Research indicates homebound seniors and non-homebound seniors with complex medical conditions benefit from home-based medical care.
For older patients, there are opportunities to expand home-based medical care, which can lower cost of care and improve clinical outcomes, a new research article says.
In particular, there is untapped potential to provide home-based medical care to homebound seniors. According to estimates, 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.
Home-based medical care, which includes services such as primary care and medical interventions, is more intense than standard home health services such as physical and occupational therapy.
Home-based primary care has been associated with decreased hospitalizations and emergency room visits. A home-based primary care program for high-risk seniors launched by the Center for Medicare and Medicaid Innovation—Independence at Home Demonstration—lowered cost of care significantly. "In its first two years, Independence at Home saved an average of $2,700 per beneficiary per year over expected patient costs," the new research article's co-authors wrote.
The research article, which was published today by Health Affairs, is based on survey data collected from more than 7,500 community-dwelling, fee-for-service Medicare beneficiaries. The study features several 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 homebound Medicare beneficiaries who did not receive home-based medical care services, those homebound beneficiaries who did receive this kind of care were more likely to live in a metropolitan area or assisted living facility
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
Compared to non-homebound Medicare beneficiaries who did not receive home-based medical care, non-homebound beneficiaries who did receive this kind of care were more socially disadvantaged
For healthcare providers, there is a golden opportunity to provide home-based medical care to homebound seniors and medically complex non-homebound seniors, the research 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."
Fee-for-service model ill-suited to home-based medical care
Fee-for-service payment models are a primary barrier to expansion of home-based medical care, according to the research article.
"Our finding of higher rates of home-based medical care among those living in assisted living facilities and in metropolitan areas likely reflects the fact that favorable factors related to geography and the built environment create operational efficiencies and opportunities to improve the financial sustainability of home-based medical care practices," the research article's co-authors wrote.
Value-based payment models are a better fit with home-based medical care, the lead author of the research article told HealthLeaders.
"Even in the absence of broader payment reform, many home-based medical care practices are pursuing value-based contracts with insurers that provide per member per month reimbursements to care for high-risk patients," said Jennifer Reckrey, MD, an associate professor at the Icahn School of Medicine at Mount Sinai in New York City.
There are strategies that home-based medical care providers can pursue to make fee-for-service payment models financially sustainable, she said. "Examples include forgoing physical office space and relying on advanced practice nurses or physician assistants to provide the majority of patient care."
Helping underserved patients
The finding that non-homebound seniors who received home-based medical care tend to be socially disadvantaged is highly significant, Reckrey said.
"Because home-based medical care provides highly personalized team-based care in the home, it is uniquely able to care for high-risk patients who are not currently well-served by the healthcare system. While the homebound as a group have difficulty accessing care, among the non-homebound social factors like poverty, lack of access to transportation, and racial and ethnic discrimination are also potentially powerful barriers to accessing needed care. Home-based medical care may be an important way for these individuals to build trust with an engaged care team and receive needed care."
Innovation initiatives during the coronavirus disease 2019 (COVID-19) pandemic were the primary focus of this month's HealthLeaders Innovation Exchange.
For health systems, hospitals, and physician practices, innovation has been critically important during the COVID-19 pandemic. For example, healthcare providers have dramatically ramped up their telehealth capabilities to continue to serve patients in a safe and effective manner.
Asaf Bitton, MD, executive director of Ariadne Labs in Boston and a practicing primary care physician at Brigham and Women's Hospital in Boston, discussed how Ariadne Labs has been promoting end-of-life conversations during the pandemic.
"A distressingly low number of patients discuss their preferences and goals with their clinicians at the end of life. We also know that, unfortunately, many clinicians do not feel comfortable having conversations about aligned care at the end of life," he said.
