In the first six months of the coronavirus pandemic, one-fifth of nursing homes reported shortages of staff and personal protective equipment.
During the coronavirus pandemic, many nursing homes have struggled with shortages of staff and personal protective equipment (PPE), a new research article shows.
Through July, nearly half of the country's COVID-19 deaths had occurred in nursing homes or other long-term care facilities, with 60,000 deaths. The virus also has taken a heavy toll on long-term care healthcare workers, with 760 deaths through July.
"Many nursing homes in the United States are poorly prepared to prevent and manage COVID-19 outbreaks, given a lack of essential PPE and staff. Despite intense policy attention and mounting mortality, the shortages did not meaningfully improve from May to July 2020," says the new research article, which was published today by Health Affairs.
The study features information gathered from more than 15,000 nursing homes. The research includes several key data points:
At the end of the study in July, 19.1% of nursing homes reported severe shortages of PPE, particularly N95 respirator masks and gowns.
At the end of the study, 21.9% of nursing homes reported staff shortages.
Nurse aids led staff shortages at 18.5%, followed by nurses at 16.0% and other staff at 9.3%
Nursing homes with the highest star ratings from the Centers for Medicare & Medicaid Services (CMS) were less likely to report staffing shortages. Compared to nursing homes with a one-star overall rating, five-star nursing homes were 6.4 percentage points to 7.5 percentage points less likely to report staffing shortages.
PPE shortages were nationwide, with dire shortfalls in northern New England, Alabama, North Carolina, Tennessee, and West Virginia.
Staff shortages were concentrated in the South and Midwest, particularly Alabama, Eastern Texas, Georgia, and Louisiana.
"Using the most comprehensive survey of nursing homes during the COVID-19 pandemic to date, we found that roughly one in five facilities faced a staff shortage or a severe shortage of PPE in early July 2020. Despite a slight decrease in facilities with any PPE shortage driven by the higher availability of gowns, overall PPE and staff shortages had not meaningfully improved since late May 2020," the research article's co-authors wrote.
Interpreting the data
Since the beginning of the pandemic, nursing homes have established good protocols for infection control, visitation, quarantine procedures, and testing. But resources remain a concern, the lead author of the research article told HealthLeaders.
"Our study looked at two fundamental resources, PPE and staffing, and found that about 20% of facilities reported each type of shortage. This obviously raises significant concerns that a lack of adequate PPE or a workforce spread too thin will be the weak points in managing COVID-19 patients and preventing outbreaks as we head into fall and winter and future COVID-19 outbreaks," said Brian McGarry, PhD, an assistant professor in the Department of Medicine at University of Rochester in Rochester, New York.
Specific types of nursing homes are at highest risk of PPE and staff shortages, he said.
"With respect to PPE shortages, we found that for-profit, chain-affiliated, and lower quality—as measured by the CMS 5-star quality score)—were more likely to report shortages. Facilities that reported having had COVID-19 cases among their residents and staff were also more likely to report a PPE shortage," McGarry said.
"In terms of staff shortages, these were more common among facilities that are government owned, have greater shares of revenue from Medicaid, and lower quality facilities, in terms of both the overall quality score and a staffing-specific quality score. Additionally, having had COVID-19 cases among staff was also associated with an increased likelihood of reporting a staff shortage," he said.
The findings indicate a pattern, McGarry said. "Disadvantaged facilities—those with lower quality and those that disproportionately serve residents with safety-net Medicaid coverage—were more likely to report shortages. These facilities may be more financially constrained and may have difficulty buying additional PPE stocks or hiring additional staff."
The American Medical Association says healthcare organizations should address physician stressors during the coronavirus pandemic.
The American Medical Association has launched five online resources to help physicians promote their wellbeing during the coronavirus disease 2019 (COVID-19) pandemic.
Research published in September 2018 indicated that nearly half of physicians nationwide were experiencing burnout symptoms. Now, the COVID-19 pandemic has introduced new burdens on physicians, including high mortality among coronavirus patients, and worry over contracting the virus and infecting family members.
Physicians need support for their mental health, Marie Brown, MD, the AMA's director of practice redesign told HealthLeaders last week.
"While it is always important to focus on physician mental health, the emergence of the COVID-19 pandemic has brought new challenges and exceptional demands that strain physicians. The AMA has responded by quickly moving new resources into the field that support the well-being of physicians during a time of acute stress," she said.
The five new online modules focus on how health systems can boost physician wellbeing during the pandemic.
Unexpected crises are stressful and thrust uncertainty and increased workload on clinicians. The model identifies common stresses on healthcare workers during a crisis and offers strategies to overcome strains and build resilient organizations.
A chief wellness officer is responsible for strategies and programs designed to foster healthcare worker wellbeing. This model has a step-by-step approach to establishing and maintaining a chief wellness officer position.
