Ode to Community Health Centers

So, it’s been a while.

The healthcare world definitely hasn’t taken a break, though, and it’s about time I hopped back on to investigate and share.

Yesterday the Department of Health and Human Services announced the assignment of Affordable Care Act funds (to the tune of $28.8 million) to go to 67 Community Health Center programs across the nation. This is timely, because it’s National Community Health Center week! These clinics do amazing things for millions of people who would not have access to healthcare. Check out the National Association of Community Health Centers to get tuned into a lot of the goings-on.

This post from “Capsules,” the blog of the Kaiser Health News talks about a surge in volume witnessed by community health centers after they expanded health insurance coverage, the same way the Affordable Care Act plans to do. Assuming that the same thing will happen across the country, will there be enough money for community health centers to support the increased demand? Studies have shown that formerly uninsured patients will continue to seek care at safety net/community health center clinics once they become insured. With all the mess surrounding our nation’s debt crises, it would seem that cuts that would be reserved for this sort of thing are very possible. If so, what’s going to happen? I guess I don’t have a good answer for that. Maybe we’ll be able to figure out a way to make ACO’s work? Maybe we just need more people like those Atul Gawande wrote about in “The Hot Spotters.”

“I love my job…I love my job…I love my job…”

Here’s a way healthcare delivery organizations can act more responsibly.  Employee satisfaction.  After all, having happy employees is an important part of running a hospital (or other facility).

A recent study in the March/April 2011 volume of the Journal of Healthcare Management (56:2) from the American College of Healthcare Executives (ACHE) discovered that nursing staff who “perceived less missed nursing care…are more satisfied in their current position and occupation.”  “Missed nursing care” is identified as necessary patient care that is ommitted.

 

To the right is a diagram, scanned from the hard copy of the journal, depicting a conceptual framework for how these factors relate to each other.  Here we see that some of the elements that lead to missed nursing care are related to personnel situations that aren’t out of the control of management.

Additionally, (as shared in the study) Aiken et al. (2008) found that “the percentage of nurses who reported that the quality of care was poor or fair (rather than good or excellent) [in their hospital] was twice as high in hospitals with poor care environments as in hospitals with better ones.”

It turns out that it’s in the patient’s best interest if nurses don’t feel the need to whisper irritably under their breath like Emily Blunt in The Devil Wears Prada.

Happy nurses means happy patients.  We now know that nurses are happier when they’re making patients happy.  It’s a win/win vicious circle.

Hospitals Have the Cure

One of the most upsetting paradoxes of our society occurs when someone enters a hospital to get better, only to become harmed instead.  Enter nosocomial (hospital-acquired) infections.  The Centers for Disease Control and Prevention (CDC) says they will happen to about 1 in 20 hospitalized patients.  They killed almost 100,000 people in 2002.  They cost the U.S. healthcare system (according to one of the best guesses available) 5.7 to 6.8 billion dollars.  That’s the low end.  The danger of organisms other than the famous culprit MRSA (methicillin-resistant Staphylococcus aureus), is growing.  It’ll be bad news if we start to see too much of an increase in drug-resistance from these other guys.  Drug companies aren’t developing antibiotics as much as they used to.

The best part about all this is that we’re talking about preventable harm and preventable deaths.  They can be avoided if people take measures like washing hands or sterilizing equipment properly.

Let’s move on to some good news.  In one category, word on the street is that rates of nosocomial infections are dropping.    A post from the Health Blog of  the Wall Street Journal suggests that this is due largely in part to initiatives like On the CUSP: Stop BSI.  This project is funded by the Agency for Healthcare Research and Quality (AHRQ), and encourages participating states to establish a “lead organization” to head the efforts in hospitals statewide to make “clinical and cultural” changes to reduce the incidence of central line-associated bloodstream infections (CLABSIs).

Enter our white knight in the battle against nosocomial infections.  He’s the author of Safe Patients, Smart Hospitals and major player in the aforementioned project; Peter Pronovost.  Pronovost has become somewhat of a celebrity in the world of healthcare for his work as a “champion of innovative but practical solutions to fix system flaws that can lead to deadly mistakes and complications in hospitals.”  Those words come from a Wall Street Journal interview.  He’s not afraid to call hospitals out for their lack of doing everything they can to prevent this harm from occuring.

