Particularly for patients who are older and frail, home-based medical care is often a viable alternative to urgent care centers, emergency rooms, and hospitalization.
The coronavirus pandemic has increased demand for home-based medical care, according to Michael Le, MD, chief medical officer at Landmark Health.
During the coronavirus disease 2019 (COVID-19) pandemic, patients have been reluctant to visit healthcare facilities due to concerns over coronavirus infection. In April, a Medical Group Management Association survey found that physician practices had experienced a 60% average decrease in patient volume.
Huntington Beach, California–based Landmark Health specializes in providing home-based medical care such as medical interventions and behavioral healthcare to older patients with multiple chronic conditions. The COVID-19 pandemic has been driving demand for this type of in-home care, says Le.
"There has been a dramatic increase in the interest for our services—about a 33% increase in demand for our type of in-home services since the pandemic began. We think that is only going to grow as the year continues, especially as we get back into the flu season in the fall," he says.
The increased demand for in-home services has boosted Landmark's finances, Le says. "From a financial standpoint, the pandemic has grown revenue. We forecast revenue will increase about 230% for this year."
Landmark focuses on risk-based and value-based contracts, mainly with Medicare Advantage health plans. The organization employs about 450 healthcare professionals such as doctors, nurse practitioners, physician assistants, dietitians, and social workers. Landmark operates in 14 states, including 46 metropolitan service areas.
Focusing on frail seniors
There is untapped potential to provide home-based medical care to homebound seniors, a recent article published in Health Affairs says.
According to estimates in a 2015 JAMA Internal Medicine article, there are about two million homebound seniors in the United States and about five million seniors who can only leave home with assistance or significant difficulty.
The Health Affairs article is based on survey data collected from more than 7,500 community-dwelling, fee-for-service Medicare beneficiaries. The study includes three key data points.
Almost 5% of the Medicare beneficiaries had received home-based medical care during the study period from 2011 to 2017
Among the Medicare beneficiaries who received home-based medical care services, 75% were homebound
Compared to non-homebound Medicare beneficiaries who did not receive home-based medical care, non-homebound beneficiaries who did receive this kind of care had more chronic illnesses, more functional impairment, and higher healthcare utilization
For healthcare providers, there is a golden opportunity to provide home-based medical care to homebound seniors and medically complex non-homebound seniors, the Health Affairs article's co-authors wrote. "The significant unmet needs of this high-need, high-cost population, and the known health and cost benefits of home-based medical care should spur stakeholders to expand the availability of this care."
Frail seniors are good candidates for home-based medical care, says Nancy Guinn, MD, medical director of Healthcare at Home, a division of Albuquerque, New Mexico–based Presbyterian Healthcare Services.
"This population is well served by being seen at home for many reasons. Even traveling to a clinic can be difficult or impossible. Patients with cognitive decline or mobility issues may be especially challenged by a clinic visit. In terms of hospital at home, patients avoid exposure to any potential hospital-based infections and are less likely to fall in a familiar setting. Seeing a patient in the home offers significant insight into their environment," she says.
Landmark's mobile care model
The average age of a Landmark patient is 79, and the average patient has eight chronic conditions, Le says.
"For the frail population, they need someone laying hands on them and looking around at the home environment, especially in this time when family members are afraid of visiting and getting their loved ones sick with the coronavirus. Our patients are even more isolated and lonely than they were before the pandemic, and having someone come to examine them and bring treatment to them helps keep them out of emergency rooms, urgent care centers, or hospitals that are full of COVID-19 patients."
Landmark's mobile geriatric care model has four primary elements, he says.
1. "Complexivist" care features a multidisciplinary team. "Complexivist care includes our doctors, nurse practitioners, physician assistants, psychiatrists, pharmacists, dietitians, and social workers. It is a full care team wrapped around the patient. It takes a village to manage the frailties of these patients," Le says.
Complexivist care is provided 24/7 in the patient's home, and caregivers spend a significant amount of time with patients, he says. "As opposed to a 10- or 15-minute office visit, our initial visits are an hour long and our follow-up visits are 50 minutes long."
2. Urgent care services are provided to patients. "We do not just lay hands on the patient and take vital signs. If we find a health problem, we can make an intervention immediately—we are like a global urgent care or emergency room. We can draw blood and check labs. We can administer medications such as Lasix, IV antibiotics, and steroids to treat and stabilize patients. We can insert catheters, perform suturing, and check X-rays or ultrasound imaging," Le says.
3. Behavioral health services are provided to patients because about 50% of Landmark's patients have behavioral health comorbidities that negatively impact their quality of life and healthcare outcomes. "We have our own behavioral health team to help address behavioral health needs and social determinants of health," he says.
4. Palliative care and advanced care planning are provided to patients because they are statistically approaching their last years of life, Le says.
"We train our providers to have end-of-life conversations with patients. As a former hospitalist, I can say there is no worse place to have those kinds of conversations than in an emergency room or an ICU. There is no better place to have those kinds of conversations than in a patient's living room while they are surrounded by their family. That way, the whole family can have discussions about goals and values."
Geared for the pandemic
Landmark's in-home service model is well-suited to rising to coronavirus pandemic challenges, Le says.
"Whether it is a direct impact from the pandemic or an inability to get out and get medications, we have seen worsening behavioral health severity among patients. Our behavioral health team—our psychiatrists, nurse practitioners, and social workers—has seen about a 180% increase in visits during the pandemic."
Landmark caregivers are serving as a "pre-frontline" during the pandemic, he says.
"We are able to go into homes and treat our patients so they do not have to go into a hospital and be around symptomatic patients who could be spreading the coronavirus. We can alleviate some of the frontline stress in the emergency rooms, so they are not overwhelmed."
Treating frail, elderly patients in their homes limits their exposure to possible infection with coronavirus, Le says.