A chief wellness officer must know how to implement initiatives that bolster healthcare worker wellbeing. This model features steps to improve wellbeing and the practice environment as well as advice for avoiding pitfalls.
Peer support is essential for clinicians during a crisis such as the pandemic. This module describes how to recruit and train peer leaders as well as how to build a peer support program.
Patient portals benefit patients and physicians by boosting communication, accessibility and efficiency that can reduce office visits during the pandemic. This module provides five steps for improving patient portals.
Coping with the pandemic
There are four primary sources of stress for physicians during the pandemic, Brown told HealthLeaders.
Life Threat: Many physicians fear they will contaminate their families due to work exposure.
Inner conflict: Physicians may experience moral distress when triaging and treating patients as well as from rationing personal protective equipment. Not having the tools to effectively prevent or treat COVID-19 may make physicians feel helpless. Some physicians have been redeployed to care for COVID-19 patients in unfamiliar settings and feel less prepared to provide care.
Loss: Many physicians are experiencing overwhelming numbers of patients, colleagues, and family members suffering or dying. In addition, many physicians have isolated themselves to protect their families from the virus and are unable to be with their loved ones.
Wear and tear: The constant accumulation of demands and relentless workload can result in tremendous physical and mental fatigue if there is little, or any, time for rest and recovery. Work-related stress is exacerbated if physicians are prevented from recharging with their family and friends.
"Early intervention may preclude the stress injury from turning into a chronic stress reaction that may include burnout, depression, exiting practice, substance use, post-traumatic stress disorder, or suicide," Brown said.
She said there are six keys to success for chief wellness officers.
Ensure that your organization's leadership embraces supporting clinicians to improve patient care and lower costs
Define scope of the job and identify needed resources to achieve your goals
Identify what programs and team members already exist within the organization
Communicate often with leadership and physicians—provide simple channels for physicians to communicate concerns and solutions
Visualize what success might look like for your team and organization
Measure burnout regularly
Peer support is a valuable resource for physicians during the COVID-19 pandemic, she said. "Developing a peer support program trains physicians to help their colleagues while providing greater opportunity for stressed physicians to receive help during distress. Peer support has added significance when physicians face barriers to seeking professional mental health services."
Effective patient portals are a win-win for patients and physicians, she said. "The principle driver of physician satisfaction and well-being is being able to deliver great quality care. When we use technology such as the patient portal to increase the quality of the care, we deliver for our patients—everyone benefits."
Contrary to popular perception, older patients appear ready to embrace telemedicine.
Telemedicine is a powerful tool in the clinical care of older patients, according to a pair of experts.
The COVID-19 pandemic has spurred widespread adoption of telemedicine along several fronts at health systems, hospitals, and physician practices—primarily over concern about the spread of the novel coronavirus in healthcare settings. Telemedicine visits for nonemergency care also have been shown to be efficient and effective from both the healthcare provider and patient perspectives.
Contrary to popular perception, older patients appear ready to embrace telemedicine as shown in a recent report from Strata Decision Technology. The report is based on data collected from 43 health systems as well as telehealth visit data drawn from the American Medical Association and the Centers for Medicare & Medicaid Services.
As a percentage of all medical visits from March to July 2020, the report found telehealth visit utilization was highest for the 30–39 age cohort, at 27.95% of all medical visits. However, telehealth visit utilization also was significant for older age cohorts:
50–59: 24.70%
60–69: 23.61%
70–79: 22.52%
80–89: 20.29%
Over 90: 19.04%
Telehealth visits provide older patients with greater access to medical care than in-person visits, says Jeffrey Gelblum, MD, a practicing neurologist at First Choice Neurology in Aventura, Florida, and an associate professor at Nova Southeastern University in Fort Lauderdale, Florida.
"Historically, we had to deal with older folks who may not be able to drive and older folks who would have difficulty finding a parking space. If the weather was bad, some older folks did not want to go to a doctor appointment. Driving for older folks is problematic in terms of compliance. But now with telehealth, that situation has been resolved," he says.
Telemedicine also gives medical practices an opportunity to see older patients more frequently than in-person visits, says Kristofer Smith, MD, MPP, president of home-based medical care at Brentwood, Tennessee–based naviHealth and former senior vice president of population health at Manhattan, New York–based Northwell Health.
"If you can increase the number of interactions with patients and families to build a relationship, you tend to get stickier relationships faster," Smith says.
Rising to the challenges
Dealing with the technology requirements of telehealth visits is the primary telemedicine challenge for older patients, Smith and Gelblum say.
"The first challenge is the ability to have enough Wi-Fi or broadband data access so that you can have a visit beyond a telephone call and have a video visit. Between 25% and 40% of communities do not have sufficient access. For many older patients, they are not technologically comfortable, so that is another challenge," Smith says.
Encouraging older patients to conduct telehealth visits on their smartphones is a prime strategy to overcome the Internet access challenge, Gelblum says.