There is a poisonous voice out there that claims, “these things happen.”  To elaborate on that idea, here’s a post from the blog of former Beth Israel Deaconness Medical Center (Boston) CEO Paul Levy.  It never ceases to amaze me how it has been acceptable for so many flaws to develop in an industry.  It’s even more unacceptable that it’s one of the most important industries out there; the one intended to protect our health.  We cannot be satisfied with the occurrence of preventable wrongs.  To quote Peter Pronovost, “hospitals have the cure.”  Furthermore, “the intervention to prevent [infections] can be spread around the country.”  Why hasn’t it happened yet?

 

Protect Insurance Companies

This blog isn’t really intended to delve into a lot of policy issues, but this was funny enough I figured I might as well post it:

Although it does make you think a little bit about some of the reasons why our health system is in trouble…

 

Let’s Give ‘Em Somethin’ to Talk About

Much of the buzz following the Affordable Care Act seems to surround the advent of Accountable Care Organizations (ACO’s).  I know I’ve mentioned a little bit about them in previous posts, but I wanted to give them a little bit more attention here.  I won’t get too deep into the debate.  It’s a pretty complex situation, but there are some good resources out there to learn more.

Let’s turn to the Kaiser Health News for what’s probably the best comprehensive look at ACO’s.  Here they offer tons of materials from the Department of Health and Human Services (HHS) and a couple news articles looking at issues surrounding ACO’s.  Here’s a link to a video a bit more serious than the one above regarding the transition to ACO’s.

This article in the Wall Street Journal from Monday, March 28th that gives some good background and context for ACO’s. 

To the right is a diagram from the print copy of the article, comparing ACO’s with their counterpart measure intended to cut costs and improve care, the medical home model.

It’s hard to see why ACO’s could end up being anything but a good thing.  Especially as a public health advocate, I want to see more participants of the delivery system collaborating.  I like that participants in ACO’s will be held to certain quality guidelines.  Health networks such as Intermountain Healthcare and Geisinger Health System have been praised by President Obama, and have become more recognized for their quality outcomes and efficient operations.  They’re about the closest thing we’ve seen to ACO’s.  As other organizations across the country start to move toward delivering the same sort of product, they will be moving toward the ACO model.  Many are concerned about the possibility of ACO’s giving hospitals and clinics too large of a market share that monopolistic conditions might come about.  That is a valid point, but I think there are other forces that would be able to keep them at bay and avoid them from going crazy controlling prices.  I’m not an economist, but that’s my opinion.  The bottom line is that I guess we really won’t know until we try.  It’s estimated that everyone will see significant savings provided that everyone really is all-in.  According to the HHS, Medicare savings could amount to $960 million in the next 3 years.  That’s easier said than done, but I can’t help but think it will be a step in the right direction.

Gonna Change My Way of Thinkin’

We’re all familiar with most of the fruits of the Affordable Care Act; insurance mandates, the “Cadillac” tax, state insurance exchanges, etc.  A less-publicized emergence of the 2,000+ page bill is the creation of the Center for Medicare and Medicaid Innovation(CMI) within the Department of Health and Human Services.  Their mission is to “help transform the Medicare, Medicaid, and CHIP programs to deliver better healthcare, better health, and reduced costs through improvement for CMS beneficiaries and, in so doing, transform the healthcare system for all Americans.”

Healthcare is often recognized as an industry that is slow to innovate.  Most of the innovations that influence the delivery of healthcare come through pharmaceutical companies, medical device companies, research labs, etc.  Definitely not hospitals themselves.  Many hospitals and health systems are recognized for improvements in operations, patient care processes, facility design, etc., but that is not the majority of what can be considered healthcare delivery innovation.

Robert Betka, Managing Director for Catalyst Management Advisors, Inc. (a healthcare consulting firm) said that innovation is, “the industry’s latest buzzword for doing what it’s supposed to be doing: continually trying to improve it’s product.”  Many like him feel that the word “innovate” is thrown around a little too much, and that most of what is considered “innovative” (checklists, Lean practices, etc.) is really just improvement.  Betka continued to explain, “health care leaders should be focused on providing measurable value for service delivered, whether ‘innovative’ or not.”  Others who concur ask, without a context of quality improvement that is outcome-based, what’s the point of innovating anything?  It’s a waste of money and effort that doesn’t result in any safer, more efficient, valuable results for patients.