"Many of our patients have diabetes, heart failure, and cancer, which puts them at higher risk if they contract COVID-19 at a healthcare facility. If they catch coronavirus, these patients will likely have a bad outcome. Our patients have another option to receive care other than just dialing 911 and being transported to an emergency room."
Bright future
Landmark focuses on the sickest and frailest patients now, but healthcare is moving in the direction of the home, he says. "Whether it is for convenience, safety, or good outcomes, more and more healthcare will be shifting toward the home. We believe there is a gap in this area."
As a care delivery method, home-based medical care is likely to follow a similar trajectory as telemedicine, Le says. "Just like telemedicine has surged and will be part of the healthcare landscape for years to come, the shift to more home-based medical care has been accelerated and will continue to grow long after the pandemic."
Guinn is equally bullish on the future of home-based medical care.
"We can't keep assuming that hospital-based care is the best choice for all of the patients that we currently hospitalize. That is not to say patients should receive lesser care—they should receive care that is appropriate for their needs. As our population ages, home-based medical care is going to be more important rather than less important," she says.
Guinn says home-based medical care is an attractive care model for frail seniors and other high-risk patients. "What a better way to get care. You stay home. The doctor comes to you. The care team spends an hour or an hour and half with you. We do flu vaccines in the home. We do Pneumovax in the home and other shots. We even have a podiatry nurse who comes in and does foot care for our diabetic patients. Who wouldn't prefer that as a way of getting care?"
Healthcare at Home model
At Presbyterian Healthcare Services, Healthcare at Home programs offer a range of care in the home from primary care, to urgent care, to Hospital at Home. The health system built its home-based medical services unconventionally, Guinn says.
"We did not follow what most people would call a normal progression. Normally, you would set up a house calls practice, then branch out. We became interested in Hospital at Home when it was being created and thought it was a good idea for us. Then we discovered that we needed broader-based services for our patients than Hospital at Home could provide. Hospital at Home really is hospitalization. We have criteria for admission just like a hospital would have criteria. But often patients do not need that level of care, so we had to broaden what we were doing. That is how we ended up backing our way to house calls," she says.
For other health systems that are considering adoption of home-based medical care services, Guinn says organizations should conduct an in-depth needs assessment first. "Whatever progression you take in launching home-based medical care services, you need to understand what the needs are. You also need to understand the stakeholders, whether they are your patients, your board of directors, your insurer source, or your hospital system. You have got to understand their needs, then construct programs that are appropriate."
More than 1,000 patients are receiving medical services through Presbyterian's Healthcare at Home programs, she says. The Hospital at Home program can serve as many as 14 patients daily. About 700 patients are receiving primary care and urgent care services through Healthcare at Home's Complete Care program. And about 300 people are receiving care at a bricks-and-mortar clinic established for Healthcare at Home patients.
"We created a small clinic for people who would prefer to be seen in a clinic setting even though they qualify medically for the home programs. What we have found is that people drift back and forth between the home and clinic settings depending on their need. If they have an urgent issue, we will see them in the home," Guinn says.
Across Healthcare at Home programs, there are 285 employees.
Patients are highly satisfied with Healthcare at Home programs, she says. In patient satisfaction scores for the second quarter of this year, 100% of Hospital at Home patients reported that they would recommend the service for others, and 95% of Complete Care patients reported that they would recommend the service for others.
Hospital at Home
There are three keys to success in operating a Hospital at Home program, Guinn says.
"First of all, it is a really good funding mechanism. Medicare does not pay for this service, which is a shame because it is valuable. So, contracts must be built with other insurers such as Medicare Advantage health plans," she says.
The second crucial Hospital at Home component is recruiting an appropriate clinical care team, Guinn says. "Hospital at Home requires a rapid response team. You have got to have a team that has the proclivity to move quickly when necessary. For example, many of our Hospital at Home nurses used to work in emergency rooms—they have the sense of the urgency of care."
Hospital at Home physicians must be able to work independently, she says. "People naturally assume that a Hospital at Home provider is a former hospitalist, but we are more likely to hire rural primary care physicians. Those clinicians are isolated enough that they are used to coping with whatever comes through the door. Our Hospital at Home clinicians need to be confident enough and have enough breadth to be able to cope with whatever they find in the field."
The third essential element of a successful Hospital at Home program is "prearrangement," Guinn says. "You need to know where you are going to get your medications and where you are going to get your durable medical equipment. You need to arrange infusions in the home and you need to establish partnerships with companies that move rapidly enough to ensure patient safety."
The Hospital at Home program is not appropriate for all patients who are sick enough to require hospitalization, she says. "Basically, it involves the idea of patient safety. There are many conditions that we can treat in the home, but there are some conditions that are advanced enough that we would prefer the patients go into a tertiary facility."
The program treats patients with nine diagnoses, including congestive heart failure exacerbation, COPD exacerbation, community-acquired pneumonia, DVT and simple pulmonary embolism, complicated cellulitis, and complicated UTI. "For all of those diagnoses, there are markers for distress that are beyond what we feel is safe for the home," Guinn says.
Funding home-based medical care services
At-risk contracts such as those set in Medicare Advantage health plans are the best fit for providing home-based medical care services, she says.
"With home-based medical care, you absolutely have to find a funding source that does not focus on payment for services rather than payment for outcomes and results. You need to have at-risk funding. The goal is always to identify how you can fund these services—acknowledging that the funding is based on value and cost savings by offering appropriate care, not on a fee-for-service model."
Healthcare at Home's Complete Care program has generated significant cost savings, Guinn says. "For the four years between January 2015 and December 2019, Complete Care reduced the cost of care by 38% compared to predicted cost for similar patients."
She says the cost savings from Complete Care are generated on several fronts, including medication management, decreased utilization of emergency department and hospitalization services, and fewer specialist visits.
