to be good listeners, Martinello says. "One of the first things we need to do is to listen to patients' questions."
It also is important to dispel misunderstandings about vaccination delicately, he says. "We need to respect that patients may have some deep-seated views; and we need to recognize that if they are accessing non-factual information, we have to be very cautious about how we approach those individuals to try to bring them around to understand the facts."
Seeking common ground is a prime strategy to encourage skeptical people to get vaccinated, Martinello says. "One strategy to approach that conversation is to think about aspects that we may agree about. If someone has deep-seated feelings and concerns that lead them not to want to get vaccinated, we need to find aspects of that conversation where we can have information that we agree upon."
4. Overcoming cultural barriers
Some minority groups, particularly African Americans, are suspicious of the medical community because of a history of injustice such as the infamous Tuskegee syphilis study that began in the 1930s.
"This is an area where we need to have a great deal of humility and patience. We need to recognize that we may not completely understand the concerns that our patients have leading to their reluctance to get vaccinated. Trying to dig into those concerns can be very helpful to better understand where that reluctance is coming from," Marinello says.
The safety of the coronavirus vaccines should be emphasized, he says. "If someone is concerned that they are being experimented on with these vaccines, we can acknowledge that these vaccines have been produced very quickly and made available to the public in a rapid fashion. If that is the concern, we can provide a better understanding as to why these vaccines were made available so quickly."
First, this conversation can focus on the history of vaccine technology, Marinello says. "There has been a great deal of research over decades in the development of new vaccine technologies. From a scientific and pharmaceutical perspective, we were prepared for this virus and positioned to prepare vaccines in a rapid fashion."
Second, the conversation can turn to how the coronavirus vaccines were developed, he says. "From a development perspective, these kinds of vaccines usually go through a very systematic and serial process to come to market. In the case of the coronavirus vaccines, there was so much investment that the developers of the vaccines were able to overlap those steps and do things concurrently rather than in a serial fashion. That helped make these vaccines available so quickly."
Third, it is important to emphasize that minority populations are not being singled out for experimentation and that minority populations will be getting equal access to vaccination, Martinello says.
"It is helpful for minority patients to understand that these vaccines are being widely used among different sorts of people. It is helpful to tell these patients that there are a lot of efforts to ensure equity and justice in the way the vaccine is being distributed. We are not only trying to have the greatest good for the greatest number of people. We are also making sure that communities that may not have had adequate or equal access to vaccines in the past will have access to these vaccines so their communities can stay healthy."
Like many fields in telehealth, teletherapy has experienced significant growth during the coronavirus pandemic, a teletherapy CEO says.
Teletherapy is likely to experience growth and other significant changes in 2021, the CEO of a teletherapy provider says.
Last March, when the coronavirus pandemic took hold in the United States, telehealth visits increased 50%, according to Frost and Sullivan. With in-person medical visits associated with the risk of coronavirus infection, virtual visits have emerged as a safe and effective way for patients to meet with their healthcare providers in many circumstances.
Trip Hofer, MBA, CEO of New York City-based teletherapy provider AbleTo has four predictions for teletherapy in 2021.
1. Upward growth trajectory
In 2021, there will likely be a continuation of the increased patient adoption of teletherapy that was seen in 2020 because of the COVID-19 pandemic, Hofer says.
"The coronavirus pandemic has been a horrific event; but for telehealth, the pandemic has advanced the industry by five years to a decade. People who were not used to telehealth have been exposed to it. We probably will see a dip in teletherapy in 2021 as people go back to office settings, but a lot of people have become comfortable with these services. As a result, the trend in 2021 is likely to be continued growth," he says.
2. Startups, mergers, and acquisitions
Teletherapy is drawing a significant amount of investment dollars, which will drive market changes this year, Hofer says.
"In 2021, you are going to see more teletherapy startups come into the market. You also are going to see more M&A activity this year because money is flowing in and larger organizations such as health plans are seeing opportunities to bring teletherapy in-house," he says.
3. Targeting outcomes
This year, there is going to be increased focus on teletherapy outcomes—both clinical and financial, Hofer says. "There is recognition that teletherapy is increasing patient access, but health plans are getting more focused on what they are getting for that access."
AbleTo works mainly with health plans, and they ask for a spectrum of data, he says. "One data point is patient satisfaction—health plans want to know whether patients are satisfied with the services they are receiving. They want to see utilization data—how much was a service utilized and how often. They also want to see data for clinical outcomes."
In teletherapy, examples of clinical outcome measurement tools include the DASS 21 and the PHQ-9.
Health plans also are interested in return on investment and financial outcomes, Hofer says.
For example, he says a large share of AbleTo's service offerings is for individuals who have a mental health need and a physical comorbidity. For a patient who is depressed and has had a heart attack, AbleTo can treat the depression, which can lower total cost of care by reducing emergency room visits and hospitalizations, Hofer says.
4. Regulatory environment
Licensure requirements are more restrictive in behavioral health than in physical health, Hofer says. "For example, nurses have compact state licensure; where if they get licensed in one state, they can get licensed in dozens of other states. We don't have that in mental health—if you are licensed in one state you can only practice in one state. Multistate licensure is onerous. On average, our therapists have two state licenses."
During the pandemic, the Centers for Medicare & Medicaid Services have relaxed the licensing requirements for behavioral health, so professionals can practice across state lines. "My hope is that CMS is going to continue to allow us to do that because it is going to provide more access for patients," he says.
If CMS ends the cross-state licensure waiver for behavioral health professionals in 2021, it is unlikely that the federal agency will make the change abruptly, Hofer says.