During the coronavirus pandemic, Ariadne Labs has adapted an existing program that provides training for clinicians to hold meaningful conversations with patients about end-of-life-related topics. The program's serious illness conversation model has seven components:
1. Setting up the conversation, including introducing the purpose of the conversation and asking permission to discuss end-of-life care
2. Assessing a patient's understanding and preferences
3. Sharing prognosis, including allowing silence and exploration of emotions
4. Exploring key topics, including goals, sources of strength, and tradeoffs
5. Closing the conversation, including a summarization, making a recommendation, and affirming commitment
6. Documenting the conversation
7. Communicating conversation to key clinicians
A randomized controlled trial published last year on the impact of the conversation program generated impressive results:
90% of clinicians found the conversation effective and efficient
87% of patients found the conversation worthwhile
Incidence of moderate-to-severe anxiety and depression among patients was reduced 50%
"Very few things—including antidepressants and anxiolytics—reduce depression and anxiety at the end of life," Bitton said during the HealthLeaders Innovation Web Exchange.
To rise to the end-of-life conversation challenge during the COVID-19 pandemic, Ariadne Labs has been able to disseminate feasible and acceptable end-of-life conversation tools with the Centers for Disease Control and Prevention, he said.
"We built open access guides for training ambulatory care clinicians on having conversations with patients who have serious illness before they have COVID-19, so the patients can start articulating their goals, wishes, hopes, and fears. We also have guides for inpatient clinicians, long-term care clinicians, as well as patients and their families."
2. Standardized care
Toledo, Ohio-based ProMedica was able to standardize coronavirus care across the health system's broad collection of metropolitan hospitals, community hospitals, and critical access hospitals, Chief Medical Information Officer Brian Miller, MD, said during the web exchange.
"To scale up standardization, we created a virtual clinical command center. On a 24/7 basis, we had critical care doctors who were connected to the COVID-19 ICUs across our health system to provide consultation for all the clinicians in all those different settings. We also got our clinicians to buy into that process," he said.
The virtual clinical command center helped ProMedica to rapidly achieve a high level of standardized coronavirus care, Miller said. "That care was not necessarily different than the care at most health systems, but we scaled it up as quickly as the evidence would show. We were proning as fast as anyone else. We were doing immunoglobulins as fast as anyone else."
The care standardization effort helped reduce COVID-19 patient mortality, he said. "As a result of our interventions, we had a very low mortality rate in our ICUs compared to the national rate. Our rate for intubated patients was about 20%, which is a very good number when you look at national benchmarks."
3. Innovation vs. transformation
In the healthcare sector, transformation is a preferable term compared to innovation, said Sameer Badlani, MD, chief information officer at Minneapolis, Minnesota-based Fairview Health Services. "I would love to replace the word innovation with the word transformation. Over the past six months, we have transformed ourselves with what already existed. We focused on the gap, evaluated the tools we had, and got it done. This was more transformation than innovation—we just did our jobs."
High degrees of focus and collaboration are essential to achieve transformation, he said.
"What COVID-19 has shown us is that if we all have focus, together we can move mountains. For example, our legacy infrastructure could barely enable remote workers above 2,000, and on a snow day we would see the system get stretched. We scaled up to 29,000 remote workers in less than three weeks. This was mission critical in our collective response to keeping our workforce safe as COVID-19 spread quickly in our communities. Everyone focused and collaborated."
Particularly for patients who are older and frail, home-based medical care is a viable alternative to urgent care centers and emergency rooms.
The coronavirus pandemic has increased demand for home-based medical care, according to the chief medical officer of 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 Michael Le, MD, Landmark's chief medical officer.
"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.
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 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."
Healthcare providers who offer a seamless telehealth experience have a competitive advantage.
Patients are embracing telemedicine during the coronavirus disease 2019 (COVID-19) pandemic, according to a new survey report.
With patients fearful of coronavirus infection during in-person visits with clinicians, the COVID-19 pandemic has accelerated adoption of telemedicine capabilities at health systems, hospitals, and physician practices. In 2020, telemedicine is projected to experience 64.3% year-over-year growth, according to Imaging Technology News.
