New study shows that patient-tailored support from community health workers can reduce hospitalization and improve control of obesity, diabetes and smoking.
Patients who received support from community health workers had 30% fewer hospital admissions in one year and saw reductions in cigarette smoking, obesity, diabetes severity, and mental illness.
That’s according to findings published this week in the AmericanJournal of Public Health, which suggests that CHW programs provide an annual return on investment of $2 for every dollar invested.
“As a nation, we have spent years arguing about healthcare. We need to focus on getting people healthy while reducing spending,” says Ralph Muller, CEO of the University of Pennsylvania Health System. “This program accomplishes both of these goals and shows us a way forward.”
Researchers from the Perelman School of Medicine at the University of Pennsylvania focused on 302 mostly Medicaid-insured people who had multiple chronic diseases. Half received regular support from IMPaCT (Individualized Management for Patient-Centered Targets) community health workers.
After six months, the patients who had received support from CHWs showed better outcomes on several measures, including lower blood sugar levels, lower body mass index and reduced cigarette smoking. Patients in the intervention group also showed greater improvements in mental health, and were 20% more likely to rate their primary care as comprehensive and supportive of their self-management of disease.
“This is the second clinical trial that shows improved health and lower hospital admissions for the IMPaCT community health worker program,” says senior author Shreva Kangovi, MD, an assistant professor of Medicine at Perelman and executive director of the Penn Center for Community Health Workers.
In 2014, Kangovi and colleagues found evidence that the IMPaCT model improved mental health and lowered hospital readmission among patients recently discharged from the hospital. “We now have evidence for state Medicaid programs or health systems looking for proven strategies to improve health and lower hospital use,” he said.
Emergency physicians across the country – especially those practicing in rural areas in the direct path of the eclipse – expect to see an influx of people seeking emergency care.
Monday’s rare solar eclipse could create a temporary surge at emergency departments across the nation, the American College of Emergency Physicians warns.
"I suspect there will be an increase in patient traffic to ERs, especially in areas expecting a large influx of eclipse-watchers, such as Oregon, Idaho, Wyoming, Kansas, Nebraska, Kentucky, Tennessee, South Carolina and Missouri," said Becky Parker, MD, president of ACEP.
"When a population surges, even temporarily, ER visits tends to rise. Anything out of the ordinary that shakes up a regular routine, like this eclipse, or daylight savings, can lead to more vehicle accidents,” Parker said. “Be mindful of that."
ACEP asked emergency physicians across the country what they expect to experience on Monday in ERs. Those physicians practicing in rural areas – especially in the direct path of the eclipse – said they expect to see an influx of people seeking emergency care.
One emergency physician said that in east Idaho they are predicting that town and city populations will triple and put pressure on local hospitals to deal with the major increase in patients.
“Like many experts have said, emergency physicians remind the public that it's extremely important to protect your eyes during this eclipse," Parker said.
“If you choose to look at it, you must use proper eye protection for safe viewing from a reputable manufacturer. Staring at the sun – even for a second – can cause severe, permanent loss of vision. Remember, regular sunglasses do not offer enough protection," Parker said.
The fallout continues after President Donald Trump’s controversial comments following the violent street confrontations that left one person dead and several others injured last weekend in Charlottesville, VA.
The Cleveland Clinic on Thursday became the latest blue-chip health system to distance itself from President Donald Trump.
A terse statement, not attributed to any individual at the health system, read: “After careful consideration, Cleveland Clinic has decided that it will not hold a Florida fundraiser at Mar-a-Lago in 2018. We thank the staff of Mar-a-Lago for their service over the years.”
No reason was provided for the decision to drop the fundraiser at the ritzy Trump property, which came days after the president’s controversial remarks about last weekend’s street clashes in Charlottesville, VA.
The confrontation between white supremacists and counter-demonstrators left one woman dead and several others injured.
The president’s remarks were seen in many quarters as deflecting blame away from neo-Nazis and other avowed white supremacist groups.
Last week the Clinic announced it would not relocate the event, despite having reviewed a public letter urging it to do so. The letter contained more than 1,100 signatures of clinicians and others.
