The health system at ground zero of the U.S. novel coronavirus epidemic is taking a three-pronged approach to clinical care for the viral disease.
Providence St. Joseph Health, which cared for the first U.S. novel coronavirus (COVID-19) patient, is sharing how the health system has responded to the crisis.
Since December, COVID-19 has spread from China to 118 countries and territories, with more than 124,000 confirmed cases and more than 4,600 deaths, according to the World Health Organization. As of March 12, 1,336 cases had been confirmed in the United States, with 38 deaths, worldometer reported.
The first U.S. COVID-19 patient was admitted to Providence Regional Medical Center Everett in Washington State after testing positive on Jan. 20, Amy Compton-Phillips, MD, EVP and chief clinical officer at Providence St. Joseph, said yesterday during a HIMSS webinar.
Providence St. Joseph operates healthcare facilities in seven states, including Washington, Oregon, and California.
Compton-Phillips' webinar presentation included the Renton, Washington-based health system's three-part clinical response to the outbreak. "We have to prepare to triage patients, test patients, and treat patients," she said.
1. Triage
With little room to increase primary care visit capacity, virtual care has been a crucial element of Providence St. Joseph's triage efforts for COVID-19, Compton-Phillips said. "We worked with our digital innovation group and with Microsoft to build a chatbot to help people go online."
The chatbot on the health system's website engages people by asking questions about symptoms, travel history, and possible exposure to the COVID-19 virus to determine the risk level for infection. Through the chatbot, people at highest risk of infection are directed to seek immediate care. Other at-risk patients can be connected with the health system's nurse line telephone service or schedule a telemedicine appointment on Providence St. Joseph's telehealth platform, Providence Express Care.
In addition to triaging patients in emergency departments, urgent care centers, and online, the health system is planning to roll out "fever clinics" by the end of this week.
"To reduce community transmission for in-person visits, we are now working on setting up fever clinics separate from regular clinics as pediatricians have done for years. During flu season, they might have afternoon hours for people with a fever so that you minimize the contamination of other patients," Compton-Phillips said.
2. Test
Inadequate testing capacity has been one of the most daunting challenges since the beginning of the U.S. COVID-19 outbreak in January, she said.
"Because of the very stringent criteria we had initially, we could only get people tested if they had traveled and had all three symptoms—fever, shortness of breath, and cough. It was incredibly frustrating for even our caregivers who thought they might have been exposed. They might have two out of the three symptoms, so we couldn't get them tested."
Testing capacity has been insufficient, but since the Food and Drug Administration issued a key emergency use authorization on Feb. 29 "opportunities have definitely opened up," Compton-Phillips said. "Pretty soon we think the pipeline will improve so that we can significantly increase our testing capacity."
Providence St. Joseph plans to ramp up testing as soon as more kits become available, she said. "The tents are ready to go and deploy as soon as the testing capacity increases. We will be running drive through clinics for testing in the same way they have done in South Korea."
The health system has developed its own COVID-19 test, but necessary reagents are unavailable from their European suppliers, Compton-Philips said.
3. Treat
As is the case with patient triage, telemedicine is playing a crucial role in treating patients, Compton-Phillips said.
Patients who are identified as likely positive for COVID-19 in an emergency department but are not admitted are being sent home with a thermometer and pulse oximeter to monitor their symptoms at home under the supervision of the health system's telehealth team, she said.
"Patients can be OK for a while, then decompensate rapidly. So, having this capacity to monitor at-risk patients at home has made a huge difference and made our clinicians much more comfortable to leave patients at home rather than admitting them for observation in our acute care facilities."
In addition to the virtual patient monitoring, virtual grand rounds have been conducted regularly to foster "rapid learning" for Providence St. Joseph clinicians who are caring for COVID-19 patients, Compton-Phillips said.
Patients who are admitted to one of the health system's hospitals are under strict isolation protocols and cannot have visitors, she said. This is particularly problematic for older patients, who can develop delirium and other complications while in isolation. To ease the isolation burden on quarantined patients, they are being given iPads to stay in touch with friends and family, Compton-Phillips said.
Improving the communication skills of clinicians and nurses builds rapport and trust with patients.
Communication between staff and patients is a crucial component of patient experience at hospitals, the founder of a communication-focused patient experience training program says.
Making hospitals more consumer-friendly for patients has been a focal point of efforts to reform U.S. healthcare, with the emergence of online reviews and widespread adoption of formal instruments to measure patient satisfaction such as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient survey.
Vidalia, Georgia–based Meadows Health, which features 70-bed Meadows Regional Medical Center, understood the importance of boosting clinician and staff member communication skills to improve the patient experience, so they began a focused training effort in December.
"We are the regional referring center, but we have limitations—we don't have an education department and we don't have the resources to fully develop a communication program. We wanted to take a programmatic approach to provider and nurse communication, so we reached out to several organizations to see who could help us the most," says Jeffrey Harden, BSN, MBA-HCM, chief nursing officer and vice president of patient care services at Meadows Health.
Anthony Orsini, DO, a practicing neonatologist and president and founder of The Orsini Way in Windermere, Florida, says communication training achieves cultural change at hospitals. Orsini has seen this come to fruition through his communication training program for healthcare professionals.
"The important thing is we are not just putting Band-Aids on the way doctors and nurses communicate. We are rewiring them and changing cultures at hospitals. Communication is not hard to learn, but it is a specialized technique and most physicians and nurses have not been trained in this area," he says.