Hospital at Home also drives cost savings, including avoided postacute care services, Guinn says. "If you don't go to the hospital, then you don't go to a skilled nursing facility. Postacute care costs are really significant for this population, and a hospitalization predisposes toward spend in postacute care costs."
A Health Affairsarticle published in 2012 found that Presbyterian's Hospital at Home program generated cost savings in patient care of 19% compared to similar patients who received care in an inpatient setting.
Photo credit: Illustration by Francesco Ciccolella
In its 2020 best performers data report, MGMA rates physician practices on operations, profitability, productivity, and value.
The Medical Group Management Association (MGMA) has released its 2020 best performers data report on physician practices.
sician-compensation-
MGMA evaluated nearly 4,000 medical groups on four metrics: operations, profitability, productivity, and value. More than 1,000 of the medical groups rated highly on at least one of the metrics, earning "better performer" status.
Operations: Less than the median for percentage of total accounts receivable over 120 days, less than the median for days adjusted fee-for-service charges in accounts receivable, and greater than the median for adjusted fee-for-service collection percent
Profitability: Less than the median for total operating cost per work relative value unit (RVU), less than the median for total cost per total RVU, less than the median for total operating cost as a percent of total medical revenue, and greater than the median for total medical revenue after operating cost per physician
Productivity: Greater than the median for total medical revenue per physician, greater than the median for total medical revenue per staff, greater than the median for work RVUs per staff, and greater than the median for provider work RVUs for at least 66% of providers
Value: Physician practices report quality metrics and practices qualify for better performer status in at least one other category
The MGMA report, which is based on 2019 data, includes several key data points and benchmarks:
Compared to lower performing practices, better performer practices reported nearly 9% higher medical total operating cost per full-time-equivalent (FTE) physician. Better performer practices also reported 19% higher median total physician compensation and benefits. These findings indicate better performers benefit from investments in staff, facilities, and operations, the report says.
Better performers have higher staff levels and slightly higher expenses. Better performers had 20% more business office staff and 18% more nursing staff than the median for all medical groups. Business office staff help drive accounts receivable collections. Additional nursing staff help clinicians to see more patients, which increases practice productivity. For example, better performers had 20% more patient visits and 10% greater total RVU production.
Based on the percentage difference between better performers and all practices, better performers have higher total compensation, ranging from 8.36% for general surgery to 27.76% for dermatology.
Based on the percentage difference between better performers and all practices, better performers have higher productivity as measured by work RVUs, ranging from 15.56% for family medicine to 29.63% for dermatology.
Better performers collect at least 6% more accounts receivable in the first 30 days.
Better performers earn at least 40% more in total medical revenue after operating cost compared to all reporting practices.
Interpreting the data
The ability to see more patients helps drive higher compensation at better performer physician practices, Andy Swanson, MPA, vice president of industry insights at Englewood, Colorado-based MGMA, told HealthLeaders. "With many medical groups having pay tied to production, more patients seen is going to net out on dollars spent for clinicians seeing patients."
Efficiency is pivotal in maximizing work RVUs, he says.
"The first step is an in-depth, minute-by-minute analysis of what a patient visit looks like, so you can identify waste or time that can be cut. Once you have done that in-depth analysis, then you get into the tools to enable a patient visit, which inevitably comes down to your electronic health record. Whoever is taking notes on a patient—whether it is a scribe, nurse, or doctor—you need to know whether that process for entering information on the patient's chart and for billing is going as smooth as it can go."
To maximize collection of accounts receivable, physician practices need to understand the payer profile of patients, Swanson says.
"You must understand not just what the patient is coming in for, but also what the patient's payment options are going to be. Do they have a government payer? Do they have a commercial payer? Or are they a self-pay patient? Once you understand who the payer is, you need to understand the financial obligations of the patient before they walk through the door, so that things like deductibles and co-pays are collected."
Different payer profiles require different accounts receivable approaches, he says.
"For government pay and commercial pay, you need to know the terms of payments on the patient's part vs. the carrier's part. If you have a self-pay patient, you need to come up with a rigorous payment plan or methodology that the clinic follows every time a self-pay patient comes in. That may look like $25 for a typical visit, then a payment plan for the next 30 days after care to get to full payment."
Financial benchmarks are important and an indicator of success, but medical groups seeking to improve their performance need to look deeper at factors related to operations, profitability, and productivity, Swanson says.
"If medical groups want to take action on financial outcomes, they are going to need to look at a myriad of key performance indicators that drive the financial measures. Spending time on those key performance indicators is where medical groups find success in moving the financial-benchmarks needle."
Research shows that clinicians can make a compassionate connection with patients in less than a minute.
The co-author of a book on compassion in healthcare says that clinicians who feel they do not have the time to make a compassionate connection with patients need a mindset change.
Many studies have shown that compassionate care generates positive outcomes. One study found that shifting from a low- to a high-scoring category of physician empathy decreased the odds of metabolic complications among diabetic patients by 41%. Another study found that homeless patients assigned to standard medical care plus compassionate contact from trained volunteers had 33% fewer emergency department visits and were twice as likely to rate their hospital experience highly.
Despite the widespread evidence on the benefits of clinicians showing compassion to their patients, a study found that 56% of physicians did not feel they had the time to be compassionate.
"That study begs the question—how long does it take to be compassionate?" says Stephen Trzeciak, chairman and chief of the Department of Medicine at Cooper University Health Care in Camden, New Jersey, and chairman of the Department of Medicine at Cooper Medical School of Rowan University in Camden. Trzeciak is co-author of the bookCompassionomics: The Revolutionary Scientific Evidence That Caring Makes a Difference.
It takes very little time for clinicians to be compassionate with patients, he says. "We devote a whole chapter in Compassionomics to the issue of time. We found the scientific evidence that timed being compassionate. There have been several studies in the literature, and what they have all found is that it takes less than a minute to make a meaningful, compassionate connection with a patient."