"I predict that CMS will continue to allow behavioral health professionals to practice across state lines for at least a period of time after the pandemic. What is most concerning is continuity of care for the patient. For example, if a therapist is licensed in Massachusetts and is treating a patient in New Hampshire then CMS ends the licensure waiver, all of a sudden the patient can lose continuity of care. I think CMS is very concerned about that."
To maintain continuity of care, CMS is likely to allow therapists to continue treating patients across state lines as long as services are needed, he says.
With new Medicare fee-for-service reimbursement, Brigham Health plans to expand its Home Hospital program.
The Centers for Medicare & Medicaid Services' (CMS) recently announced the Acute Hospital Care At Home waiver is a huge step forward for home-based hospital care, the leader of the Brigham Health Home Hospital program says.
In the United States, the hospital at home model was pioneered by Johns Hopkins Medicine, which launched a program in 1994. The coronavirus pandemic has spurred adoption of the care model, including the launch of virtual hospital at home programs.
In November, CMS announced the creation of the Acute Hospital Care At Home program during the coronavirus public health emergency to help health systems and hospital increase care capacity during the pandemic. Six healthcare organizations were designated as the first participants in the Acute Hospital Care At Home program, including Boston-based Brigham Health.
The Brigham Health Home Hospital program has been shown effective in reducing cost of care.
In a randomized controlled trial published a year ago in the Annals of Internal Medicine, the adjusted mean cost of Home Hospital acute care episodes was 38% lower for home patients compared to control patients receiving traditional hospital care.
HealthLeaders recently discussed the new CMS hospital at home waiver and Brigham Health Home Hospital with David Levine, MD, MPH, MA, medical director of strategy and innovation for Brigham Health Home Hospital, and an assistant professor of medicine at Harvard Medical School. The following is a lightly edited transcript of that conversation.
HealthLeaders: What is the impact of getting Medicare fee-for-service reimbursement for hospital at home care?
David Levine: This is the change that we all have been waiting for. It is an enormous step forward for the field because it opens the care pathway to large numbers of patients who have Medicare as their only insurance.
For our program, we have been in a very fortunate position, where our population health team has supported our Home Hospital work at the enterprise level and our hospital has supported our Home Hospital work significantly. However, we have been constrained budgetarily. When you cannot bill for most of your services and you must rely on a fixed budget from central sources, that constrains the size and scope of your program. So, we are excited that we will be able to recoup much of the care costs from delivering care to patients. It will allow us to expand the program.
HL:What are your plans to expand Brigham Health Home Hospital?
Levine: We consider ourselves to be an innovation shop in home hospital care. So, we are continually adding sensors, new technologies, and different care pathways. Having a stable revenue source for our program allows us to expand in a very stable and guaranteed way.
On one end, we are continuing our innovation pathways and pursuits. That means different kinds of patients will be able to get Home Hospital care than before. We will hopefully be able to increase the quality, safety, and patient experience of the care that we deliver through new technologies and new care pathways.
On the other end, we are going to be able to offer this care to more people. Previously, our Home Hospital program was always full—it was capped because as soon as we discharged a patient, we took on another patient. We did not have a large care team to take care of all the patients who wanted Home Hospital care. With a more stable revenue source, we will be able to expand this offering to more patients.
HL: What was your previous cap on Home Hospital patients and what are your plans to increase the number of patients in the program?
Levine: A year ago, our cap was four patients. With COVID-19, we expanded to nine patients, and I am hoping we will be at 12 to 16 patients soon.
HL: Did Brigham Health Home Hospital have to be modified to participate in the CMS Acute Hospital Care At Home program?
Levine: The largest change is that the CMS Acute Hospital Care At Home waiver requires that a nurse either see the patient in person or by video at least once a day.
Our program is at the leading edge of using mobile integrated paramedics, who have a higher level of training than regular paramedics. We use mobile integrated paramedics quite frequently; oftentimes, they will see one of our patients twice a day along with a physician visit. That way of caring for patients does not fulfill the requirement of at least one daily touch by a nurse, so we have altered our practice to include a nurse visit daily. We will likely be having split visits—in the morning, the patient may be seen by a paramedic, and in the afternoon the patient may be seen by a nurse, or vice versa.
HL: What kind of special training and skills do mobile integrated paramedics have?
Levine: These are paramedics who build additional skills in acute care medicine such as administering more kinds of medications. For example, paramedics usually do not administer antibiotics, but mobile integrated paramedics do. Our paramedics can do more procedures such as putting in a Foley catheter, which is not something that paramedics usually do but we do it in the hospital, so that is a skill that our paramedics learn.
Mobile integrated paramedics also develop social and emotional skills. They function almost like a community health worker or a social worker. Finally, there is care coordination training.
The fundamental aspect is that paramedics are well trained, and they are often underutilized. They have intense expertise in the home. They have intense expertise in acute management. They have expertise in medication reconciliation. So, adding very thoughtfully to their skill set has been a boon to our program.
HL: What do you think the future holds for the hospital-at-home care model?
Levine: I am extremely enthusiastic about the future of home hospital care. We have been seeing an explosion in the number of programs and the use of this care model throughout the country. The CMS waiver has taken the next step to helping these programs to thrive and spread.
Presently, the CMS waiver is only authorized through the public health emergency; but, hopefully, we will be able to formalize the waiver in a rule that is much more permanent and final.
We need more next steps. We definitely need to see other payers follow CMS' lead. We need to see commercial fee-for-service payers to follow CMS' lead. We need to see Medicaid agency's follow CMS' lead—CMS has already signaled that change. We need to see the full fee-for-service structure embrace home hospital care.