Communication training generates positive results, Orsini says. "We have achieved significant improvements in HCAHPS scores and patient satisfaction scores in every program we have done so far. We had one hospital that achieved a 60% improvement in their overall HCAHPS score ranking."
In intensive care nurseries, he says the training program has achieved a 50% improvement in overall patient satisfaction, and 100% improvement in the subset of the HCAHPS survey for physician communication. In emergency room settings, he says the training program has resulted in 70% improvement in overall patient satisfaction.
Training at Georgia hospital
Meadows Health chose The Orsini Way for its training because the emphasis was not on HCAHPS score improvement, but how to better communicate, Harden says. "We found out the Orsini program focuses more on communication as a whole, how communication can make your day-to-day job easier, how communication improvement and certain skills can help avoid burnout, and how all of those factors can lead to improved outcomes and improved relations with the patient."
At Meadows Health, the training program has focused on the emergency department, he says. "Over the past couple of years, we have been working toward improving our emergency department patient satisfaction, and we knew one of our big opportunities was going to be communication."
Although Harden hopes to extend the training throughout Meadows Health, the ED was a logical place to start, he says. "If you look at the number of patient grievances that we have, about 70% of them come from the emergency room."
The primary training program at The Orsini Way is called "It's All in the Delivery." The program has three elements.
1. Series of three-hour workshops: Most hospital staff members participate in the workshops, including doctors, nurses, receptionists, and therapists. The workshops teach staff members how to build rapport and relationships with patients in a timely manner.
2. Digital learning: Hospital staff members complete a digital course over eight to 10 weeks. Through text messages or email, participants receive a training technique every week that is highlighted in a five-minute video. Participants are then asked to put the technique into practice.
3. Improvisational role-playing: Professional actors role-play with hospital leaders, who eventually become on-site trainers. The role-playing is videotaped and reviewed by Orsini instructors, who replay the videos with the hospital leaders to see how they performed. Instructors comment on verbal and nonverbal communication techniques in the videos to teach the hospital leaders how to train staff members.
Some hospitals choose not to conduct the role-playing component. The cost of the training ranges from $50,000 to $100,000 per hospital.
Meadows Health decided not to utilize the improvisational role-playing, Harden says. "We took advantage of the lectures with Dr. Orsini and the digital platform, which has been great for employees who could not get to a lecture but wanted access to the program. The digital platform provides reminders, tips, and check points to see whether the tips are being used."
So far, the results have been promising, Harden says.
"Even though we just started the training in December, we have seen some improvement in satisfaction scores. What we have seen in the ED is the biggest result for me. I'm not hearing from any ED nurses or providers that they are too busy to be polite. For the ED nurses and providers, the program has done a good job of highlighting that communication is just as important as a clinical component of their jobs—communication is a clinical tool."
The effort is well worth the investment, Harden says. "As a community hospital that is surrounded by three larger systems within a 30-minute drive, the way the community perceives us and the way we treat our patients is major. I need everybody in my organization from the frontline staff to the executive team thinking this way."
Communication training approaches
A key component of the training program workshops is teaching specific communication techniques as well as verbal and nonverbal language skills, Orsini says.
For example, Orsini encourages clinicians and nurses to sit down as soon as possible when they enter a patient's room. "The most common mistake physicians and nurses make when they go into a patient's room is speaking while standing up. The nonverbal message that is being sent is that they don't have the time to spend with the patient."
Other communication techniques are designed to build rapport and trust with the patient, he says. "Multitasking while you are visiting a patient such as typing into the electronic medical record sends a nonverbal message that the patient is not the most important person in the room."
Nurse managers can build trust with their patients while conducting rounds, Orsini says. "They should not just poke their head into patient rooms and ask whether they need anything. I teach nurse managers to go into the room, introduce themselves, and say they like to get to know their patients. Then they can ask the patient how it is going."
Benefits of telemedicine screening for COVID-19 include convenience for patients and safely assessing patients in their homes.
Some health systems are offering virtual screening for the novel coronavirus, COVID-19.
After reaching epidemic proportions in Wuhan, China, in December, COVID-19 has spread to 110 countries or territories, with more than 113,000 confirmed cases and more than 4,000 deaths, according to the World Health Organization. As of March 10, there had been 729 confirmed cased in the United States, with 27 deaths, worldometer reported.
Grand Rapids, Michigan-based Spectrum Health, which features 15 hospitals and 11 urgent care centers, began free telemedicine screening for COVID-19 last week.
"Telemedicine is a good fit for screening. For screening, it is a matter of asking the appropriate questions and ensuring that you have the right answers and a triage plan. We can't do a full examination of someone with telemedicine, but we can screen to determine whether someone is at low risk and can wait to see their doctor the next day, or is at high risk and needs to be seen right away, says Darryl Elmouchi, MD, MBA, chief medical officer at Spectrum Health.
He says the free telemedicine screening initiative has four advantages.
1. It is much more convenient for people to be screened in their homes rather than having to visit an emergency room or urgent care center. The convenience should lower the barrier to get screening easily.
2. From a public health standpoint, telemedicine screening can help avoid inundating healthcare settings with patients who are at low risk of having COVID-19, which maintains capacity to treat patients who are at high risk.