The American Cancer Society on Thursday also pulled out of a commitment to host an event at Mar-a-Lago in 2018.
Earlier this year, the Dana-Farber Cancer Institute, the Leukemia and Lymphoma Society, and Bascom Palmer Eye Institute announced that they would move events from Mar-a-Largo to other venues.
Earlier this week, Cleveland Clinic CEO Toby Cosgrove said he planned to remain on President Donald Trump’s Strategic and Policy Forum, even as other CEOs resigned in the wake of Trump’s comments. The White House has since disbanded the forum.
With more than half of patients in the cardiac intensive care unit admitted for non-cardiac conditions, critical care cardiology specialists may require additional training or help from interventionists.
The cardiac intensive care unit is no longer reserved exclusively for patients recovering from heart attacks.
In fact, a University of Michigan study out this week has found that more than half of heart patients are admitted to the CICU for non-cardiac conditions, such as sepsis or renal failure, rather than for a heart condition.
Sinha’s team examined Medicare data from 3.4 million CICU admissions between 2003 and 2013. They found that nearly 52% of admissions represented a primary non-cardiac diagnosis in 2013, up from 38% in 2003.
Rates of infectious diseases (15%) and respiratory diseases (7.6%) were the fastest-growing non-cardiac admittees. At the same time, the CICU was seeing fewer patients with a primary diagnosis of coronary artery disease, as patients are living longer with chronic heart conditions.
Overall, patients had increased rates of comorbidities including heart failure, pulmonary vascular disease, valvular heart disease and renal failure.
“In order to get admitted to a CICU, you either have a primary cardiac condition – such as a heart attack or heart failure – or you have a sick heart from a prior event and now are admitted with a primary non-cardiac condition – such as sepsis or lung or kidney failure,” Sinha said.
“We found a remarkable rise in primary non-cardiac conditions associated with a rise in secondary cardiac comorbidities,” he said. “This suggests patients with sick hearts from prior disease are now getting admitted to CICUs with conditions that anyone can get.”
Sinha said this is the first data on numbers, types and outcomes of elderly CICU patients across the nation, although others have reported similar findings at single academic centers.
“Although patients with primary non-cardiac diagnoses appear to be more complex and require more procedures, the outcomes haven’t suggested overall care is compromised in the present configuration,” he said.
Study co-author Michael Sjoding, MD, an assistant professor of internal medicine and pulmonologist at Michigan Medicine, said it’s important to understand what types of patients are being admitted to the CICU to ensure that staff are appropriately trained.
“Among the patients in the CICU, we’re seeing the same trend that we see overall in intensive care, which is sepsis and respiratory failure are becoming more common,” says Sjoding, adding that the data provides another reminder that sepsis has become such an important diagnosis, particularly for the critically ill.
In 2012, the American Heart Association published a scientific statement on the need to train cardiologists on managing these non-cardiac conditions in the CICU. In 2015, the American College of Cardiology enhanced training requirements, including requiring critical care cardiology trainees to learn ventilator management.
Sjoding said the training for the critical care cardiology workforce could be different in many ways. That could include training cardiologists to develop additional expertise in critical care or bringing in intensivists to co-manage those patients with non-cardiac conditions such as infectious diseases or respiratory failure.
Struggling general surgery residents are more likely to complete their training when programs offer more opportunities for remediation to improve deficiencies.
A recent review shows that attrition rates in general surgery training programs were lower than expected, and researchers credit remediation programs designed to help struggling residents.
The study, published today in the Journal of the American Medical Association Surgery, found that attrition was lower than previously determined – 8.8% instead of 20% – in the 21 programs that researchers surveyed. The study also found that program directors’ attitudes and support for struggling residents and resident education were significantly different when the authors compared high- and low-attrition programs.
“Our survey found general surgery residents were more likely to complete their training in programs that offered more opportunities for formal or informal remediation programs that were designed to improve their deficiencies (or weaknesses)” said Christian de Virgilio, MD, an LA BioMed researcher and corresponding author for the study.
“We feel that some program directors view themselves more as gatekeepers whose responsibility is to redirect general surgery residents who should not be surgeons, whereas others see themselves as shepherds whose role is to help guide those residents who are initially struggling to successfully complete the rigors of surgical residency," de Virgilio said.