To illustrate that it takes little time for clinicians to be compassionate, Trzeciak cited a Johns Hopkins study involving survivors of breast cancer. The breast cancer patients were exposed to two different interactions with oncologists. One interaction was purely informational, and the experimental arm of the study had an interaction that was both informational and compassionate.
"What they found was that the experimental arm compared to the standard informational arm had a statistically significant reduction in anxiety among the cancer survivors. In the experimental arm, oncologists provided the same consultation with just a little bit of extra communication before and after the purely informational interaction. There were statements such as, 'We are here together. You are not going to go through this alone. I am here with you,'" he says.
In the Johns Hopkins study, the amount of time devoted to being compassionate was negligible, Trzeciak says. "Just 40 seconds of extra communication with those types of statements generated a statistically significant reduction in the anxiety of these cancer patients using a validated scale to measure anxiety. Even what some people might consider to be small doses of compassion make not only meaningful differences for patients but also measurable differences for patients."
For clinicians, having time to be compassionate is a matter of perception, he says. "It all goes to mindset. When clinicians say, 'I don't have enough time,' the data shows that being compassionate does not take you any longer. Mindset is the most important factor. It is just not true that being compassionate takes more time—we just think that it does. That is what the evidence shows."
Organizational benefits
Employing clinicians who show compassion to their patients has benefits for healthcare organizations, Trzeciak says. "More compassionate care is associated with higher quality care, fewer medical errors, and higher patient satisfaction."
When clinicians show compassion to their patients, it improves patient experience, he says.
"When you look at surveys of patients, they talk about the relational aspects of healthcare. They do not talk about the technical aspects of healthcare. Some clinicians find that surprising; but, in general, most patients believe that their doctors and nurses know what they are doing. They just presume technical proficiency. What they want is the caring part of healthcare."
Compassionate care has a powerful impact on patient experience and the financial gains that a positive patient experience can generate, Trzeciak says.
"There is compelling evidence that, on average, healthcare organizations that do better with patient experience do better in terms of financial performance. Compassion matters for overall patient experience, and patient experience drives bottom line."
Healing the healers
Compassionate care also helps address clinician burnout, he says. "There is evidence that compassion for others can be a powerful therapy for the giver. The evidence in the literature shows that compassion is beneficial for the giver in that compassion for others promotes resilience and resistance to burnout."
Compassionate connections and strengthening relationships with compassion help prevent clinician burnout, Trzeciak says.
"We all know about the burnout crisis in healthcare and the costs of burnout in terms of employee turnover. The preponderance of evidence in the scientific literatures shows that compassionate connections with others and the quality of your relationships—whether it is the quality of relationships with your patients or relationships with colleagues—are the key to resilience and resistance to burnout."
Given the benefits of compassion for patients, healthcare organizations, and clinicians, it should be viewed as an integral part of medicine, he says. "What we found is that compassion matters, not just in sentimental and emotional ways but also in evidence-based ways. We consider compassion to be part of evidence-based medicine."
The United States has reported more coronavirus deaths than any other country.
U.S. coronavirus deaths are likely understated, and the United States has relatively high COVID-19 mortality compared to 18 similar countries, a pair of recent studies published by the Journal of the American Medical Association shows.
The United States has led the world in reported coronavirus deaths. As of Oct. 15, more than 221,000 Americans had died of COVID-19, according to worldometer. The country with the next highest death count was Brazil at more than 150,000.
"Few people will forget the Great Pandemic of 2020, where and how they lived, how it substantially changed their lives, and for many, the profound human toll it has taken," an editorial accompanying the JAMA studies says.
Accounting for coronavirus deaths
One of the JAMA studies focuses on U.S. excess deaths—the difference between observed and expected deaths—from March to July 2020. The study includes several key data points.
From March 1 to Aug. 1, there was a 20% increase over expected deaths, with 1,336,561 deaths reported and 1,111,031 deaths expected.
Of the 225,530 excess deaths, only 67% were attributed to COVID-19.
The Top 10 states for highest per capita excess death rates were New York, New Jersey, Massachusetts, Louisiana, Arizona, Mississippi, Maryland, Delaware, Rhode Island, and Michigan.
There were statistically significant increases in two other causes of death—heart disease and Alzheimer disease/dementia. The increase in heart disease deaths coincided with the spring surge of coronavirus deaths. The increase in Alzheimer disease/dementia deaths coincided with the spring and summer surges of coronavirus deaths.
The number of excess deaths attributed to the coronavirus is likely understated, the study's co-authors wrote. "Although total U.S. death counts are remarkably consistent from year to year, U.S. deaths increased by 20% during March-July 2020. COVID-19 was a documented cause of only 67% of these excess deaths."
Two factors may account for the understated number of excess deaths tied to the coronavirus, they wrote.
"U.S. deaths attributed to some noninfectious causes increased during COVID-19 surges. Excess deaths attributed to causes other than COVID-19 could reflect deaths from unrecognized or undocumented infection with severe acute respiratory syndrome coronavirus 2 or deaths among uninfected patients resulting from disruptions produced by the pandemic."
Comparative data
In terms of COVID-19 deaths, the United States fares poorly in a comparison with 18 other Organisation for Economic Co-operation and Development countries, the other JAMA study found.
The study compares U.S. coronavirus mortality to 18 other OECD countries with a population of at least 5 million and a per capita gross domestic product of at least $25,000. The countries were categorized by COVID-19 per capita mortality as low, moderate, or high.
The research includes several key data points.
On Sept. 19, 2020, the United States reported COVID-19 per capita mortality at 60.3 per 100,000 of population, which was higher than countries with low or moderate coronavirus mortality but comparable to other high-mortality countries.
Australia was categorized as a low-mortality country, with 3.3 COVID-19 deaths per 100,000. If the United States had been able to match Australia's per capita mortality, 94% of American deaths could have been avoided.