3. The telemedicine screening can help prevent the spread of COVID-19 because as long as patients are not critically ill, they can be triaged at home rather than visiting an emergency room or clinic, where other people could become infected.
4. The free screening lowers the cost barrier to getting a COVID-19 assessment.
How the screening works
The screening process is simple, Elmouchi says.
"A person can call a hotline number, which is answered by someone who walks them through downloading our app if they don't have the app already on their phone or tablet. They can also log in on a computer. Then a time is scheduled when a provider will be available for the virtual visit, which is a video visit much like FaceTime or Skype," he says.
The telemedicine screening is following Centers for Disease Control and Prevention guidelines such as asking about COVID-19 symptoms—fever, cough, and shortness of breath—and travel to infection hotspots such as China, Iran, and Italy.
Ideally, if a patient is at high risk of COVID-19, testing can be conducted at the patient's home, Elmouchi says.
The virtual visit is conducted by a physician, physician assistant, or nurse practitioner. Most of the clinicians work at the health system's telehealth platform, Spectrum Health Now, but they are being supplemented with clinicians from urgent care centers and primary care clinics who have spare time, he says.
For now, there is enough staff to provide the telemedicine screening, Elmouchi says. "We launched this on Friday evening, and on Saturday and Sunday we averaged about 20 patients each day. By 11 a.m. Monday morning, we already had 33 people who had called to schedule visits. At this point, we have untapped capacity through the rest of our medical group, but if we had to screen several hundred people per day that would be challenging.
Telemedicine opportunity
The screening initiative has revealed a largely unexplored frontier of telemedicine, Elmouchi says. "This is definitely an example of the untapped potential of telemedicine. There are many different areas where talking with someone and looking at someone virtually can be important for communication, getting information, screening, and reassurance."
The screening is an opportunity to rise to a public health challenge, he says.
"We think this is our duty as a caretaker for the community. We want to make sure that we prevent infections and we make it easy for people to dispel concerns. We are not directing any of the care to our own settings specifically. We are redirecting people back to their primary care doctor or a health system where they already get their care. The goal here is not to increase business. The goal is to make sure people get the right care, where they need it, and when they need it."
Other health systems offering telemedicine screening for COVID-19 include Indianapolis-based IU Health and Charleston, South Carolina-based MUSC Health.
Researchers find that amenities such as private rooms have a greater impact on hospital patient satisfaction than quality measures such as mortality rates.
Consumer satisfaction is a weak driver of quality and safety at hospitals, recent research indicates.
Viewing patients as consumers has been a focal point of efforts to reform U.S. healthcare, with the emergence of online reviews and formal instruments to measure patient satisfaction such as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient survey. However, hospitals are a challenging setting to have consumer satisfaction impact quality of care because most medical services are provided out of patients' view.
The recent research, which was published in the journal Social Forces, found that amenities such as private rooms have a greater effect on patient satisfaction than the quality of medical services.
"We find that neither medical quality nor patient survival rates have much impact on patient satisfaction with their hospital. In contrast, patients are very sensitive to the 'room and board' aspects of care that are highly visible. Quiet rooms have a larger impact on patient satisfaction than medical quality, and communication with nurses affects satisfaction far more than the hospital-level risk of dying. Hospitality experiences create a halo effect of patient goodwill," the study co-authors wrote.
Research data
The researchers examined Centers for Medicare & Medicaid Services data for 3,000 acute care and critical access hospitals nationwide.
Medical quality was measured based on adherence to standards of care for heart attack, heart failure, general surgical practice, and pneumonia. Patient safety was measured based on hospital mortality rates. Hospitality was measured based on several metrics in the HCAHPS patient survey such as quality of nurse communication, cleanliness of rooms, and room noise levels at night.
The research includes several key data points.
Hospitals with the highest mortality rates have patient satisfaction scores only 2.0 percentage points lower than hospitals with the lowest mortality rates.
Hospitals posting medical quality scores in the highest decile have patient satisfaction scores only 3.3 percentage points higher than hospitals with medical quality scores in the lowest decile.
Nurse communication has a major impact on patient satisfaction. Hospitals with the lowest decile score for nurse communication have an average patient satisfaction rating of about 50%. Hospitals with the highest decile score for nurse communication have an average patient satisfaction rating of more than 75%.
The noise level in patient rooms has an 86% larger-in-magnitude impact on patient satisfaction than the hospital mortality rate.
The noise level in patient rooms has a 40% larger impact on patient satisfaction than medical quality.
For more than 300 of the hospitals, the researchers examined 18 measures of local competition to determine the association of competitive markets with patient satisfaction and medical quality. For 17 of the measures, competitive markets lowered patient discontent. For 14 of the measures, competitive markets lowered medical quality. "Local competition among hospitals leads to higher patient satisfaction, but lower medical quality. This provides further evidence of decoupling between medical excellence and patient satisfaction," the study co-authors wrote.
The data shows the hospitality halo effect in how patients view their hospitals, the co-authors wrote. "When patients complain about their hospitals, it is primarily due to the room and board aspects of their stay—and especially about the personal interaction with nurses. … Hospitality is the fast track to customer satisfaction in medicine."
Interpretations and solutions
The lead author of the study told HealthLeaders the finding that hospital competition for patients leads to lower medical quality and higher patient satisfaction is troubling.
"I take it as a sign that high pressure incentives to attract and please patients change hospital priorities and investments," said Cristobal Young, PhD, an associate professor in the Department of Sociology at Cornell University in Ithaca, New York.