The new telemedicine survey report, which was published by DocASAP, is based on information collected from 1,000 consumers last month. The survey report includes several key data points:
Emergency rooms and urgent care centers (12%) were at the bottom of the list of facilities where consumers felt safe: grocery store, 42%; pharmacy, 37%; hospital, 32%; doctor's office, 26%; work office, 20%; public transportation, 13%
43% of survey respondents said they would not feel safe visiting any healthcare setting until at least the fall
68% of survey respondents had cancelled or postponed an in-person medical visit during the pandemic
50% of survey respondents had scheduled a telehealth visit online
40% of survey respondents have had a telemedicine appointment
91% of survey respondents who have had a telehealth appointment were likely to schedule another telehealth appointment instead of an in-person visit
40% of survey respondents said easy access to quality care would influence their decision to schedule a telehealth visit
45% of survey respondents said whether healthcare providers offered telehealth services would impact their desire to use those healthcare providers
The Top 3 factors that survey respondents said would influence their decision to schedule a telehealth visit were coronavirus safety concerns (47%), whether the telehealth visit was covered by insurance (43%), and the ease of accessing quality care (40%)
Survey respondents said the Top 4 most satisfying elements of their telehealth visits were appointment wait time (38%), pre-appointment communication (33%), the quality of the video or audio technology (33%), and providing health insurance information (31%)
The Top 6 appointment-related activities consumers would prefer to do online were scheduling appointments (45%), checking symptoms before a visit (42%), checking the cost of a visit (32%), completing intake forms (32%), providing insurance information (29%), and receiving directions to prepare for a visit (29%)
More than 90% of survey respondents said they were satisfied with their overall telehealth visit experience
"Consumers today are looking for convenience, transparency, and efficiency in all their transactions, including healthcare. Those providers that offer a seamless telehealth experience from scheduling to follow-up will earn a competitive advantage," the survey report says.
Interpreting the data
DocASAP CEO Puneet Maheshwari, MBA, told HealthLeaders that increased use of telemedicine is part of the new normal and will continue to be popular with patients well into the future.
"Across all demographics, for certain types of visits, we are seeing that patients are finding telemedicine more convenient and efficient than in-person visits. From our survey, we see that an overwhelming majority of respondents (91%) who have had a telehealth appointment said they are more likely to schedule a telehealth appointment instead of an in-person visit in the future. Furthermore, nearly half of all respondents (45%) said if a provider offers telehealth appointments, it would influence their decision to use them," he said.
Healthcare providers, patients, and payers are aligned when it comes to telemedicine, Maheshwari said.
"Providers are now readily adopting telemedicine tools and technologies to accommodate patients in the new normal of healthcare. How thoroughly telemedicine is being adopted by providers—as well as to what degree payers continue to support it—will determine if this trend is sustainable. I am confident, though. It is not often you see patients, providers, and payers advocating for the same thing."
Primary care is a good fit for telemedicine, he said.
"We expect virtual services to play a broader role in primary care, including both preventative care and chronic care management. With tools such as automatic symptom checking and triaging capabilities to virtual care delivery with video, digital solutions will complement in-person visits. Going forward, we believe that close to 50% of primary care visits could be done virtually."
The expansion of telemedicine is part of a paradigm shift in healthcare, Maheshwari said.
"Overall, the care delivery model is going to evolve from a traditional scheduled-based model to an event-based model. Consumers will get care when and how they need it. For example, historically if a patient needed care, he or she would typically schedule an appointment with a long lead time. But, with increased capacity due to the efficiency of telemedicine, providers can handle more patients. Thus, consumers will be proactively redirected to the right provider and setting based on their specific healthcare event."
As the telemedicine landscape evolves, healthcare organizations are likely to view telehealth services as an integral component of care delivery rather than a standalone capability, he said.
"Incorporating telemedicine into health systems' end-to-end care delivery model will drive efficiency and effectiveness. It's not simply about the technology. It's about redefining care delivery, programs, and models to capitalize on this new trend of telemedicine while learning to use technology in a more effective manner to help facilitate better outcomes and experiences."