Canada was categorized as a moderate-mortality country, with 24.6 COVID-19 deaths per 100,000. If the United States had been able to match Canada's per capita mortality, 59% of American deaths could have been avoided.
The United States had a lower coronavirus mortality rate than high-mortality countries during the early spring, but the U.S. coronavirus mortality rate has been higher than all other high-mortality countries since May 10.
The U.S. per capita coronavirus mortality rate has been relatively high compared to OECD peers, the study's coauthors wrote. "After the first peak in early spring, U.S. death rates from COVID-19 and from all causes remained higher than even countries with high COVID-19 mortality. This may have been a result of several factors, including weak public health infrastructure and a decentralized, inconsistent U.S. response to the pandemic."
Mobile stroke programs provide speedy evaluation and treatment of patients when every minute counts.
A Cincinnati-based health system with a history of innovation in stroke care has launched a mobile stroke unit.
Nearly 800,000 people have strokes annually, according to the American Heart Association. A rapid response to stroke is crucial for positive outcomes. If a stroke is caused by a clot lodging in a blood vessel supplying the brain, most patients need the clot-busting drug tissue plasminogen activator (tPA) within three hours.
UC Health crafted the FAST method for detecting stroke and played a leading role in the development of tPA in the late 1980s. FAST stands for Face drooping, Arm weakness, Speech difficulty, and Time to call 911.
In August, UC Health launched a mobile stroke unit that responds to a patient's home when acute stroke is suspected. "The overall goal of the Mobile Stroke Unit is to bring a lot of what we can do in the emergency department for acute stroke patients to the curbside of patients, so we can diagnose and potentially treat in a very timely manner," says Christopher Richards, MD, MS, medical director of UC Health's Mobile Stroke Unit program.
The Mobile Stroke Unit deploys out of the firehouse at Springfield Township, Ohio, which is centrally located in UC Health's service area. The service is available seven days a week from 7 a.m. to 7 p.m.
The startup costs for the program—including the ambulance, equipment, supplies, and training—were $1 million. The annual operating costs, which consist mainly of personnel and supplies, are about $500,000.
How the Mobile Stroke Unit works
The Mobile Stroke Unit ambulance is manned by a paramedic, nurse, CT scan technician, and EMT/driver. A key element of the personnel is a stroke neurologist who participates in Mobile Stroke Unit calls virtually, Richards says.
"The stroke neurologist who joins the team virtually is a critical part of the operation. The decisions about clot-busting medications, reversing bleeding strokes, and blood pressure management are beyond the scope of a critical care nurse or a paramedic. So, the consultation we have from the UC Health stroke team is a critical part of the Mobile Stroke Unit," he says.
The nurse and paramedic facilitate the stroke neurologist's examination with an iPad, so the physician can not only interact with the patient but also watch as the patient is screened for symptoms such as poor coordination and speech difficulty. "The evaluation is the same as a patient would receive in an emergency room," Richards says.
A patient receives a CT scan in UC Health's Mobile Stroke Unit. Photo Credit: UC Health
Having CT scan capability in the ambulance plays an essential role, he says. "When the patient is brought to the Mobile Stroke Unit, one of the first things the team can do is give a CT scan. That is a huge differentiator in stroke care to determine whether there is a bleeding stroke, which has a vastly different treatment pathway, or a more common ischemic stroke with blockage of an artery."
The Mobile Stroke Unit works in concert with local emergency medical services ambulances, Richards says.
"What typically happens is that a patient, loved one, or bystander will call 911. They communicate with a dispatcher about what is happening. If the dispatcher suspects stroke, they will dispatch a local EMS ambulance and may dispatch the Mobile Stroke Unit at the same time. Oftentimes, a local EMS paramedic will be on the scene first and conduct screening and evaluations, then the Mobile Stroke Unit arrives."
The local EMS crew takes charge of the scene, he says.
"We help in whatever way we can with patients. To foster that relationship before we launched, we did significant outreach to our EMS partners in the areas where we would be responding to make sure they understood what we could do, what we could not do, how we could help, and how we would interact on scene."
For patients suffering ischemic stroke, the Mobile Stroke Unit plays a pivotal role in speeding up administration of tPA to dissolve blood clots, Richards says.
"Without the Mobile Stroke Unit, the best scenario is paramedics get on scene quickly, they do some screening and recognize a stroke is occurring, then there is transport to the hospital, an intake process at the hospital, and a CT scan. By being able to bring a CT scanner, tPA, and a stroke team physician virtually to the curbside, the Mobile Stroke Unit cuts out a lot of time."
Other mobile stroke programs have reported that they can speed up administration of tPA by 30 to 45 minutes. "That time could be the difference in levels of disability and in receiving tPA or not," he says.
The Mobile Stroke Unit is at the curbside for as long as an hour, and most patients are transported to local hospitals.
Keys to success
There are five elements to operating a successful mobile stroke program, Richards says.
1. Accounting for the entire episode of care: The treatment of stroke is a "chain of survival" and the chain is only as strong as its weakest link, he says. "The chain stretches from laypersons at home recognizing that a loved one may be having stroke symptoms, to the 911 dispatcher, to paramedics, then all the way down the line to the hospital. The Mobile Stroke Unit is a way to compress that chain of survival."
2. Laying a foundation: The community must be involved in establishing a mobile stroke program, Richards says. "When we set up our program, one consideration was how the Mobile Stroke Unit was going to be received by the public, who is used to their local EMS ambulance showing up and knowing they are going to be on the scene for a short period of time. It is a change of mindset for the public. Our Mobile Stroke Unit is going to be on the scene for an extended period."
3. Engaging EMS partners: Establishing a working relationship with local EMS crews is crucial, he says. "We operate in a system where we ask to be invited to participate with our local EMS agencies."
4. Creating hospital partnerships: Once patients have been evaluated and treated as needed, the UC Health Mobile Stroke Unit sends patients to the closest and most appropriate hospital, regardless of whether the hospital is part of the health system. The logistics of sharing information is pivotal, Richards says.