"We tell our older patients that they got their Apple phones for a reason and, 'let's go there for your telehealth encounter. The quality is going to be great. If you do not have Internet access, there are no worries—you go on a 4G or 5G network.' So, the smartphone is much more liberating for our senior population. At least down here in South Florida, most older patients are smartphone-equipped," Gelblum says.
At Northwell Health, the health system enlisted emergency medical technicians to facilitate telehealth visits in patient homes, Smith says. The EMTs would bring Wi-Fi devices with them as well as a laptop or iPad.
With the EMT model of telehealth care, Northwell Health was able to achieve nearly 100% execution of video visits. In addition to facilitating the telehealth visits, having an EMT present has an added benefit, Smith says. "When the healthcare provider in the central location needed additional information such as a physical exam or a medication review, we had a trained professional who could augment the video visit with additional data so that we could make better clinical decisions about the next steps for the patients."
The EMT model is only possible for patients who have insurance coverage through at-risk contracts such as Medicare Advantage, he says. "For the frail elderly practice that we ran at Northwell Health, we were at risk for total cost of care. So, we were responsible for keeping patients out of the emergency room and the hospital. With being at risk for total cost of care, we could afford these types of augmentation for clinical care. In a fee-for-service model, it simply does not work."
Best practices in telehealth visits for older patients
Unlike younger patients, who are intimately familiar with using computer and smartphone technology, older patients should be walked through their telehealth visits, Gelblum says. "There has to be clear, succinct, step-by-step instructions because the technology is not intuitive for them. So, we have an instruction sheet that we send to them via email that gives them step-by-step instructions."
For older patients, a telehealth visit must be simple, Smith says. "The pace of the interaction has to be slow and clear. So, you need to work with the patients and families to make sure you are asking single questions at a time. You pause to make sure that the patient heard the question because many of these patients are hard of hearing. You pause to make sure you get the answer."
To make sure older patients are comfortable during a telehealth visit, it is important to engage them on a personal level, Gelblum says.
"As far as I am concerned, a telemedicine visit is an old-fashioned house call with a smartphone. I like to engage my patients with what they are doing. I might see something on the stove in the background and I will ask what they are cooking. Then the conversation may become a 10-minute discourse on a homemade recipe for cabbage soup."
Telehealth visits present significant opportunities for patient engagement, Gelblum says.
"For any clinicians getting into conducting visits via telemedicine, I would tell them that they are going to have great avenues of discussion—more avenues of discussion than you could ever get in your office. That is because your office is your environment. When you use telehealth, you are seeing the ultimate in the activities of daily living and emotional status."
The new plan includes promoting an organizational culture of wellness and adoption of targeted programs.
The Ohio State University College of Nursing and the Health Policy Institute of Ohio have released a comprehensive plan to improve clinician wellbeing.
Burnout is one of the top challenges facing clinicians and other healthcare workers nationwide. In a report published last week by The Physicians Foundation, 30% of more than 2,300 physicians surveyed cited feelings of hopelessness or having no purpose due to changes in their practices related to the coronavirus pandemic. Research published in September 2018 indicates that nearly half of physicians across the country are experiencing burnout symptoms.
The new comprehensive plan to improve clinician wellbeing has four primary components.
1. Wellness culture
The plan calls on health systems and hospitals to advance an organizational culture that supports wellness such as appointing a chief wellness officer.
"You must take a systematic, multi-component approach to culture. That means you have got to work this from the grassroots to managers, supervisors, and top leaders. You have got to hit all of those areas if you really expect to change culture," says Bernadette Melnyk, PhD, RN, APRN-CNP, dean of the College of Nursing and chief wellness officer at The Ohio State University in Columbus, Ohio.
She gave several examples of a multi-faceted strategy to establish a wellness culture.
"You have got to have policies that are directed to people's wellbeing. You have got to have a system-wide team under the chief wellness officer that can work with point-of-care clinicians. But first, anybody who is serious about creating a culture of wellness must assess the extent of the issue—that is super important. To do a survey for the sake of doing a survey is not worth doing. You need to assess the problem first, then use that data for targeted interventions."
Flex work is a good example of a policy that supports clinician wellness, Melnyk says. "Clinicians need leaders to give them permission to have some flexibility in their work."
2. Targeted programs
To foster clinician wellness, health systems and hospitals should promote programs that reduce burnout and strengthen resiliency among healthcare students and clinicians such as cognitive behavioral therapy and trauma support.
Promoting resiliency is a preventive measure to address burnout, Melnyk says. "It is protective against burnout, and it is protective against depression and anxiety. There is a big misperception about resiliency. A lot of people think you are either born with it or not. That could not be further from the truth. Resiliency skills can be built across your lifetime."
Clinicians should not view resiliency training as a form of victim blaming, she says.