The Association of American Medical Colleges has predicted a shortage of between 20,000 and 29,000 surgeons by 2030. AAMC said the number of surgeons in training remains about the same as in previous years but is not keeping pace with population growth, which is expected to grow by about 12% by 2030.
Also by 2030, the number of U.S. residents aged 65 and older is expected to increase by 55%, and the number of people aged 75 and older will grow by 73%.
Of the 21 programs examined in the JAMA study, 12 were university-based programs, three were affiliated with a university and six were independent. In those programs, 85 of the 966 general surgery residents failed to complete their training over a five-year period from July 2010 through June 2015.
Of those who failed to complete their general surgery training, 15 left during the first year of training; 34 during the second year, and 36 during the third year or later.
The researchers found a nearly seven-fold difference between the training program with the lowest attrition rate, 2.2%, and the one with the highest rate, 14.3%, over five years.
In the programs with lower attrition rates, researchers found one-in-five residents received some support or remediation to help ensure they would complete their general surgery training. In the programs with higher attrition rates, the researchers reported that only about one-in-15 residents received remediation.
“Residents’ early departures from their general surgery training programs can have an adverse impact on the morale of the other residents who continue in the program and on the training schedules for these programs,” de Virgilio said.
“These losses also threaten both the individual programs and the medical profession’s ability to meet the future needs for general surgeons to care for our nation’s population,” he said.
Community Hospital Corp. has formed a nonprofit organization to provide low- and no-cost consultations and viability assessments for financially troubled rural and community hospitals.
Plano, TX-based Community Hospital Corp. has formed the Rural & Community Healthcare Collaborative, which will make available no- and low-cost consulting services to troubled community and rural hospitals to assess their solvency and sustainability.
A 501(c)3 organization, RCHC is led by CHC CEO Emeritus Michael D. Williams.
The consultancy received seed funding of more than $50,000 this spring from CHC employees and supporters, and will now expand fundraising efforts across the nation. Williams spoke with HealthLeaders Media about RCHC, what it hopes to accomplish, and why it’s needed. The following is a lightly edited transcript.
HLM: Why is RCHC needed?
Mike Williams: We’re trying to bring the fate of smaller community hospitals’ to more people’s attention and provide funding that will allow the assessment of the potential viability of some of these hospitals. We've found there are so many hospitals out there that can't pay the cost of doing an assessment. So, we thought we'd have to launch some effort to raise funds for these hospitals that potentially are viable, but don't know that they are.
HLM: How does RCHC work?
Williams: We'll use hospital report cards. That is an objective assessment tool that allows our staff to look at critical success factors for any hospital in any sized area, other than the urban marketplaces, and make an assessment of the things that need to be done to sustain the hospital as a short-term acute care hospital. If that is not sustainable, is there an alternative model for access to care in this marketplace?
HLM: Where’s the funding coming from?
Williams: We will use the 501(c)3 framework to apply for grants from large foundations, governmental entities, etc.
HLM: Have you provided any assessments yet?
Williams: The state of South Carolina identified some of the hospitals that they thought were at risk. We did an assessment of four of those hospitals and came forward with some plans for viability. Of the four, three have moved forward and are much more sustainable today by virtue of either improving their operations in focused areas, going to a different care delivery model, or affiliating with a larger entity.
HLM: What is your anticipated operating budget?
Williams: Based on the size of the hospital and its location and the intensity of the effort, it will cost between $30,000 and $50,000 per institution to do an assessment. Consequently, based on the numbers of hospitals that are involved, we are going to approach states like South Carolina to provide this service. If we are successful getting the grants and foundations to help, the annual operating budget could exceed $1 million.
HLM: What does an RCHC assessment look like?
Williams: It will provide an assessment in five strategic areas.
First, it’s going to look at market strategy. What is the hospital doing in terms of maintaining a relationship with people in their community who could receive services? Why is there out-migration? Why are people choosing to go to larger communities for care?
Secondly, it’s going to look at their costs, particularly in terms of productivity. So many small and community hospitals have not been optimal in their staffing. We’re going to do a cost-center-by-cost-center assessment based upon the type of population and what you need.