"When we do a CT scan in the back of the Mobile Stroke Unit, our radiologists at UC Health read those images, but that read and those images have to be accessible to a receiving hospital if it is not a UC Health facility. So, we have worked through the logistics of the interoperability of systems, which has been a critical component of our program."
The Mobile Stroke Unit program also has established protocols for communication between the virtual stroke neurologist and the treatment teams at local hospitals, he says. "That has allowed us to do a couple of things. First, while we most commonly transport patients to an emergency department, we can go directly to an interventional suite if the patient has the type of clot that neuro-interventionists can take out. We also can go directly to a neurological intensive care unit."
5. Stocking supplies: It is essential for a mobile stroke program to have medical supplies to meet the needs of patients with suspected stroke, Richards says. "We have worked closely with our pharmacy colleagues to think about which medications we should have onboard."
ECMO life support can be used when coronavirus patients with acute respiratory distress syndrome respond poorly to mechanical ventilation.
Seriously ill coronavirus patients placed on extracorporeal membrane oxygenation life support have a similar mortality rate as other patients placed on ECMO with acute respiratory distress syndrome (ARDS), a recent research article says.
ECMO is a form of life support that features a machine that performs essential functions of the heart and lungs. The ECMO machine is connected to a patient through plastic tubes that are placed in large veins and arteries in the legs, neck, or chest, according to the American Thoracic Society. Blood flows through the ECMO machine, which adds oxygen to the blood and removes carbon dioxide, then the blood is returned to the patient.
The co-authors of the recent research article wrote that the study provides "provisional support" for using ECMO to treat coronavirus patients with acute hypoxemic respiratory failure. "In ECMO-supported patients with COVID-19 and characterized as having ARDS, estimated in-hospital mortality 90 days after ECMO initiation was 38.0%, consistent with previous mortality rates in non-COVID-19 ECMO-supported patients with ARDS and acute respiratory failure."
The recent journal article, which was published by The Lancet, features data collected from more than 1,000 ECMO patients at more than 200 hospitals. The study includes two key data points.
COVID-19 patients with ARDS who received respiratory (venovenous) ECMO had a 38.0% estimated cumulative incidence of in-hospital mortality 90 days after ECMO began.
COVID-19 patients with ARDS who received respiratory ECMO had a mortality rate similar to the mortality rate found in the largest randomized controlled trial of ECMO for ARDS patients without coronavirus—the ECMO to Rescue Lung Injury in Severe ARDS (EOLIA) trial. In the EOLIA trial, 60-day mortality for ECMO patients with ARDS was 35%.
Interpreting the data
The lead author of the study told HealthLeaders that the research is significant because it provides a generalizable estimate of mortality for ECMO-supported patients with COVID-19, and the estimate is similar to the reported mortality in other major studies of ECMO support for ARDS patients.
"If your center is experienced in providing ECMO support to patients with ARDS you might expect similar results when providing ECMO support to patients with COVID-19-related ARDS," said Ryan Barbaro, MD, MS, an assistant professor at University of Michigan in Ann Arbor, Michigan.
Organ injury is a key factor for survival of coronavirus patients with ARDS who receive ECMO, he said.
"We found that patients had a higher risk of dying if they had worse lung disease, required circulatory support, had kidney injury, or experienced a cardiac arrest. Our study did not answer when is the best time to initiate ECMO support for patients with COVID-19. However, it does suggest that patients who initiated ECMO support with less organ injury had less risk of dying."
Barbaro speculated that ECMO can be an effective treatment for coronavirus patients with ARDS because the technology avoids lung damage associated with mechanical ventilation and effectively oxygenates a patient's blood.
"The World Health Organization recommends doctors consider ECMO support in patients who have failed lung protective ventilation. In theory, ECMO benefits patients because it avoids the accumulation of injury caused by high ventilator pressures or caused by the inability to provide enough oxygen to the patient. In these cases, ECMO support can do the work of the lung outside of the body—this is analogous to how dialysis can do the work of the kidney outside of the body."
In healthcare, disruptive behaviors weigh heavily on physicians, nurses, and other staff members.
A former senior nurse is leading a for-profit institute dedicated to addressing bullying and incivility in healthcare settings.
Bullying and incivility are rampant in healthcare organizations. A 2018 study found that 43% of nurses had experienced at least two negative behaviors on a weekly or daily basis, and 12% of nurses self-identified as victims of negative behaviors. A 2020 study found that one or more of six disruptive behaviors were reported at 97.8% of healthcare workplaces, with disruptive behaviors associated with poorer teamwork climate, safety climate, job satisfaction, and perceptions of management.
Renee Thompson, DNP, RN, left nursing a decade ago to become a national speaker on bullying and incivility in healthcare. In 2017, she founded the Oldsmar, Florida-based Healthy Workforce Institute, which provides resources to curb bullying and incivility, consultancy services, and training for healthcare leaders.
Thompson recently talked with HealthLeaders about the scope of healthcare workplace bullying and incivility as well as the Healthy Workforce Institute's efforts to address the problem. The following is a lightly edited transcript of that conversation.
HealthLeaders: Why are bullying and incivility widespread in healthcare?
Renee Thompson, DNP, RN: There is more bullying and incivility in healthcare than any other industry. For many people, it is unexpected because healthcare is a caring and compassionate industry.
There are a couple of reasons. First, think about the high level of stress, particularly this year. Our healthcare teams are dealing with more stress than they ever have had to deal with before. When people are burned out and they are stressed, they do not behave well. There also is the unpredictability of care and the life-and-death situations that healthcare professionals find themselves in.
Another reason is we accept bad behavior as the norm in healthcare. One of the things we hear about physicians is that we tolerate bad behavior because of how excellent they are clinically. So, we have normalized deviant behaviors—we do workarounds, and we justify, and we rationalize for why someone behaves badly.