"To fix the burnout problem, you cannot just put it on the clinicians and the nurses because we have major system problems that need to be fixed. When you spend more of your time in the electronic health record than you do taking care of your patients—which is the main reason nurses and physicians came into the profession—you have a system problem that is taking away purpose and joy in work. So, we must fix the system, but we also must give clinicians permission to take good self-care. How can we be at our best or fully engaged in our practices and in our jobs if we are totally burned out?"
3. Focus on mental health
Health systems and hospitals should require confidential mental health and addiction screening, provide referral and treatment services for healthcare students and clinicians, and address mental health and addiction prejudice such as stigmatizing language on clinician licensure applications.
Provision of mental health services is a key factor in promoting clinician wellness, Melnyk says. "In a national study I did, depression among nurses was the leading cause of medical errors. In this sample, I had nearly 1,800 nurses from across the country. Depression also is the biggest predictor of suicide."
4. Statewide reporting system
Health systems and hospitals should participate in a statewide reporting mechanism to monitor and track data on healthcare student and clinician wellness.
This kind of reporting system can play a pivotal role in boosting clinician wellness and addressing burnout, Melnyk says. "You need reporting so you can hot-spot problem areas and target them with interventions."
A statewide reporting system should not only include clinician outcomes such as depression, burnout, anxiety, and suicidal intent, she says.
"In addition to tracking clinician outcomes, you need to track key outcome indicators for the hospitals and health systems. With that information, you can see what is predictive of factors such as clinician turnover, patient complications, and medical errors."
Low-acuity coronavirus patients can be safely monitored remotely at home.
A Denver-based health system has used remote monitoring to care for coronavirus disease 2019 (COVID-19) patients who do not require hospitalization.
Although there are therapeutics for treating seriously ill COVID-19 patients in the inpatient setting—remdesivir and dexamethasone—there are no therapeutics that have been found effective in treating coronavirus patients in the outpatient setting. Given that limitation, monitoring low-acuity COVID-19 patients at home is a viable option.
Denver Health created its Virtual Hospital at Home (VHH) program to care for COVID-19 patients who do not require inpatient care. "A remote home monitoring program can provide a safe care mechanism for a diverse population of COVID-19 infected patients who do not meet admission criteria, yet have risk factors for severe COVID-19 complications. Remote monitoring may also be beneficial in managing future surge hospital capacities," a recent research article written by Denver Health clinicians says.
The research article, which was published by Infection Control & Hospital Epidemiology and features data from more than 200 patients, includes several key data points.
81.5% of the patients in the VHH program were successfully discharged
13.3% of the patients in the VHH program required a higher level of care, with 38.7% of those patients admitted for hospitalization
The majority of the VHH patients were either uninsured (28.3%) or covered by Colorado Medicaid (38.2%)
"The VHH provided a safe and effective mechanism to remotely monitor a population that has been disproportionately affected by the COVID-19 pandemic. As 95% of patients referred participated, it seemed to be well received by patients, and successfully managed the majority of patients within their own homes," the research article's co-authors wrote.
Virtual Hospital at Home benefits
The VHH program has four primary advantages in the care of low-acuity COVID-19 patients in the outpatient setting, according to the research article.
The VHH program helps manage hospital-based resources in two ways. First, VHH allows emergency department clinicians to send low-acuity patients home rather than admitting them to an observation inpatient stay. Second, hospitalists can use the VHH program to safely discharge recovering COVID-19 patients to home, where they receive outpatient oversight and care guidance.
VHH COVID-19 patients receive at least two phone calls per day—once from a clinician and once from a nurse. So, the telehealth approach allowed Denver Health to conserve personal protective equipment supplies.
Many of the VHH participants were members of ethnic minority groups who were either uninsured or on some form of government insurance. These patients demonstrated an acceptance of the novel telehealth program.
The VHH provided Denver Health with an opportunity to connect patients with primary care providers if they did not have an existing relationship with a primary care clinician.
Keys to home monitoring success
The daily calls to VHH patients were a crucial element of the program, two of the research article's co-authors told HealthLeaders.
"The intent was for patients to receive one clinician call daily and one nurse call daily. We tried to make one call in the morning and one in the afternoon. The ability to have an ongoing dialogue all day allowed us to have a lot of back-and-forth interaction. Patients could sound very different in the morning vs. the afternoon," said Jeremy Long, MD, MPH, medical director of the Intensive Outpatient Clinic at Denver Health.
"The biggest piece of advice that I would offer to other health systems is making sure that they have a sustainable way to have frequent touches with the patient. The patients can have big swings in their course—even within the same day. So, you need to make sure there are multiple touches with the patient throughout the day to make sure this is a safe program," said Patrick Ryan, MD, medical director of the Hospital Transitions Clinic at Denver Health.
Targeting low-acuity patients also was pivotal for the VHH program's success, Ryan said.