A recent survey indicates the coronavirus pandemic has significantly impacted healthcare professional employment, clinician burnout, and telemedicine.
The coronavirus disease 2019 (COVID-19) pandemic has had a profound impact on the healthcare sector, a recent LocumTenens.com survey shows.
The COVID-19 pandemic has impacted healthcare organizations and their employees across several dimensions, earlier research has found. For example, the American Hospital Association estimates health systems and hospital lost $202.6 billion from March through June. And the healthcare workforce decreased 9.5% from February through April, with 1.5 million healthcare workers losing their jobs, according to the Kaiser Family Foundation.
The LocumTenens.com survey was conducted in June and highlights information collected from 940 healthcare professionals in 35 medical specialties. The survey features several key data points:
The employment status of survey respondents fell into four categories: 45% employee, 30% locum tenens or independent contractor, 13% owner or partner in independent practice, and 6% unemployed
64% of survey respondents who said they were unemployed reported losing their jobs due to the impact of COVID-19 on their healthcare organizations
Professionals who had worked in the healthcare sector for five years or less had the highest rate of unemployment at 9%
The vast majority of independent owners reported concern over the future of their physician practices: 54% were very concerned and 34% were mildly concerned
Retired clinicians had either come out of retirement (23%) or were considering coming out of retirement (42%)
28% of survey respondents worked at healthcare organizations that had experienced furloughs, 18% worked at healthcare organizations that had experience furloughs and layoffs, and 8% worked at healthcare organizations that had experienced layoffs
71% of survey respondents said there had been at least a 25% decrease in patients receiving preventive care
78% of survey respondents said patients were canceling appointments due to fear of novel coronavirus infection
73% of survey respondents said they were concerned about newly uninsured patients
52% of clinicians reported experiencing increases in stress, burnout, or mental health issues
Interpreting the data
LocumTenens.com President Chris Franklin told HealthLeaders that the COVID-19 pandemic has had a dramatic impact on the clinician job market.
"The coronavirus pandemic has turned the healthcare industry upside down; and now more than ever, the job market for clinicians is in a constant state of flux. For example, an increased number of critical care and hospital medicine clinicians have been a necessary part of the response in various hotspots across the country ever since the pandemic began. Clinicians in other specialties—many associated with elective surgeries—saw a dramatic drop in demand for their services due to patients either having to delay care, whether it was due to financial concerns or loss of health insurance, or choosing to delay care out of fear of contracting the virus."
The clinician job market is rebounding, he said. "As we begin to see an uptick in elective procedures, or as procedures that were once considered elective are now becoming urgent due to a delay in care, we are seeing demand for clinicians across all specialties increase. More patients are beginning to resume in-person primary care visits, too."
Burnout was a major issue affecting clinicians well before the pandemic struck, but the pandemic has exacerbated the problem, Franklin said. "The pandemic has highlighted not only the significant work our clinicians do to care for our patients, but also the work we need to do to ensure we take care of our clinicians."
A hospitalist who participated in the LocumTenens.com survey said clinician burnout and mental health problems are a primary concern during the pandemic. "We all have a universal stress as healthcare practitioners with the rise of a pandemic. I am concerned for patients. I am concerned for myself. I am concerned for my neighbors. It will be important to incorporate stress management for our providers, including protected time off, stress outlets, and mental health counseling."
The survey shows telemedicine has expanded broadly during the pandemic, said Kevin Thill, executive vice president of LocumTenens.com.
"Almost three-quarters (74%) of respondents say their organization has increased their use of telehealth services due to COVID-19, and almost half (44%) say they have invested in new technology solutions to be able to communicate with patients remotely. The pandemic has shown clinicians and healthcare administrators the value telehealth adds to their practice, as it was the only way many practices were able to continue to care for patients at the height of the pandemic," Thill said.
Coronavirus concerns and a desire to be more consumer-friendly are driving a shift away from waiting rooms at a Florida-based health system.