HL: What role can healthcare organization leaders play in addressing bullying and incivility?
Thompson: What we have found is that executives are not doing a good job equipping their frontline leaders with the skills and tools they need to address disruptive behaviors. Leaders need to be equipped with skills to address disruptive behaviors in the same way that they are equipped with skills for managing budgets and meeting regulatory requirements.
HL: What are the kinds of skills you teach healthcare leaders?
Thompson: First, we always start with heightening awareness. People in healthcare have been behaving badly for decades. You can't just come in and say, "We are going to start being nice to each other." You must heighten awareness because some people do not realize that their behavior needs to change.
We do things like build in content related to disruptive behaviors into new employee orientation, nurse residency programs, preceptor programs, and physician residency programs. It must be ongoing. You must infuse content related to behavior in everything you do.
With the leaders, we do the same thing. We equip them with the tools they need to heighten awareness among their staff. We teach them how to set behavioral expectations as a team.
We spend a lot of time teaching leaders how to confront disruptive behaviors. You may have a seasoned, experienced, and clinically excellent nurse who is toxic. We teach leaders how to have a conversation with that kind of an employee. We are big on scripting—giving leaders scripts to know what to say to someone, when to say it, and how to say it.
Leaders also have to hard wire addressing bullying and incivility. Once you create a caring culture, it can quickly regress if you do not hard wire healthy workforce best practices into the fabric of your hospital departments. For example, if a leader is interviewing a job candidate, the department norms should be pulled out. A leader should say, "This is what you can expect from us, and this is the behavior we expect of you. Things like kindness, respect, and giving and receiving feedback are not optional here—they are part of the job requirements."
HL: Is there a connection between bullying and incivility on one hand and burnout on the other?
Thompson: During the pandemic, we are seeing an uptick in bad behavior. There are some healthcare teams that are pulling together, but there are a lot of teams that are falling apart. You must acknowledge that when people are stressed and burned out, they do not behave well.
So, you must address burnout to address bullying and incivility. There is a strong connection between somebody's well-being, their stress level, and how they perform in the workplace. When you are under stress, you are not always behaving in a professional manner.
Burnout is one of the most vexing challenges facing physicians and other healthcare workers nationwide. Research published in September 2018 found that nearly half of physicians nationwide were experiencing burnout symptoms, and a study published in October 2018 found burnout increases the odds of physician involvement in patient safety incidents, unprofessionalism, and lower patient satisfaction.
The summit is being hosted by The Ohio State University colleges of dentistry, medicine, nursing, optometry, pharmacy, public health, social work, and veterinary medicine, as well as The Ohio State University Wexner Medical Center and the National Academy of Medicine Action Collaborative on Clinician Well-Being and Resilience.
The event was formed last year to address a pressing need among healthcare professionals, says summit co-chair Bernadette Melnyk, PhD, RN, APRN-CNP, dean of the College of Nursing and chief wellness officer at The Ohio State University in Columbus, Ohio.
"It was launched because we wanted to make an impact on the rates of clinician burnout, depression, and suicide. Now, with the coronavirus pandemic, those rates have worsened even more. Doctors and nurses are suffering now from post-traumatic stress disorder, burnout, anxiety, and depression," she says.
The mission of the summit is to share best practices on how to improve healthcare professional well-being and resilience as well as to spur people to action, Melnyk says.
"This year, we are going to have a call to action for the 90 days after the summit. What are you going to do personally as well as at your workplace to take some of the evidence-based strategies you have learned at the summit and implement them? I am going to send a follow-up survey 90 days after the event, so we can document some outcomes from the summit."
Summit agenda highlights
This year's summit has five themes:
1. Promoting well-being and healthy lifestyle behaviors in healthcare professionals
2. Promoting well-being and healthy lifestyle behaviors in health sciences students and faculty
3. Organizational and systemwide initiatives to enhance workplace wellness culture
4. Innovations to promote well-being, resilience, and healthy lifestyle behaviors
5. Innovative solutions launched during the coronavirus pandemic
The summit will begin with several workshops during the afternoon of Oct. 21. Then full days of sessions will be held on Oct. 22 and Oct. 23.
U.S. Surgeon General Jerome Adams, MD, MPH, is a late addition to the roster of presenters. He is slated to speak at 9 a.m. on Oct. 22.
There will be two keynote presentations:
Liselotte "Lotte" Dyrbye, MD, MHPE, of Mayo Clinic will conduct a presentation titled "Burnout: Strategies to Get to System-Level Solutions"
Doug Smith, MBA, who is co-founder of Positive Foundry and a former CEO of Kraft Foods Canada, will conduct a presentation titled "The Science and Skill of Flourishing"
Phoenix-based Equality Health gathers social determinant data at primary care practices to connect patients with social services.
Equality Health has included addressing social determinants of health in the health system's care delivery system, with primary care practices playing a leading role.
Social determinants of health (SDOH) such as housing, food security, and transportation can have a pivotal impact on the physical and mental health of patients. By making direct investments in initiatives designed to address social determinants and working with community partners, healthcare organizations can help their patients in profound ways beyond the traditional provision of medical services.
"The model for our delivery of healthcare incorporates social determinants and a cultural approach to care. For us, social determinants are not a standalone project. That is a key element of the success that we have seen so far. It is not a bolt-on program. We are not doing it to be compliant with a government mandate. We are addressing social determinants because we think it is the best way to deliver care and improve outcomes," says Mark Stephan, MD, MBA, chief medical officer of Equality Health.
Including social needs in care delivery
Primary care practices are a foundational element of Equality Health's social determinant efforts, screening patients for social needs and cultural preferences with the health system's Social Cultural Risk Assessment survey. The risk assessment tool queries patient about housing, transportation, food insecurity, cultural beliefs and preferences around healthcare and medications, behavioral health, physical activity, sense of wellbeing, and spiritual needs.