"For COVID-19 hospital admissions, it came down to whether patients needed supplemental oxygen or if the clinicians found reasons for the patients to receive IV antibiotics, IV fluids, or intensive cardiac monitoring such as telemetry. Those are services we would not be able to offer through our Virtual Hospital at Home program. With our Virtual Hospital at Home program, we are only able to monitor pulse, pulse oximetry, blood pressure, and temperature. With those limitations, patients who needed more intensive monitoring helped guide clinicians to admit patients for hospitalization rather than sending them home with Virtual Hospital at Home," he said.
Ensuring that payers would support the VHH program also was important, Long said. "Another important piece is to be aligned with your payers. You need to be talking with the Medicaid program in your state and the Medicare Advantage companies to be sure there is alignment in terms of reimbursement. That is one of the things that helped us with this Virtual Hospital at Home program. We were doing provider visits over the phone and receiving reimbursement."
In addition, effective internal communication at Denver Health was essential, Ryan said. "Our team communication was critical to ensure that this was a safe program for patients. Through our electronic health record, we have a chat function, so all members of the team on a given day can chat constantly to give updates on their phone calls with patients. This chat function helped monitor changes in the courses of patients at home, and it helped make decisions about whether patients could continue to be safely monitored at home or admitted to the hospital."
Finally, having a narrow focus on COVID-19 patients helped achieve success in the VHH program, Long said.
"If we just wanted to shorten length of stay across the board in inpatient admissions through Virtual Hospital at Home, that would be hazardous. Focusing on a single disease process boosts safety. For example, with the right expertise and the right technology, heart failure patients could be good candidates for a Virtual Hospital at Home program. Other examples include emphysema, community-acquired pneumonia, and some infections, where patients can safely receive a transition from intravenous to oral antibiotics."
The more physical and occupational therapy visits pneumonia patients receive while hospitalized, the lower the risk of readmission or death, study finds.
Physical and occupational therapy for pneumonia patients in the acute care setting lowers hospital readmission and mortality risk, a recent research article says.
For adults, pneumonia is a leading cause of mortality and hospitalization. The respiratory condition also is a common reason for hospital readmission. Since 2012, Medicare has been penalizing hospitals financially for readmissions linked to several targeted conditions including pneumonia.
The recent research article, which was published by JAMA Network Open, is based on information collected from more than 30,000 patients with pneumonia or influenza-related conditions at a dozen acute care hospitals in Pennsylvania. The number of physical and occupational therapy visits provided during hospitalizations was categorized as none, low (1-3), medium (4-6), or high (greater than 6).
The study features several key data points:
18.4% of patients had a hospital readmission within 30 days of discharge
3.7% of patients died within 30 days of discharge
Compared to no therapy visits, risk of 30-day readmission or death decreased as therapy visits increased: low visits, odds ratio 0.98; medium visits, odds ratio 0.89; and high visits, odds ratio 0.86
The inverse relationship between therapy visits and risk of 30-day readmission or death was stronger in patients with low functional mobility and individuals discharged to a community setting
Receiving both physical and occupational therapy visits was associated with a decreased risk of 30-day readmission or death (odds ratio 0.90)
Compared to having no therapy visits, patients discharged to home who had at least 7 therapy visits had a decreased risk of hospital readmission or death within 30 days of discharge (odds ratio 0.68)
"In this study, we examined the association between therapy visits and the risk of 30-day readmission or death in adults hospitalized with a diagnosis of pneumonia or influenza-related conditions. We found that the number of therapy visits received was inversely associated with the risk of readmission or death. This association was greater in the subgroups of patients with lower mobility and patients discharged to the community," the research article's co-authors wrote.
Interpreting the data
The study's co-authors speculated about why the association between therapy and positive outcomes was strongest for patients who had lower mobility or were discharged to home.
"These findings make theoretical sense given that individuals with lower mobility are likely to benefit from therapy. Contact with a [physical therapist] or [occupational therapist] for individuals discharged to the community with functional limitations may also ensure that the patient receives appropriate follow-up care in a timely manner," they wrote.
Readmission risk may have been reduced because therapy decreased the level of functional decline patients experienced during their hospitalization, the co-authors wrote. "Because pneumonia and influenza-related conditions are likely to resolve with appropriate medical management, therapy may be particularly useful in targeting impaired function, a modifiable risk factor for hospital readmission."
The number of therapy visits received was a key factor in reducing the risk of hospital readmission or death, the co-authors wrote. "Our findings also suggest that it is the number of therapy visits received, more than the types of therapists seen, that was associated with the risk of readmission or death."
Rapid diagnosis and treatment of sepsis saves lives.
In recent years, HCA Healthcare and OhioHealth have been able to reduce sepsis mortality significantly.
September is Sepsis Awareness Month. Sepsis and the body's response to the infection is one of the deadliest medical syndromes in the United States, according to the Centers for Disease Control and Prevention. About 1.7 million adult Americans develop sepsis annually and the condition claims about 270,000 lives each year. About one-third of patients who die in hospitals succumb to sepsis.