The third part is an assessment of the revenue cycle. How many patients are being seen that do not have coverage who, if the right information was obtained, could be eligible for some type of state or federal coverage? What is the process through which the institution is negotiating managed care rates for those patients where it’s appropriate? Many of these institutions do not have managed care expertise. What is the process of getting the bills out and the documentation in place and getting the money back into the coffers as quickly and appropriately as possible?
The fourth area is information technology. What are the strengths and weaknesses of the IT that the organization is using? What could they do differently?
The fifth area is supply chain. So many institutions buy independently and they leave so much money on the table as compared to what they could do if they bought in a collaborative effort.
HLM: What happens if your assessment is grim?
Williams: If it becomes obvious that the hospital cannot sustain its level of operations with the patients that are being served, then an alternative model would be recommended. If there is a population sufficient to support it, it could be a short-stay hospital, a clinic, rural health clinic, things that could be viable and an access point for that community. All of this information is in a 150-page document that is lay oriented for the board of trustees, the governmental entities, whomever is engaged, with a third-party objective assessment of what is going on. Here are the options for improvements. With the improvements, here is the bottom line. If that bottom line is not sustainable as a hospital, here are some models that could be employed for continued access to community care.
HLM: Who is eligible for these free or reduced-cost assessments?
Williams: Obviously, any organization that is financially distressed that is in a secondary market area. The expertise we bring to the table will not allow us to do this type of assessment at a tertiary institution in an urban marketplace. Our expertise has been and continues to be the sole community providers in secondary markets that might have two hospitals, that might go up to 250 beds. Those are not absolute criteria, but that is where we see the most distress, particularly in the rural settings where there is not access to the expertise to show how they can optimally operate.
HLM: How do you define distressed?
Williams: Most of these institutions are in a negative financial position. If they are not in a negative financial position losing money from the bottom line, they are not providing sufficient cash flow to fund the depreciation on the capital that they have. Many of these institutions are old, with worn out buildings and equipment. Consequently, as they look to buy new equipment, many of them don’t have the access to capital to do that. most of the institutions we’re talking about are losing money from a cash-flow perspective.
HLM: What metrics will you use to ensure that RCHC is working?
Williams: A couple: First, what is the level of interest that we can generate across the country in having individuals, corporations and foundations provide funding for these assessments? Secondly, once that funding is available, what is the result of the assessments that we do in the first year to provide an alternative for more successful operations or an alternative model for continued operations.
On a longer-term basis, how can we make people more aware of the plight of rural and community hospitals relative to healthcare reform? The Affordable Care Act is not perfect, but if the House and Senate make good on their proposals to cut the Medicaid expansion, it would harm most of these hospitals that we work with because they have a high Medicaid population. If they are not Medicaid-covered, many are no-pay patients. There is a sustainability factor. What is the impact of removing the Medicaid expansion in the continued success of these hospitals?
HLM: Should rural and community hospitals brace for profound change in the way they do business?
Williams: All hospitals should take a closer look to see if they are operating efficiently. Specifically, community and rural hospitals are going to close at a rate that we heretofore have not experienced. What we are forgetting with those closures is that there are many individuals being served in those small communities who don’t have the wherewithal, the physical ability, the financial ability, to travel to the urban marketplace. Absolutely yes there will be story after story about the impact of change in healthcare on the viability of these hospitals, but more importantly to the patients they have been serving.
The widely used biomarker contributes to the hundreds of millions of dollars spent annually on cardiac care, but adds no value in evaluating patients with suspected acute coronary syndrome, researchers say.
The widely used creatine kinase-myocardial band testing provides little value for detecting damaged heart muscles and should be eliminated from clinical settings, according to a paper published this week in JAMA Internal Medicine.
The research also cites studies showing that troponin testing is a more definitive predictor of in-hospital mortality and severity of disease.
The efficacy of CK-MB testing has been called into question since at least the turn of the century.
The report is the first of several peer-reviewed implementation guides co-authored by faculty from the High Value Practice Academic Alliance, a coalition created by The Johns Hopkins University School of Medicine. Faculty from more than 80 academic institutions, representing 15 medical specialties and subspecialties, have joined HVPAA to advance quality-driven value improvement.