He said it is highly unlikely that private patient rooms improve medical service quality—even though patients love the privacy of a hotel-like experience, private rooms are an expensive capital expenditure.
"Stanford Health Care spent a whopping $2 billion on a new hospital building with private rooms—largely because the old one had shared rooms and it was hurting their reputation, as one of the vice presidents told me. If you start to think about all the things that could be done with $2 billion, it is hard to believe that building private rooms is the best medical use of those resources," Young said.
Rather than focusing on metrics of customer satisfaction, hospitals should focus more on customer health and longevity, he said. "No one really wants to talk about patient survival rates, but those metrics exist on Medicare's Hospital Compare website. They are available, and informed patients should know about them."
Downgrading the emphasis on customer satisfaction in favor of customer health and longevity would be challenging, he said. "The analogy I use is that no restaurant wants to talk about food poisoning or health and safety standards—even if they are the best and safest restaurant in the city. They don't want the minds of their potential customers drifting into something that is a negative."
Despite the challenge, hospitals have an obligation to elevate the importance of medical quality and safety, Young said. "Hospitals are not supposed to be selling patients a happy, feel-good marketing campaign. They have a responsibility to the best interests of their patients, and that means being honest about medical quality and patient survival."
Public health officials, healthcare settings, and diagnostic manufacturers face multiple coronavirus challenges.
U.S. healthcare organizations should be taking urgent preparation and response actions to address the possibility of a coronavirus pandemic, a new journal article says.
After reaching epidemic proportions in Wuhan, China, in December, corona virus disease 2019 (COVID-19) has spread to 77 countries, with more than 90,000 confirmed cases and more than 3,000 deaths, according to the World Health Organization. As of March 5, there had been 162 confirmed cased in the United States, with 11 deaths, worldometer reported.
Although Americans are not at high risk of COVID-19 infection now, the situation in the United States and other countries is likely to worsen, the CDC says. "This virus is NOT currently spreading widely in the United States. However, it is important to note that current global circumstances suggest it is likely that this virus will cause a pandemic."
The new journal article, which was published this week in the Journal of the American Medical Association, features four steps that U.S. healthcare organizations should be taking to address the COVID-19 crisis.
1. Preparedness planning
Healthcare organizations should base preparedness planning on plans for earlier pandemics such as the 2009 H1N1 influenza outbreak, the journal article's co-authors wrote.
"In many ways, the current coronavirus epidemic is reminiscent of the beginning of the 2009 influenza pandemic. Many healthcare institutions did substantial work on those plans at that time, and to the extent they still exist, institutions should use those plans as the foundation for needed planning efforts now," they wrote.
Planning efforts for the 2009 influenza pandemic included protection of healthcare workers, staffing shortage contingencies, coping with patient surges, triage topics, and addressing scarce resources.
There are several actions that hospitals can take to accommodate patient surges, the lead author of the journal article told HealthLeaders.
"Hospitals will have to become efficient at managing bed capacity—converting non-patient care space into bed space and creating intensive care unit beds out of stepdown units and post-anesthesia care units. They will have to become more efficient at handling their ordinary admissions and optimize staffing," said Amesh Adalja, MD, a senior scholar at the Johns Hopkins Center for Health Security in Baltimore, Maryland.
2. Hospital and clinic response
Hospitals and clinics should be prepared to rise to several challenges if the COVID-19 virus spreads widely in the United States, the journal co-authors wrote.
For patients who may be infected, protocols should be created for triage and isolation of the patients in emergency rooms, urgent care centers, and outpatient clinics so they do not spread the illness. Similar measures should be taken in settings with vulnerable populations such as skilled nursing facilities, assisted living sites, and long-term care facilities.
Hospitals and clinics should be prepared to protect healthcare workers and prevent the spread of COVID-19 to uninfected patients. Measures include engineering efforts, staff training, and acquisition of personal protective equipment.
With some COVID-19 patients experiencing respiratory distress, hospitals should assess ICU capacity, including bed space and mechanical ventilator resources.
Hospitals with the expertise and resources should be prepared to provide extracorporeal membrane oxygenation for patients with severe acute respiratory distress syndrome (ARDS).
As knowledge of COVID-19 advances, clinicians will have to stay updated on care guidance. For now, clinicians should follow existing guidance for ARDS, pneumonia, and sepsis.
3. Expansion of diagnostic testing
Compared to countries such as South Korea, Italy, and the United Kingdom, the United States has lagged in testing for COVID-19 infections. U.S. testing must increase, the journal article co-authors wrote.
"Medical and public health experts need to expand testing to all patients who have unexplained ARDS or severe pneumonia, and ultimately to patients who have mild symptoms consistent with COVID-19. … To reach a high-level testing capacity will require the major clinical diagnostic companies to develop and manufacture testing kits at large scale."
The CDC and state-operated labs have insufficient testing capacity, Adalja told HealthLeaders.
"To speed up diagnostic testing, it will be necessary to move beyond the government labs that are doing the current testing and have commercial labs engage. It is also important that hospitals should have the capacity to develop their own tests. Eventually, we will hopefully have commercial test kits that can be used at point of care," he said.
4. Public health responses
Public health officials can take several actions to slow the spread of COVID-19 in the United States, including rapid diagnosis and isolation of infected people, tracking people who have come into contact with infected individuals and urging them to stay home during the two-week incubation period, and communicating with the public about ways to avoid infection such as handwashing techniques.