Decision support tool
HCA Healthcare has developed a computer-based decision support tool called Sepsis Prediction and Optimization of Therapy(SPOT), and it can detect sepsis 18 hours earlier than the best clinicians, says Jonathan Perlin, MD, PhD, president of clinical services and chief medical officer at the Nashville-based health system.
"This is the future. Military fighter planes can't fly without decision support. Healthcare is equally complex. To think that we can manage all the variables without assistive technology is inconsistent with how we think about high-reliability endeavors like aviation and healthcare," he says.
HCA Healthcare started adopting elements of the Surviving Sepsis Campaign in 2013. From 2013 to 2017, sepsis mortality at the health system's hospitals fell 39%. HCA Healthcare launched the SPOT initiative in 2018. From 2017 to 2018, sepsis mortality at the health system's hospitals dropped nearly 23%.
SPOT features an algorithm embedded in HCA Healthcare's electronic health record that was built with Red Hat open source software. To indicate the onset of sepsis, the SPOT algorithm combines factors such as patient demographics data and medical history with continuous monitoring for signs and symptoms of sepsis as well as key elements of clinical care:
Body temperature
Blood pressure
Heart rate
Platelet count
Medications
Laboratory tests
Patient transfers such as moves to an ICU
"The SPOT algorithm surveils 24 hours a day, seven days a week to look for the signs and symptoms of sepsis. When those signs are found, they are teed up and presented to the caregivers," Perlin says.
When the algorithm detects a likely case of sepsis, SPOT initiates an alert similar to a heart attack or stroke code that prompts clinical care teams to take action. Caregivers who receive the alerts include telemetry units, nurse leaders, sepsis code teams, and rapid response teams.
An essential component of the SPOT initiative is the algorithm's diagnostic accuracy, Perlin says.
"We were able to train the algorithm to be more than 100% sensitive—we picked up cases of sepsis that the care providers did not see, and our rate of false positives was half that of care providers. So, the specificity was twice as good as clinicians. It not only improved care but also the efficiency of doctors and nurses," he says.
OhioHealth's approach
At OhioHealth, a systemwide initiative involving physicians, nurses, laboratory operations, and pharmacists has helped the Columbus, Ohio-based health system reduce its sepsis mortality rate.
Starting in July 2015, OhioHealth reduced sepsis mortality by educating staff members, utilizing a rapid diagnostic test, reducing the medication response time from hospital-based pharmacists, and creating a clinical culture that tolerates false diagnosis.
The effort required engaging thousands of health system workers about sepsis and highlighting an opportunity for care improvement, says James M. O'Brien Jr., MD, MSc, system vice president for operations and population health. "A big piece has been making the case that this work is important to us as an organization by looking at the underlying data of what our baseline mortality rate was and how many people it was affecting across our health system."
When OhioHealth launched the sepsis effort in 2015, the sepsis mortality rate was 24.3%. In 2018, mortality in sepsis patients was 20%.
Rapid sepsis testing reduced the laboratory time required to diagnose sepsis and narrow down the best antibiotic treatment from a day or more to a couple of hours, O'Brien says.
The previous generation of sepsis tests required a lengthy two-step process. First, a blood culture test would determine whether a patient was positive for sepsis, then the blood culture would be challenged with multiple antibiotics to see which antibiotic would be best for treating the patient.
With the rapid testing technology, once a blood culture tests positive for sepsis, molecular testing quickly narrows down the best antibiotic to treat the patient.
Once an OhioHealth clinician has prescribed an antibiotic, pharmacists are expected to have the medication at the bedside in less than an hour, O'Brien says. "In pharmacy, you need engagement with the medication safety pharmacist and the antibiotic stewardship pharmacist. They are the folks who tend to be most in tune with our pattern of resistance to antibiotics and what is appropriate."
Achieving rapid treatment for sepsis patients requires creating a clinical culture that does not penalize clinicians for "false-alarm" diagnoses, O'Brien says. "We have to be really careful to understand that clinicians are doing a difficult task in trying to figure out what to do, because this is a disease for which there is no single test that says, 'This is absolutely sepsis.' They are making decisions with uncertainty."
Anil Keswani, MD, discusses the outpatient setting, patient safety, and value-based care.
Scripps Health has split the health system's chief medical officer position into two roles.
In August, Anil Keswani, MD, was appointed as chief medical officer for ambulatory and accountable care at the San Diego–based health system. He had previously led population health efforts at Scripps and earlier served as vice president of medical management at Chicago-based Advocate Health Care.
Also in August, Ghazala Sharieff, MD, MBA, was appointed chief medical officer for acute care, clinical excellence, and experience.
Keswani recently talked with HealthLeaders about the outpatient setting and value-based care. The following is a lightly edited transcript of that conversation.
HealthLeaders: What are the primary strategies to manage the shift of treatment from the inpatient setting to the outpatient setting?