“This article is the first in a series of collaborative multi-institutional publications designed to bridge knowledge to high-value practice,” said lead author Jeffrey Trost, MD, an assistant professor of medicine at the Johns Hopkins University School of Medicine.
“We present multiple quality improvement initiatives that safely eliminated CK-MB to give providers reassurance about trusting troponin levels when managing patients with suspected acute coronary syndrome.”
The efficacy of CK-MB testing has been called into question since at least the turn of the century. As recently as 2014, American Heart Association/American College of Cardiology guidelines concluded that CK-MB provides no value for diagnosing heart attacks.
Despite that assessment, Trost said, a 2013 survey conducted by the College of American Pathologists found that 77% of nearly 2,000 labs in the U.S. still use CK-MB as a cardiac damage biomarker. Researchers estimate that all blood tests for diagnosing heart attacks add $416 million each year to the cost of care.
Trost said the JAMA report provides a four-step plan to phase out CK-MB based on the U.S. Health Resources & Services Administration’s quality improvement initiative.
The four steps listed include:
Design and implement a hospital-wide education campaign.
Partner with clinical stakeholders in cardiology, emergency medicine, internal medicine, laboratory/pathology to remove CK-MB from standardized heart disease routine order sets.
Enlist information technology/laboratory medicine staff to create and integrate a best practice “alert” that appears on any computerized provider order entry system when clinicians order CK-MB.
Measure use of the test and patient care quality and safety outcomes before and after the intervention.
As far back as 2000, the American College of Cardiology and the European Society of Cardiology identified cardiac troponin as the ideal biomarker due to its high sensitivity for detecting injury to the heart.
Fifty-six percent of physicians in a Merritt Hawkins survey support a single-payer healthcare model, while 41% oppose it. The results are a direct inversion of the same question posed by the physician recruiting firm in a 2008 survey.
A plurality of physicians strongly supports a single payer healthcare system, according to a survey by physician recruiters Merritt Hawkins.
The survey of 1,033 physicians indicates that 42% strongly support a single payer healthcare system while 14% are somewhat supportive. Thirty-five percent strongly oppose a single payer system while 6% are somewhat against it. The remaining 3% are neutral on the issue.
The results are a near-exact inversion of a national survey of physicians Merritt Hawkins conducted in 2008, which found that 58% of physicians opposed single payer and 42% supported it.
Jack Ende, MD, MACP, president of the American College of Physicians, said he was not surprised to see the shift in physicians’ attitudes toward single payer, and said that “several factors are in play here.”
“First, the proportion of physicians in private practice vs. employed-salaried positions has decreased, so there is less concern with direct reimbursement,” Ende said in an email exchange with HealthLeaders Media. “Second, the average age of physicians has decreased, and along with that there has been a generational decrease in concern about physician autonomy and economic independence.”
“And third, the recent ‘sturm und drang’ of the healthcare imbroglio over the ACA has made physicians somewhat distrustful of leaving healthcare to the whims of politicians, and more aligned with settling this issue once and for all with a system that will provide universal access to healthcare, and enable us to move forward, i.e. with a single payer system,” Ende said. “And so we find a more egalitarian, socially committed physician community that is more comfortable with a government controlled system of payment than was the case in 2008.”
Merritt Hawkins Vice President of Communications Phil Miller, responded by email to a query from HealthLeaders Media, and offered a handful of theories for the inversion.
Doctors want clarity and stability. The fits and starts of health reform and the complexity of our current hybrid system are a daily strain. Many believe single payer will reduce the distractions and allow them to focus on what they have paid a fairly high price to do: care for patients.
It's generational. The surveys we have conducted for the Physicians Foundation show that younger doctors are more accepting of Obamacare, ACOs, EHR, and change in general than are older physicians. As the new generation of physicians comes up, there is less stigma among doctors about single payer.
Part of it is resignation rather than enthusiasm about single payer. Doctors see the writing on the wall and want to get it over with. The 14% of physicians who said they "somewhat" support single payer are probably in this group.