"Social distancing" such as cancelling large gatherings and closing schools should also be considered, the co-authors wrote.
Adalja said public health officials should weigh school closures carefully. "If community spread is already commenced, school closures may not have an impact. It is also important to remember that most school closure data comes from influenza, which has a different epidemiological dynamic and is much more dependent on children transmission than coronavirus."
The length of school closures is another key factor, he said. "Will children congregate outside of school and defeat the purpose? Will parents have to take off work? And what about children who get their meals at school?"
The primary goal of the project is to keep most geriatric patients at rural hospitals through telemedicine rather than transferring them to Dartmouth-Hitchcock Medical Center.
Telemedicine is the cornerstone of a Dartmouth-Hitchcock Medical Center geriatric emergency department (GED) initiative with four rural hospitals.
The number of Americans over age 65 is expected to double to nearly 100 million by 2060. With multiple chronic conditions and high costs of care at end of life, older adults have relatively higher healthcare costs compared to younger Americans. In 2010, citizens over age 65 were 13% of the population but accounted for 34% of healthcare spending.
In a partnership with West Health, Lebanon, New Hampshire–based Dartmouth-Hitchcock Medical Center (DHMC) has launched a three-year effort to build a "hub-and-spoke" model GED. Work to establish the hub at the medical center began in fall 2019 and is set to finish at the end of this year. Four rural hospitals will join in the effort as spoke facilities during year two and year three of the initiative.
"Most of the other accredited GEDs nationally are in more urban settings than ours. Related to that, we will be the first GED that uses telemedicine to extend central resources to rural spoke sites," says Scott Rodi, MD, chief and regional director of emergency medicine at DHMC.
The GED initiative is expected to be a threefold win. Older adult patients will benefit by receiving high-quality emergency department services close to home, the four rural hospitals will benefit from having fewer patients transferred to DHMC, and the medical center will benefit from being able to keep more beds open for high-acuity patients who generate higher reimbursement rates.
"The idea is to keep geriatric patients near home in their regional hospitals and to keep the most complicated cases coming to Dartmouth-Hitchcock rather than patients who are frail with simple medical problems and needing a lot of social support. If we can do that, we will provide better care and increase capacity at Dartmouth-Hitchcock for the complicated patients who need tertiary care and generate increased reimbursement," says Daniel Stadler, MD, director of geriatrics at DHMC.
How the rural GED will work
The GED initiative has five primary building blocks, Rodi and Stadler say.
1. Hub: The first step in the initiative is creating a GED at the medical center's emergency department.
Rodi says the organization is creating an area in the existing emergency department that will be generally dedicated to the geriatric population. Modifications to the space include larger clock faces, non-skid surfaces, and telephones that have a large keyboard. Telemedicine equipment will likely be cart-based.
"The project is much more about people and process than it is about bricks and mortar," Rodi says.
2. Staffing: Staffing the GED will include using new or "repurposed" personnel, Rodi says. Stadler will serve as a co-director of the GED with an ER physician, a new emergency department nurse will develop care protocols and implement screening tools, and new care management staff members will help establish community connections and bring local resources to bear for the geriatric population.
Rodi and Stadler are also creating a pool of geriatricians who will be on call for the GED at the medical center and via telemedicine when the spoke sites are activated. "We will have access 24/7 to a geriatrician who is part of this project," Rodi says.
3. Screening: At the triage level, screening tools are an essential process component of the GED project, Rodi says. "When a patient who is over 65 years old presents, there will be screening for dementia, fall risk, and other factors that will trigger additional actions such as reviewing the medication list or bringing home-care resources to bear depending on the screening tool that has been activated."
4. Accreditation: The GED at the medical center hit its first milestone in January, when the first geriatric patients received care at the GED. The next milestone for the hub site is gaining Level 1 GED accreditation status. "It's analogous to trauma certification. You have Level 1 trauma centers and now there are going to be Level 1 GEDs," Rodi says.
The accrediting organization is the American College of Emergency Physicians, and the spoke hospitals will be required to attain Level 2 or Level 3 GED accreditation.
5. Spokes: Criteria for selection as a spoke hospital features operating in a rural market, Rodi says. "In our area, many of the hospitals are considered critical access hospitals. Their financial viability is only possible because they get some preferential federal pricing for their services. Critical access hospitals are generally rural, with limited access to tertiary care. Almost certainly, our four spoke sites will be critical access hospitals."
In addition to geriatrician consults 24/7, the spoke hospitals will receive a range of services from the medical center's GED, Stadler says. Care managers will be well-versed in the community resources available near DMHC and the spoke hospitals.
"As another example, if a spoke hospital felt they could keep a patient if only they could get an endocrine consult or a cardiology consult, we are hopeful that we would be able to leverage telehealth to bring specialty consults to that hospital," Stadler says.
Modes of telemedicine communication will be telephone calls and video links, he says. "Whether we are on-site or not, we can pull in the son who lives in California, the daughter who lives in Chicago, and a member of the primary care team down the road all using telehealth. They can all engage in a meeting—we call it Brady Bunch technology because of all the faces on the screen. We're training care managers to facilitate those conversations."
Monitoring progress
The initiative is set to receive $4.5 million in funding over the first three years, with West Health contributing $3 million and Dartmouth-Hitchcock Health contributing $1.5 million.