Anil Keswani, MD: First, we are creating ambulatory facilities and hubs that provide primary care as well as specialty care, imaging, infusion centers, and much more. In essence, we have created hubs of care that can do a lot more than a primary care clinic.
The most recent supersite we created in Oceanside has primary care, specialists, an ambulatory surgery center, and an infusion center with beautiful views. It is really a health center with everything built into it. This kind of site not only helps prevent people from getting sick, but also eliminates the need to go to a hospital for services that can be done on the outpatient side such as colonoscopy and orthopedic procedures.
The second strategy involves moving from hospitals and even ambulatory centers to the home. Last year, we launched a program in conjunction with our physicians that allows us to do house calls. These are not the house calls of years ago; they are house calls with a system of support built around them to make sure that the patients who are most vulnerable or frail receive care in the home for everything from the primary care they need to advanced care planning. It is a way to keep people happy and healthy in their home, and to prevent the need to go to an acute care setting.
The third strategy is a digital strategy with remote patient monitoring. This is incredibly important for us to be sure when people are at home that we have a continuous touch point with them. Again, this helps prevent patients from needing care in an acute care setting.
HL: What is a primary strategy for ensuring patient safety in the outpatient setting?
Keswani: Epic is our electronic health record, and we have Epic wall-to-wall throughout our clinics and our hospitals. When we look at patient safety, breakdowns are often related to breaks in continuous information or communication between people.
One of our primary patient safety strategies is to use Epic appropriately and properly to make sure that we have connected our entire system of care. We want information to flow from imaging to doctors and everything in between. We use MyChart to make sure we are transparent in sharing results with the patient.
This has become a different way of engaging the patient in their healthcare. It provides another set of eyes to make sure that patients are also ensuring their own safety.
HL: Where are the biggest opportunities to improve the value of medical care?
Keswani: There are three hot opportunities, and they probably are timeless.
One is access. As long as I have been in leadership, we have always had a focus on access. Years ago, the focus was on primary care access, then the focus was on specialty care access. Now, the focus on access is not just on the ability of a patient to physically come in for a visit—it is how we use care coordination, how we use remote monitoring, how we connect with people by email, and how we connect with patients where they want to be.
Access is an important process measure that speaks to the Triple Aim.
The second hot opportunity to improve the value of medical care is the patient experience. At Scripps, patient experience is deeply rooted in our culture—we want to improve how patients are heard and their connection to the health system.
For example, more than a year ago, we created Scripps Health Express, which is express clinics built within our health centers using our existing electronic health record. Scripps Health Express is not just a pop-in-and-pop-out setting to get an antibiotic. It has everything from nurse triage by phone before a patient comes in, to being seen the same day, to 100% of patients getting a follow-up call the next day.
Scripps Health Express is an access measure, but it is also off the chart as a patient experience measure.
The third hot opportunity for improving value is making healthcare affordable. Years ago, healthcare professionals were not interested in talking about the total cost of care. Now, Scripps is looking at total cost of care as an access measure—meaning that if we are unaffordable people cannot come to us.
So, whereas quality and experience are absolutely important, they have to be balanced with whether we are providing an affordable total cost of care. We need to make sure we are using the right generic medications and we are using the right protocols.
HL: From the healthcare provider perspective, what are the keys to success in value-based contracting?
Keswani: First, you must have a health system aligned and committed to want to deliver on value. It takes executive leadership and physician leadership to say, 'Yes, we are going to lead toward value.' Doing the value-based contracting without a value-based culture is a fool's errand.
I also have found that bringing the operations team and physician leadership to the table in the contracting is incredibly important. When we talk about value-based contracts, if there is a quality metric, it is important to know whether that quality metric is valuable and measurable. Oftentimes, it will be our physician leaders and operational leaders who will guide us through these contracts.
You also need a strong contracting team to make sure we are successful in the contracting process. Then you need to deliver on the contract, with the infrastructure set up well to make sure you can deliver.
The Merit-based Incentive Payment System may give a payment edge to health system-affiliated outpatient clinicians compared to independent clinicians.
Clinicians affiliated with health systems have posted significantly better performance ratings in the Merit-based Incentive Payment System (MIPS) compared to independent clinicians, recent research found.
Most clinicians participate in MIPS, which is a value-based payment system created by the Centers for Medicare & Medicaid Services (CMS). The first payment year for MIPS was 2019, with payment based on 2017 performance. Last year, clinicians participating in MIPS received payment bonuses or penalties as high as 4% of Medicare reimbursement based on performance scores for quality and cost metrics.
The recent research, which was published by the Journal of the American Medical Association, features data collected from more than 630,000 clinicians working at outpatient clinics across the country. Nearly half of the clinicians were affiliated with a health system.
The study features several key data points:
The mean final MIPS performance score for clinicians affiliated with health systems was 79.0 vs. 60.3 for independent clinicians. The final MIPS performance score ranges from 0 to 100, with higher scores indicating better performance.