The risk assessment survey, which was developed by Equality Health and has undergone several revisions, is administered to patients while they wait for their primary care appointments.
"It is a brief questionnaire but covers a lot of ground," Stephan says.
Primary care practices were chosen to play a frontline role in the effort to address SDOH because the clinics have relationships with patients, he says. "The doctor's office is still very much a trusted source of care. There is a doctor-patient relationship. It is an effective area to collect a survey from a workflow perspective."
Equality Health's onboarding of new primary care practices features four hours of training, which includes instruction on cultural awareness and SDOH for the entire staff.
"We go beyond cultural competence in our training to what I call cultural care delivery. There are three levels. One is cultural awareness. Another is cultural competence—being sensitive to how things are presented. Finally, there is cultural care delivery, which means we are expecting there to be cultural preferences in how healthcare is accessed and utilized," Stephan says.
An example of cultural care delivery is accommodating the participation of several family members during primary care visits, which is a cultural preference of many ethnic minority groups.
If a patient screens positive for a social need, clinicians can make referrals to community-based organizations and other local resources. The referrals are managed digitally in a two-step process, he says. First, social needs referrals are entered in Equality Health's care coordination platform with other "wrap-around" services such as patient education counseling. Second, social needs referrals are placed on a social determinants platform that can be accessed by local social services providers.
"The next step is making the social determinants platform available so that a referral done at a practice will go directly into that platform," he says.
Equality Health has curated its network of social service providers, Stephan says. "It is a mix, but the majority are community-based organizations."
The health system engages patients to make sure referrals result in action, he says. "On the surface, you think you just point people in the right direction of a community-based organization and hope for the best. But we reach out to patients digitally and we reach out telephonically."
Primary care practices receive a quarterly financial incentive from Equality Health for administering the Social Cultural Risk Assessment survey, he says. "What we have done is break incentives down into quarterly payments, so that we are closer to real time. It gives more immediate feedback on the activities that doctors have done to earn the incentive."
Addressing healthcare disparities
Tackling SDOH is only part of Equality Health's approach to closing healthcare disparity gaps, Stephan says.
"Socioeconomic status makes a difference in people's ability to access care and to understand the plan of care; but beyond that is the core of our thesis, which is how you perceive the delivery of care and how you perceive the relationship with the clinicians and practices that are delivering care. That matters as much as anything because when it comes down to it, when you are discussing going through a procedure the key to success is the relationship between the clinician and the patient."
Cultural care delivery promotes positive relationships between clinicians and members of minority ethnic groups, he says. "There has to be trust. The more trust and deeper the relationship, the more mutual understanding, and the more likelihood that the care plan will be successful and there will be a better health outcome."
While it is difficult to tease out the impact of social needs referrals and cultural care delivery, Equality Health believes its approach is making a difference for the health system and the communities it serves, Stephan says.
"We know directionally that by incorporating this survey, by doing the training, by deploying our model across our network, we are being successful partnering with health plans and physician practices, and better outcomes are happening. The cost of care is going down and the quality is improving."
New research shows total primary care visits decreased 21.4% in the second quarter of 2020 compared to the second quarters of 2018 and 2019.
Despite a significant increase in telemedicine visits, primary care utilization has fallen significantly during the coronavirus pandemic, a new research article shows.
COVID-19 is a highly infectious and potentially deadly illness. As of Oct. 5, more than 7.6 million Americans had been infected, with more than 210,000 deaths, according to worldometer. Largely due to concern over the spread of the virus in healthcare settings, many patients have avoided in-person primary care visits and physician practices have expanded telemedicine visits.
The new research article, which was published last week by JAMA Network Open, features data collected from millions of primary care visits in the 10 calendar quarters between Q1 of 2018 and Q2 2020. The study has several key data points.
From January 2018 to December 2019, quarterly primary care visits ranged from 122.4 million to 130.3 million, with 92.9% of visits conducted in person.
In 2020, Q1 primary care visits decreased to 117.9 million and Q2 primary care visits decreased to 99.3 million. The Q2 visits were 21.4% lower than the average Q2 levels in 2018 and 2019.
In-person primary care visits decreased 50.2% in Q2 2020 compared to Q2 in 2018 and 2019.
Telemedicine primary care visits increased from 1.1% of the total visits in Q2 of 2018 and 2019 to 35.3% of the total visits in Q2 of 2020.
In Q2 2020 compared to Q2 2018 and Q2 2019, blood pressure level assessment decreased 50.1% and cholesterol level assessment decreased 36.9%.
Blood pressure and cholesterol assessments were lower in telemedicine visits compared to in-person visits. Blood pressure was assessed in 9.6% of telemedicine visits vs. 69.7% of in-person visits. Cholesterol was assessed in 13.5% of telemedicine visits vs. 21.6% of in-person visits.
Interpreting the data
During the pandemic, telemedicine visits have partially offset a significant decrease in total primary care visits, the new research article's co-authors wrote. "The pandemic has been associated with a more than 25% decrease in primary care volume, which has been offset in part by increases in the delivery of telemedicine, which accounted for 35.3% of encounters during the second quarter of 2020."
Primary care assessment of cardiovascular risk factors such as blood pressure and cholesterol levels have decreased during the pandemic, due to a reduction in total visit volume and lower assessment rates in telemedicine visits compared to in-person visits. The reduced assessments in telemedicine visits suggest a significant limitation of how telehealth is being practiced, the study's co-authors wrote.
"Our finding that such visits were less likely to include blood pressure or cholesterol assessments underscores the limitation of telemedicine, at least in its current form, for an important component of primary care prevention and chronic disease management," they wrote.
Primary care has undergone fundamental changes during the pandemic, they wrote. "The COVID-19 pandemic has been associated with changes in the structure of primary care, with the content of telemedicine visits differing from that of office-based encounters."