"West Health is paying more in the beginning and Dartmouth-Hitchcock will be taking on more over time. The thought is that once the three-year period is over, Dartmouth-Hitchcock will fund the GED going forward," Stadler says.
Project managers will be monitoring several metrics, he says.
Patient transfer rates from spoke hospitals
The time that geriatric patients spend in emergency departments. "We know the longer geriatric patients spend in an emergency department the higher the risk of delirium, falls, and decompensation," Stadler says.
Goals of care such as determining whether patient care is in concordance with advance directives
Percentage of patients screened
Percentage of patients referred to community resources
Emergency department throughput for geriatric patients, which will help to determine whether low-acuity patients are being admitted for inpatient care at DHMC
"There is good data showing that when frail elders are cared for in quieter settings with their family around, they have better outcomes and spend less time in the hospital. When they come to busy tertiary academic centers far from home and far from familiar surroundings, they have a much higher tendency to get delirious and they generally have long hospital stays," Stadler says.
Yale New Haven Hospital's Late Career Practitioner Policy violates two anti-discrimination laws, federal lawsuit contends.
Yale New Haven Hospital's Late Career Practitioner Policy, which features an assessment of whether clinicians 70 and older are fit to practice medicine independently, has been challenged in federal court.
Like the general population, the proportion of the country's physician workforce entering retirement age is growing. In 2019, the American Association of Medical Colleges reported that nearly half of physicians were either at retirement age or approaching retirement age in the next decade: 15% of physicians were more than 65 years old and 27% of physicians were between the age of 55 and 64.
The Late Career Practitioner Policy at Yale New Haven Hospital (YNHH) requires clinicians who are at least 70 years old and seeking reappointment to the medical staff to undergo vision and neuropsychological assessments. The evaluation of cognitive functioning includes a battery of 16 tests. The hospital's Medical Staff Review Committee supervises the process of determining whether impaired clinicians can practice medicine independently or should retire.
Clinicians under age 70 are not subject to the evaluation.
Last month, the federal Equal Employment Opportunity Commission (EEOC) filed a lawsuit in the U.S. District Court for the District of Connecticut challenging the Late Career Practitioner Policy. The lawsuit claims the hospital's policy violates the Age Discrimination in Employment Act and the Americans with Disabilities Act.
"While Yale New Haven Hospital may claim its policy is well-intentioned, it violates anti-discrimination laws. There are many other non-discriminatory methods already in place to ensure the competence of all of its physicians and other healthcare providers, regardless of age," Jeffrey Burstein, regional attorney for the EEOC's New York District Office, said in a prepared statement.
The EEOC's New York District Office oversees Connecticut, Maine, Massachusetts, New Hampshire, New York, Northern New Jersey, Rhode Island, and Vermont.
A YNHH spokesman told HealthLeaders the hospital is confident that the policy will withstand the court challenge.
"Yale New Haven Hospital's Late Career Practitioner Policy is designed to protect our patients from potential harm while including safeguards to ensure that our physicians are treated fairly. The policy is modeled on similar standards in other industries and we are confident that no discrimination has occurred and will vigorously defend ourselves in this matter," YNHH spokesman Mark D'Antonio said.
A tentative shift from fee-for-service to value-based payment models has constrained primary care initiatives under the Affordable Care Act, new research suggests.
In its first decade, the Affordable Care Act (ACA) sparked significant innovations to boost primary care but new payment models lacked sufficient incentives to drive change, new research suggests.
President Barack Obama signed the ACA into law on March 23, 2010. One of the top goals of the healthcare reform law is to improve primary care. A body of research indicates that robust primary care capabilities are linked to lower healthcare spending, better clinical outcomes, and lower mortality rates for several conditions.
The new research, which was published today by Health Affairs, examines the impact of primary care reform initiatives launched under the ACA through the Center for Medicare & Medicaid Innovation (CMMI). The initiatives generated mixed results, the study co-authors wrote.
"Considerable progress has been made in understanding how to implement and support different approaches to improving primary care delivery in that decade, though evaluations showed little progress in spending or quality outcomes. This may be because none of the models was able to test substantial increases in primary care payment or strong incentives for other providers to coordinate with primary care to reduce costs and improve quality."
Research data
The Health Affairs study includes data showing the largely limited impact of seven CMMI primary care reform initiatives on healthcare spending, utilization, and quality for Medicare fee-for-service beneficiaries.
1. Comprehensive Primary Care (CPC)
Spending: No effect
Hospitalizations: Reduced by 2%
Quality: No significant effect
2. Comprehensive Primary Care Plus (CPC+)
Spending: Increased by 2% to 3% in first year
Hospitalizations: No effect
Quality: Small quality-of-care measure improvements
3. Federally Qualified Health Center Advanced Primary Care Practice Demonstration
Spending: Small increases
Hospitalizations: Small increases
Quality: Mixed patient experience impacts
4. Independence at Home Demonstration
Spending: No effect
Hospitalizations: No effect
Quality: Reduced preventable hospitalizations by 6.7%, but there was no effect on hospital readmissions
5. Health Care Innovation Awards: Primary Care Redesign programs
Spending: One awardee (hospital) achieved a 31% reduction in Medicare spending
Hospitalizations: Two awardees reduced combined hospitalizations and emergency department visits by 6% and 15%
Quality: Awardees improved quality-of-care measures by 2% to 10%
6. Multi-Payer Advanced Primary Care Practice Demonstration
Spending: No states achieved savings and two states increased spending
Hospitalizations: Decreased in one state but increased in two states
Quality: Three states improved process-of-care measures, but three states had unfavorable results in process-of-care measures
7. State Innovation Models initiative, round one
Spending: Increased in one of three states by 12.3%
Hospitalizations: Inpatient admission rates were reduced by 34.6% in one state but increased by 15.5% in another state
Quality: Two states achieved small improvements in quality-of-care measures
"Model results show how hard it is for primary care delivery—in the context of modestly reformed payment that still rests firmly on a fee-for-service chassis—to improve cost and quality outcomes," the study co-authors wrote.