The percentage of clinicians who received a penalty payment adjustment was 2.8% for clinicians affiliated with a health system vs. 13.7% for independent clinicians.
The percentage of clinicians who received a positive payment adjustment was 97.1 for clinicians affiliated with a health system vs. 82.6% for independent clinicians.
The percentage of clinicians who received a bonus payment adjustment was 73.9% for clinicians affiliated with a health system vs. 55.1% for independent clinicians.
"For clinicians participating in the 2019 MIPS, health system affiliation was associated with substantially better performance scores. Health system affiliation was also associated with more favorable value-based reimbursement," the study's co-authors wrote.
Interpreting the data
The study speculates the technological advantages that health systems hold over most independent physician practices may account for the better MIPS performance by clinicians affiliated with health systems.
"Clinicians who were affiliated with health systems had higher rates of reporting and performance on technology-dependent measures, such as providing patients access to their health records or electronic prescribing compared with their unaffiliated peers," the study's co-authors wrote.
In addition, two MIPS performance measurement domains are dependent on technology—meaningful use of electronic health records and practice process improvement activities. "Thus, health system affiliation may provide needed technology and management infrastructure that helps clinicians succeed across a range of metrics under value-based payment," the study's co-authors wrote.
Beyond a technological advantage, health systems may generate other MIPS benefits for their clinicians compared to independent clinicians, according to the study.
"Integration in the healthcare delivery system is associated with higher screening rates, better quality on process of care measures for chronic conditions such as diabetes, improved meaningful use of electronic health records, and more use of care management. In addition, practices affiliated with health systems may have more resources to support the measurement, selection, and reporting of quality measures to the CMS."
The study did not reach a conclusion on whether clinicians affiliated with health systems provide a higher level of quality care to patients compared to independent clinicians.
Telemedicine adoption has increased for both physicians and patients since the coronavirus pandemic began, a new Doximity physician network report says.
The volume and financial value of telemedicine visits will increase significantly in 2020 due to the coronavirus disease 2019 (COVID-19) pandemic, according to a new report.
The COVID-19 pandemic has spurred widespread adoption of telemedicine along several fronts at health systems, hospitals, and physician practices—primarily over concern about the spread of the novel coronavirus in healthcare settings. Telemedicine visits for nonemergency care also have been shown to be efficient and effective from both the healthcare provider and patient perspectives.
The new report, which was published last week by the Doximity physician network, is based on three resources: a randomized survey of 2,000 American adults to collect patient data, Doximity network data to reflect "physician adoption insights," and data from the Medical Expenditure Panel Survey and commercial insurance claims to gauge the telemedicine market.
"Physicians have found telemedicine has served as a vital lifeline for practices negatively impacted financially by the pandemic. In our view, the rapid uptake of telemedicine has important structural implications for the U.S. healthcare system," Christopher Whaley, PhD, lead author of the report and assistant adjunct professor at the University of California's Berkeley School of Public Health, said in a prepared statement.
Telemedicine market
The report features three data points on the telemedicine market:
About 20% of all medical visits will be conducted via telemedicine this year
The financial value of telemedicine visits this year will be more than $29.3 billion
The financial value of telemedicine visits is projected to be $106 billion by 2023
Physician perspectives
The report includes three data points on physician adoption of telemedicine:
In a telemedicine report Doximity published last year, the number of physicians who self-reported telehealth as a skill increased annually by 20% between 2015 and 2018. From 2019 to 2020, the number of physicians reporting telehealth as a skill increased 38%.
Female physicians are adopting telemedicine at a higher rate than their male colleagues. In last year's Doximity telemedicine report, female physicians engaged in telemedicine job ads at a rate 10% higher than male physicians. This year's report found female physicians are using telemedicine at a rate 24% higher than male physicians.
This year, the top two specialties using telemedicine are endocrinology and rheumatology. "Treating long-term chronic conditions like diabetes and arthritis require frequent patient visits, but they don’t always need to be in-person. For patients that require long-term care, telemedicine tools can reduce taxing trips to hospitals or clinics," the new report says.
Patient perspectives
The new report includes several data points on patient utilization of telemedicine:
Before the COVID-19 pandemic, 14% of Americans had participated in a telemedicine visit at least once.
Since the COVID-19 pandemic began, the number of Americans participating in at least one telemedicine visit has increased 57%. The number of Americans with chronic conditions who have participated in a telemedicine visit at least once has increased 77%.
Once the pandemic has passed, 23% of survey respondents report they plan to participate in telemedicine visits.
Since the pandemic began, 27% of survey respondents report feeling more comfortable using telemedicine.
More than a quarter of survey respondents reported feeling telemedicine visits have the same or better quality compared to in-person doctor visits. More than half of survey respondents with chronic conditions reported telemedicine visits have the same or better quality compared to in-person doctor visits.
Nearly half of survey respondents reported cell phones are the preferred device for conducting telemedicine visits, with 39% preferring laptops.