Spurred on by the coronavirus pandemic, AdventHealth has implemented curbside check-in and contactless registration at physician practice offices.
The coronavirus disease 2019 (COVID-19) pandemic has made patients hesitant about visiting doctor offices due to fear of infection. In April, a Medical Group Management Association survey found that physician practices had experienced 60% average decrease in patient volume.
Altamonte Springs, Florida-based AdventHealth had been planning to launch curbside check-in and contactless registration at physician practices before the coronavirus pandemic, but the outbreak sped up the process, says Shelly Nash, DO, chief medical information officer of physician enterprise.
"Curbside check-in and contactless registration were something that we were interested in doing before COVID-19, but the pandemic accelerated our desire to do it because of patient concerns. In general, the idea of a waiting room in healthcare is something patients have accepted, but no one wants to wait."
At AdventHealth, which has more than 700 medical group locations, curbside check-in and contactless registration has seven primary elements:
Patients confirm their appointments online
Visit registration documents including COVID-19 screening questions are completed online
When patients arrive at physician practices, they text the practice office
The practice office sends a text back saying the clinician is ready for the visit or that the office will call back when the clinician is ready
Patients are greeted at the practice entrance, where a temperature check is conducted to screen for coronavirus infection
Patients are escorted to their exam room
After the visit is over, patients are escorted back to the parking lot
"There is no paper document that the patient has to fill out, and patients do not have to interact with other patients while sitting in a waiting room, which puts them at risk of infection," Nash says.
The online registration process has several steps, she says.
"The forms we send to patients verify their demographics such as address and birthday. We ask for a government-issued ID, which they can scan or photograph with their phone then send to us. They also confirm their insurance information—patients can take a picture of their insurance card with their phone. Then we ask patients to review outstanding balances and co-pays, and we ask them to sign electronically for treatment consent. They also are asked screening questions for COVID-19 such as whether they have a fever or have traveled recently."
Physician practice staff can monitor the contactless registration process, Nash says. "The forms are sent out five days before a patient's visit, and we have a dashboard that our staff follows. If the patient has not completed or initiated the forms after two days, the forms are sent out again. Then, if we still do not see activity on the dashboard, a staff member calls the patient to see whether there is a problem."
The curbside check-in and contactless registration initiative was started in the spring, and patients have responded favorably, she says. About 75% of physician practice patients are participating, and patient satisfaction with the process is at 95%.
"Eventually, I hope we become so efficient that it is like the airlines, where you show your boarding pass and you get right onto your flight," Nash says.
One of the largest physician practice organizations in Massachusetts has prioritized consumer-friendly features in its operational model.
In recent years, health systems, hospitals, and physician practices across the country have been working to become more consumer-oriented in line with other service-sector organizations. Patient experience is five times more likely to influence brand loyalty than conventional marketing tools such as billboards, or television, print, or radio ads, a Press Ganey report says.
Newton, Massachusetts–based Atrius Health operates 30 medical practice locations in Eastern Massachusetts. The organization employs more than 700 physicians and primary care providers, along with more than 400 additional clinicians.
Atrius Health has made catering to consumers a primary objective, says Marci Sindell, MBA, former chief marketing officer and senior vice president of external affairs, who left the organization recently.
"Being consumer-friendly starts with how you design your physician practices. At Atrius Health, we serve a very diverse population across all dimensions, and our goal is to make sure we can meet their individualized needs both for care and how they communicate with us. We also try to ensure patients are receiving the right care, which builds trust," she says.
There are four primary consumer-friendly facets at Atrius Health, Sindell says.
1. Access
Atrius Health provides 24/7 access to advanced practice providers, Sindell says. "When our practices close, patients can still call 365 days a year, 24/7, and get a nurse practitioner or physician assistant with access to the patient's medical record who can address medications, schedule an appointment for urgent care, or give medical advice."
Same-day appointments at primary care practices are the key element of the organization's urgent care model, she says. "For us, urgent care is really extended primary care, and we have that available throughout our region 365 days a year, which allows us to keep people from going to an emergency room unnecessarily."