ACA primary care model keys to success
The lead author of the study, who has experience as an evaluator of the CPC and CPC+ initiatives, told HealthLeaders that primary care practices can have their greatest effect on overall healthcare spending by reducing hospitalizations.
"Many of the models encouraged practices to work with hospitals to alert the practice when a patient was admitted or discharged from the hospital or the emergency room, so they could work with patients to prevent future admissions when clinically appropriate," said Deborah Peikes, PhD, MPA, a senior fellow at Princeton, New Jersey-based Mathematica.
She said there are three other main ways primary care practices could reduce hospitalizations through the CMMI initiatives or other programs.
First, primary care practices in the CMMI models were encouraged to enhance care management for patients with complex needs, including teaching patients self-care for chronic conditions. "The goal of enhanced care management and self-care is to improve patients' quality of life and to prevent patients' conditions from worsening, thereby avoiding preventable hospitalizations," Peikes said.
Second, some CMMI models also attempt to improve the coordination of care with specialists, she said.
Third, Peikes said data feedback to help clinicians understand which patients and diagnoses are driving costs can also be helpful.
She also provided advice for primary care practices seeking to make gains through CMMI initiatives.
Practices should be prepared to make substantial changes in how care is delivered, Peikes said. "To succeed in such efforts, it is important to build buy-in among the practitioners and staff at the practice. A healthy learning culture where everyone has a voice and feels empowered to try new things and see what worked well and what did not will help practices redesign multi-step work processes and avoid team burnout."
Patients are an important piece of the puzzle, she said. "Primary care practices that engage their patients, encourage them to set goals and take better care of themselves, and solicit their feedback on how to improve their experience are more likely to be successful. Promising approaches include shifting from dictating recommendations to exploring the patient's readiness to change and using motivational interviewing."
Primary care practices should consider the impact of participating in a CMMI model carefully, Peikes said. "Practices should make sure they understand the incentives baked into the new payment approaches tested in the ACA models, which patients are covered, and the standards that need to be met to earn any bonuses or shared savings. They should weigh the benefits versus costs of model participation and investment in care delivery changes, such as new staff, technology, and time spent on different aspects of care."
At Bascom Palmer Eye Institute, the annual cost savings from switching to alcohol-based scrubbing is estimated at $281,000 per operating room.
Switching from water-based surgical scrubbing to an alcohol-based method generates substantial cost savings and environmental benefits, new research shows.
Preoperative hand scrubbing has been an established practice since the 1800s. The safety and efficacy of alcohol-based scrubbing is well-established, including an endorsement published in 2014 by the American Hospital Association, the Infectious Diseases Society of America, The Joint Commission, and the Society for Health and Epidemiology of America.
The new research, which was published today by JAMA Ophthalmology, examines the potential for cost savings from alcohol-based scrubbing at the University of Miami Miller School of Medicine's Bascom Palmer Eye Institute (BPEI).
"Waterless hand antisepsis is now well established as equal to or superior to traditional running-water scrubs in safety and efficacy. Our study suggests that the actual cost saving in water alone is eclipsed by savings in supplies as well as staff and facilities resources," the research co-authors wrote.
Research data
The JAMA Ophthalmology study, which was conducted in 2019, developed several key data points.
Eliminating water-based scrubbing would result in saving $277 in water and sewer cost per operating room per year.
For supply costs, savings from switching to alcohol-based surgical scrubbing range from $548 to $1,360 per operating room per year.
When calculating personnel costs associated with standard 5-minute and 6-minute scrubbing with soap and water, alcohol-based scrubbing would save between $280,000 and $348,000 per operating room per year. The World Health Organization's recommendation for waterless scrubbing is 40-70 seconds.
At BPEI, which has 10 ORs, the annual savings from lower personnel costs associated with alcohol-based scrubbing would be $2.8 million to $3.4 million.
If every surgical procedure at BPEI was performed with water-based scrubbing, about 163,000 gallons of water would be consumed annually.
From 2014 to 2018, BPEI performed an average of nearly 13,000 surgical procedures annually, with an average of three scrubbed staff members in the OR per procedure.
"A conversion from traditional water-based preoperative hand antisepsis to waterless, alcohol-based techniques has the potential to save a modern U.S. healthcare institution $281,323 per OR per year with a surgical volume similar to that of BPEI. Although there are environmental imperatives for saving water, by far the largest component of actual cost savings is attributable to the lower costs of supplies and the savings in chargeable OR time associated with waterless scrub techniques," the study co-authors wrote.