There is a philosophical change among physicians that I think the public and many politicians now share, which is that as a society we should cover everybody. That wasn't always the case and is one area where Obamacare should gain some credit. It established that as a society we need to do better when it comes to providing care for our citizens.
The survey was emailed to 70,000 physicians nationwide on Aug. 3, and has a margin of error of +/- 3.1%. Miller said the response rate to the question “is not the only factor to consider.”
“Net number of responses also is significant,” Miller said. “If you got 1,000 doctors in a room and asked them a question, their answers would have some significance: 50 doctors, not as much. We submit our surveys to a Ph.D. in statistical response analysis at the University of Tennessee to determine margin of error rate. He put the survey at +/- 3.1% -- well within the accepted range for credibility.”
Miller says the Merritt Hawkins survey findings are consistent with a survey from LinkedIn that came out earlier this year showing 48% of physicians support single payer, and 32% oppose it.
Emergency physicians call for partnerships between emergency medicine and primary care to reverse the trend of failing health in underserved parts of the country.
The ongoing and well-publicized struggles of small, isolated hospitals to keep the lights on and the doors open has prompted calls for significant reforms for care delivery in rural America.
The latest proposal comes from a group of emergency physicians in Michigan, who have called for better coordination of care between emergency and primary care clinicians.
“The traditional urban model of healthcare has been ineffective at improving rural health," said Margaret Greenwood-Ericksen, MD, MPH of the Department of Emergency Medicine at the University of Michigan in Ann Arbor, lead author of a paper published online this week in Annals of Emergency Medicine.
"Our emergency medicine-primary care model embraces the role that emergency departments play in providing primary care in rural areas while also connecting patients to other physicians and resources in the community,” Greenwood-Ericksen said. “Rural hospitals can serve as a hub for emergency care, primary and preventive care, and social services for improving rural population health."
The model proposed by Greenwood-Ericksen would supplement – not supplant -- the existing outpatient rural safety net, comprised of federally qualified health centers and rural health clinics.
The paper cites Carolinas HealthCare System Anson in Wadesboro, NC as an example of a new rural hospital designed to provide both emergency and primary care, calling it "a test of a new model of rural healthcare delivery." The final design has no physical walls separating emergency and primary care.
Similar partnerships in other communities could optimize emergency care, meet unscheduled acute care needs, address rural social determinants of health across the care continuum, achieve financial solvency and support public health, Greenwood-Ericksen said.
"There is an urgent need for a rural-specific model of care aimed at improving the sharply declining health of rural Americans," she said. "The partnership we propose is novel yet practical and acknowledges that an emergency department might be the closest source of health care for rural patients. Emergency medicine-primary care partnerships can address rural populations' most pressing social and medical needs."
Affiliation will enhance medical, surgical and related healthcare services around San Francisco by improving coordination of primary and specialized care.
Dignity Health and UCSF Health have entered a formal affiliation that the two health systems say will bring the academic medical center’s clinical expertise to community-based care settings in the San Francisco Bay Area.
The affiliation puts UCSF Health's clinical expertise into three Dignity Health hospitals: Sequoia Hospital in Redwood City, and Saint Francis Memorial Hospital and St. Mary's Medical Center in San Francisco, according to a joint announcement this week.
The two health systems have signed a letter of intent for physicians at Dignity Health Medical Group Sequoia and at Dignity Health Medical Group Saint Francis/St. Mary's, both services of Dignity Health Medical Foundation, to collaborate with UCSF clinical faculty to share best practices and improve access, quality, efficiency and coordination of care. The Dignity Health hospitals have joined the Canopy Health accountable care network to provide a continuum of care during the transitions between primary and specialty care.
"Healthcare works best when we collaborate to offer the best thinking and the latest medical advances to our patients," said Shelby Decosta, senior vice president and chief strategy officer for UCSF Health. "Dignity Health's focus on excellent care, as well as the humanity of that care in a community setting, is the perfect balance for UCSF Health's depth of knowledge and specialty services. Together, we can draw upon each other's expertise for quality and service improvements, and best practices, and to provide specialty care with shorter wait times and a better patient experience."
Dignity Health and UCSF Health have previously collaborated to improve pediatric burn care, acute rehabilitation, and cardiac arrhythmia, among other conditions.