On a regional basis and at larger practice sites, Atrius Health has additional staff available to make sure there are an adequate number of same-day appointments during regular business hours. Atrius Health also has evening hours until about 8 p.m. during the week, and it typically has sites open from 9 a.m. to 3 p.m. or 8 a.m. to 8 p.m. on Saturdays and Sundays.
2. Technology
Atrius Health has several technological consumer-friendly features.
Data from 2019 shows the organization's online portal is popular with patients:
More than 590,000 patients were registered on the portal, accounting for about 80% of Atrius Health's patient population
More than 2.1 million lab results were released to patients through the portal
Patients used the portal to send 1.5 million messages to Atrius Health clinicians and administrative staff
56,000 appointments were booked through the portal
Atrius Health used the portal to send out 273,000 offers for an earlier appointment and 15,000 of those offers were accepted
This year, Atrius Health launched a new portal feature called Scheduling Tickets, Sindell says. "If a primary care doctor gives a patient a referral for a specialist, the patient gets a scheduling ticket if they are on the portal, so they can go ahead and book the specialist appointment themselves."
The Atrius Health website also generates a high level of patient engagement, she says. "Our website had 3.4 million visits last year. So, the website is a way to make sure that patients have the information that they need—that's one of the reasons why we are moving forward with building a new website that is set to be launched in 2021."
Atrius Health is working with Boston-based Kyruus to add an enhanced provider directory to the new website, Sindell says.
Currently, Atrius Health patients have relatively limited options to search for primary care doctors and other clinicians such as searching by specialty, location, or the name of the provider. The new website will allow patients to search the clinician directory with thousands of consumer-friendly terms, she says.
"For example, if a patient is looking for a provider who treats breast cancer, today the patient would have to look up hematology-oncology, which they might not know to do. With the new website, patients will be able to look up breast cancer and find our breast surgeons and oncologists who specialize in breast cancer."
Atrius Health has had a tele-dermatology program for more than four years.
If a patient sees a primary care doctor and presents with a mysterious skin condition, the clinician takes a photo of the skin and an Atrius Health dermatologist examines the image within 48 hours. The Atrius Health dermatology department then contacts the patient directly.
"About 60% of those patients do not need to come in and see a dermatologist—they can be cared for via telemedicine. "In 2019, we had 8,500 tele-dermatology visits," Sindell says.
Atrius Health conducts e-consults for several other specialties, she says. "We save the patient a specialty visit by having the primary care doctor reach out and consult electronically with a specialist, who reviews the patient's medical record and writes up a summary for a treatment plan. We did nearly 4,000 of those e-consults in 2019."
Many Atrius Health patients use the organization's online bill pay service, Sindell says. In 2019, the organization collected nearly $22 million through online bill pay.
3. Convenience
Most Atrius Health locations are designed as "one-stop shop" operations, she says.
Pharmacies and specialists are co-located with primary care practices. "One of the reasons why we have on-site pharmacies is so that physicians who are at that location can have particular medications and medical supplies on hand. For example, a podiatrist will have orthotics at his site's pharmacy, and patients can get a discount," Sindell says.
4. Price transparency
Atrius Health has a price transparency phone line in its billing department that patients can call before getting services, she says.
Typically, patients call about advanced imaging such as MRIs as well as colonoscopies and lab tests. The service price that patients receive includes insurance coverage.
Coronavirus pandemic impact
The coronavirus disease 2019 pandemic has prompted Atrius Health to introduce new consumer-friendly services designed to protect patients and staff, Sindell says.
Atrius Health quickly established a call center manned with about 80 staff members—mostly nurses. The call center has directed patients to drive-through coronavirus testing sites, arranged home visits for care follow up, and set up telehealth and urgent care visits.
"Out of 11,000 calls handled in this way during a busy three weeks from the end of March to early April, fewer than 100 people were directed to a hospital emergency department. Additionally, many of the doctors have done telephone encounters, especially in situations where either a visual encounter with the patient was not needed or where the patient did not have telemedicine-capable technology and needed to be treated," she says.