Environmental impact
Alcohol-based scrubbing contributes to water conservation, the co-authors wrote. "Access to clean water is a large obstacle to improving health outcomes in impoverished regions. Conserving water in the OR will help to alleviate the burden of healthcare on public water stores."
Waterless scrubbing also helps protect the environment, they wrote.
"Antibacterial agents used in hand soaps immediately enter the sewer system and pass through a sewage treatment plant to enter rivers and coastal waters. In doing so, they create a toxic environment for aquatic life, which is of growing concern worldwide. Alcohol-based scrubs, on the other hand, do not enter the ecosystem, except to the extent that residues are later washed off the skin during casual handwashing, bathing, or swimming."
Operating room black boxes collect video and audio of the OR staff as well as images of the surgical field.
Black boxes not only help ensure airliner safety, but they are now used to ensure the quality and safety in Northwell Health operating rooms.
In February 2019, the Manhattan-based health system became the first in the nation to deploy OR Black Box, technology developed at Surgical Safety Technologies in Toronto, Canada. At Northwell, OR Black Box has been used to examine adverse events in granular detail, to assess teaching in ORs, and to look for improvement opportunities.
Northwell is piloting the black box technology with laparoscopic urologic and colon surgical teams at Long Island Jewish Medical Center, says Mark Jarrett, MD, MBA, senior vice president, chief quality officer, and deputy chief medical officer at the health system. "It takes several inputs from the room—the physiology, audio from microphones, video of the staff, and the digital image from the scope to make certain that the gradings of the surgical technique and the teaching going on are analyzed."
OR Black Box is designed to record laparoscopic procedures, which is why urologic and colon procedures were chosen to pilot the technology, he says. "We wanted laparoscopic surgery because it depends on the digital feed from the camera of the actual surgery."
Northwell also picked urologic and colon surgical teams to be the first ORs with the black box technology because there were eager physician champions willing to pioneer the initiative, Jarrett says. "It required a physician champion with a team in the OR that would feel comfortable doing this."
The OR Black Box computer packages the scope video with video and audio collected from the OR staff as well as physiology data collected from the patient such as heart rate, pulse, blood pressure, and oxygen level. Then all the time-synched data is sent electronically to Surgical Safety Technologies for analysis.
"It pays for all of us to do the analysis centrally—it leads to more reliability and validity. By doing the analysis centrally, we can also share information between hospitals. For example, if Northwell does 150 urology cases and five other medical centers do 150 urology cases each, we can have 900 cases analyzed. That will give us better information in terms of things that happen frequently and infrequently. Maybe there is a near miss that happens once every 300 cases," Jarrett says.
The cost of the black box equipment is $100,000 per OR.
How Northwell uses black box technology in operating rooms
At Northwell, all black box data collected in an OR is de-identified, he says.
"It's the team approach that we look at. Everything is de-identified. The cameras blur out the faces of the OR team members. The purpose is to look for system issues—not individual people issues. That was important because one of the fears of people was having Big Brother watching over them. We are not looking to get anyone in trouble. What we are looking for is system issues that we can correct to protect the patients. It's about taking a proactive approach based on the data."
De-identifying the data also protects patient privacy, Jarrett says.
Taking a team approach for analysis of OR Black Box data is a key element of capitalizing on the new technology for OR performance improvement, he says.
"Outcomes are not totally dependent on the surgeon. They are also dependent on the interplay between all the nurses in the room, the anesthesiologist, the problems that occur no matter how good the surgeon is, and how those problems are addressed. All those things can be looked at because the technology uses digital algorithms much like a black box in a plane."
Northwell is also generating surgical technique and teaching gains from the black box technology, Jarrett says.
"When we do the analysis of the video for technique, we can give scores for it and we can show what happened. We can use this information at conferences to show how a surgeon approached a problem and achieved a great outcome. So, you can use this information for teaching. For residents who rotate into a service for four months, you can see whether there is improvement in performance or not to assess the quality of the teaching program."
And the black box technology is well-suited to analyzing adverse events, he says.
"Adverse outcomes can occur even when nobody does anything wrong—it can be the anatomy of the patient. However, when we analyze the surgery, we can ask whether there was any way to anticipate the anatomy was different than expected and how the situation was addressed. Was it addressed in a timely fashion? Did the surgeon communicate that there was a problem and what was needed to address it? Was all the right equipment in the room?"
Jarrett says "it's too early in the game" to measure the impact of OR Black Box at Northwell, but the pilot program is focusing on an area for improvement—distractions. "There are a lot of distractions in the OR. Not all of them are bad, but there are more distractions than we realized, which is one of the reasons we are studying their impact."
A major distraction identified in analyzing the black box data is people leaving and entering the OR, he says.
"Some people go out of the room for breaks, some people go out of the room to get special equipment, but the question is do we need to have that happening all the time? We may want to limit people going in and out of the OR, and the black box technology can tell us whether that kind of a rule makes a difference. We want to base decisions about our protocols on real data rather than assumptions."
Adapting to black box technology
The OR teams that have worked with OR Black Box have acclimated to the technology, Jarrett says. "Now that we have been doing this for a year, the first team performs like it doesn't even know the black box is there. They turn it on at the beginning of a case, turn it off at the end of a case, and work as if it wasn't even there. They get used to it."
Northwell is considering whether to install the black box technology at more hospitals in the health system, and several other U.S. health systems are contracting for OR Black Box with Surgical Safety Technologies this year, he says.