Expansion of telehealth services has been a crucial element for patients to conveniently access safe care, says Christopher Andreoli, MD, chief transformation officer at Atrius Health.
"Toward the beginning of the pandemic, we trained over 700 clinicians in telehealth across specialties and service lines. The response from patients and effort from our clinical and IT teams has been incredible. Prior to COVID-19, we had 500 telehealth video visits since 2016. Now, we are doing about 2,500 per day. We are hopeful that policy measures taken during the pandemic to reimburse telehealth at the same rates as in-person care become permanent, so that patients can continue to benefit from better access to care," he says.
Atrius Health has also expanded pharmacy services during the pandemic, including free prescription mail service and contactless curbside pickup of prescriptions, Andreoli says.
For COVID-19 patients admitted for ICU care, the highest risk factors for death are older age, presence of hypoxemia, and liver dysfunction, new research shows.
New research has linked several factors with risk of death in critically ill patients with coronavirus disease 2019 (COVID-19).
In the United States, the COVID-19 pandemic is developing into the most deadly infectious disease outbreak since the 1918 Spanish flu. As of July 21, more than 3,900,000 Americans had contracted the novel coronavirus and more than 143,0 had died, according to worldometer.
The new research, which was published by JAMA Internal Medicine, is based on data collected from more than 2,000 adults diagnosed with COVID-19 who were admitted to ICUs at 65 hospitals across the United States from March 4 to April 4.
The study includes several key data points:
35.4% of the ICU patients died within 28 days
Older age (patients at least 80 years old vs. patients less than 40 years old) was associated with a high risk of death, odds ratio 11.15
Men had a relatively high risk of death compared to women, odds ratio 1.50
Higher body mass index (at least 40 vs. less than 25) was associated with a high risk of death, odds ratio 1.51
Coronary artery disease was associated with a high risk of death, odds ratio 1.47
Active cancer was associated with a high risk of death, odds ratio 2.15
Presence of hypoxemia was associated with a high risk of death, odds ratio 2.94
Liver dysfunction was associated with a high risk of death, odds ratio 2.61
Kidney dysfunction was associated with a high risk of death, odds ratio 2.43
The most common medications administered to the patients were hydroxychloroquine (79.5%), azithromycin (59.6%), and therapeutic anticoagulants (41.5%)
Hospitals with fewer ICU beds were associated with a higher risk of death
The researchers identified significant variation in the administration of medications and supportive therapies at the hospitals in the study. "Sources of this variation may include the limited high-quality evidence on which to base clinical practice, variation in hospital resources to implement personnel-intensive interventions (e.g., prone positioning), variation in the availability of certain medications (e.g., remdesivir), or unmeasured variation in patient and practitioner characteristics across centers," the researchers wrote.
The factors associated with higher risk of death can help clinicians determine courses of treatment for the sickest COVID-19 patients, they wrote. "This study identified demographic, clinical, and hospital-level factors associated with death in critically ill patients with COVID-19 that may be used to facilitate the identification of medications and supportive therapies that can improve outcomes."
New research provides more evidence that electronic health record use contributes to physician burnout.
Most physicians experience fatigue working with electronic health records (EHRs) for as little as 22 minutes, a recent research article indicates.
EHR use has been directly linked to physician burnout. For years, physicians have complained about click-intense and data-busy EHR interfaces. Excessive EHR screen time has been associated with medical errors.
The recent research article, which was published by JAMA Network Open, features data collected from 25 physicians who completed four simulated reviews of ICU patients using the Epic EHR.
"Physicians experience electronic health record-related fatigue in short periods of continuous electronic health record use, which may be associated with inefficient and suboptimal electronic health record use. … The use of electronic health records is directly associated with physician burnout. An underlying factor associated with burnout may be EHR-related fatigue owing to insufficient user-centered interface design and suboptimal usability," the researchers wrote.
The research article features several key data points:
Every physician in the study experienced physiological fatigue at some point in reviewing the four simulated ICU cases with the EHR
36% of the physicians experienced fatigue in the first minute of the study
64% of the physicians experienced fatigue at least once in the first 20 minutes of the study
80% of the physicians experienced fatigue after 22 minutes of the study
If a physician experienced fatigue while reviewing one simulated ICU case, the next case took more time, more mouse clicks, and more EHR screen visits to finish
The study's findings probably underestimate the level of fatigue physicians experience when using an EHR, the researchers wrote. "When compared with a typical day in an ICU, the simulation undertested the clinical demands of a physician. First-year trainees routinely review five or more patients, while upper-level residents, fellows, and attending physicians routinely review 12 or more patients."
Research implications
Continuous EHR use negatively affects physician efficiency and performance, which can compromise patient safety, the lead author of the research article told HealthLeaders.
"Once fatigued, physicians spend more time and effort completing tasks for the next patient. Consequently, fatigued physicians may be at a higher risk of missing key patient information that is needed to make accurate assessments and care plans. Therefore, the 'carry-over' effect of EHR-related fatigue is directly associated with patient safety risks," said Saif Khairat, PhD, MPH, an assistant professor at University of North Carolina at Chapel Hill.
The research also has implications for physician burnout, he said.
"It takes only 22 minutes for 80% of physicians to experience fatigue. In reality, physicians spend hours working in the EHR; and therefore, it is evident that physicians experience recurring instances of fatigue while using the EHR. The long-term effect of constant and recurring EHR-related fatigue leads to physician burnout."
New research suggests organizational approaches to reducing physician burnout such as improving the work environment are more effective than resilience training.
Physicians have a higher level of resilience compared to the general U.S. working population, which has significant implications for addressing physician burnout, a recent research article says.
Earlier research indicates that 44% of physicians nationwide experience burnout symptoms such as emotional exhaustion and depersonalization. Resilience training has been proposed as method to reduce physician burnout.
The recent research article, which was published by JAMA Network Open, is based on data collected from more than 5,000 physicians and more than 5,000 individuals in the general working population.
The Connor-Davidson Resilience Scale was used to measure resilience. The scale ranges from 0 to 8, with higher scores indicating higher levels of resilience. The Maslach Burnout Inventory, which includes measures for emotional exhaustion and depersonalization, was used to measure burnout.
The study generated several key data points.
Physicians had higher mean resilience scores compared to the general working population, 6.49 vs. 6.25.
Physicians who did not show signs of overall burnout had higher mean resilience scores than physicians with burnout, 6.82 vs. 6.13.
A 1-point increase in resilience score was linked to 36% lower odds of overall burnout, but 29% of physicians with the highest possible resilience score experienced burnout.
In an analysis of resilience scores by medical specialty, physicians in emergency medicine, neurosurgery, and preventive and occupational medicine posted the highest resilience scores. Physicians in general pediatrics, neurology, and obstetrics and gynecology posted the lowest resiliency scores.
Interpreting the data
The results of the study indicate that physicians as a whole do not have a resilience deficit compared to the general working population—a finding that should help guide the response to physician burnout, the lead author of the research article told HealthLeaders.
"Resilience training should not be the mainstay of responses to prevent burnout and promote well-being. Maintaining resilience is still important, but we need to look more to the work environment for solutions to burnout, as individual limitations are not driving physician distress and focusing on them may even be seen as a form of 'victim-blaming,'" said Colin West, MD, PhD, a general internal medicine physician and consultant in the Department of Internal Medicine at Rochester, Minnesota-based Mayo Clinic.
The study's data—particularly the finding that 29% of physicians with the highest possible resilience score experienced burnout—has significant implications, one of the research article's co-authors told HealthLeaders.
"These findings indicate that a focus on increasing personal resilience is inadequate to address the high rates of burnout in physicians," said Tait Shanafelt, MD, chief wellness officer at Stanford Medicine and professor of medicine at Stanford University in Palo Alto, California.