This brings us to question what exactly the innovation proposed by the CMI entails, and are we ready for it?

As for what the CMI plans to do, they have established a standard process for change.  It is as follows:

1.  Solicit ideas for new payment and service delivery models

2.  Select the most promising models

3.  Test and evaluate models

4.  Spread successful models

You can read more details about their planned methods at the link provided.  We’ll have to hope that there some good ideas out there to “solicit,” hopefully it is a good sign that venture capitalist investments in the healthcare industry seem to be on the rise.  Also, we’ll have to hope that the testing and evaluation phase will be realistic, accounting for normal market fluctuations, etc.

Venture capitalist Lisa Suennen, on her blog, discusses the unique position we are in upon creation of the CMI.  With $10 billion to figure out how to do things in a new and better way,

This will be interesting, because many of the potential areas of improvement may be in organizations that don’t yet exist, such as specialized new health plans, provider organizations  and payment structures that have been much discussed but barely tried in practice. This effort will require a broad range of public and private views, including that of entrepreneurs who have those “not yet existing” ideas, to be considered.

We need to nurture companies that come out of left field with disruptive ideas that blow up conventional wisdom and replace it with completely new ways of doing things, particularly thing that impart convenience, personalization, health-optimization and cost-effectiveness into the healthcare equation. Will today’s healthcare giants be tomorrow’s healthcare leaders? Good question, but not likely unless they are willing to reinvent themselves completely—something very hard to do. It’s a little like shooting your dog because he’s ugly, even though he gave you years of companionship.

Something future healthcare organization administrators have to be prepared for is the “need to collaborate with people and organizations with whom, in the past, we did not even talk.”  These words come from Dr. Rulon Stacey, President/CEO of the Poudre Valley Health System in Fort Collins, CO and the current chairman of the American College of Healthcare Executives.  He was interviewed in the March/April 2011 issue of Healthcare Executive.  Even though it may not be exactly what Dr. Stacey meant, these organizations who enter the picture might not even exist, let alone currently “talk” with hospitals and health systems.

This blog post raises some interesting questions about whether or not the government makes a good venture capitalist.  Often political motives interfere with pursuing options that would yield significant innovation but carry risk.  It also seems realistic to me that the government is often unable to apply the concept of sunk costs, dwelling too much on past investments/outcomes in trying to plan for the future.

 

An oft-cited problem in healthcare is near-sightedness, resistance to change, and too much satisfaction with the status-quo.  I know that I would be much more optimistic about significant change happening if we had more systems in place that would foster the same innovation that can be found in other industries.  There is an almost infinite number of ways to look at this issue and try to predict what will come of the CMI.  I tried to open up a little bit of a discussion about what’s going to happen down the road.  Time will have to tell.  Our current healthcare system might have too many holes in it to make significant progress, or this may be the beginning of the progress we need.  Hopefully the $10 billion is a good investment.

 

 

A Critical Analysis

A review entitled, “Long-term complications of critical care” published in the February 2011 volume of the journal Critical Care Medicine directs our attention to problems associated with ICU patients — after they are discharged.  Until recently, there hasn’t been a huge focus on the health issues and complications faced by critical care survivors.  More patients survive the ICU than don’t, no newsflash there, but patient mortality rates are dropping.  As the baby boomer population ages, we will likely see more and more ICU survivors.  Patients discharged from the ICU suffer from mental health conditions (PTSD, depression, anxiety, for example) and physical health conditions (such as impaired lung function or neuromuscular weakness).  These issues may be long-term.  Aside from decreased quality of life and a burden on friends and family, these effects of ICU stays translate into overuse of the healthcare system and unnecessary costs.  To quote the authors of the review, “the goals of critical care must extend beyond patient survival and include shared, multidisciplinary collaboration to prevent and manage the long-term complications of critical care.”

The review mentioned above discusses important risk factors for certain conditions seen in critical care survivors and suggestions to manage the complications.  Age, comorbidity, and severity of ICU illness are among the most significant risk factors.

Below is a diagram from the review that outlines some examples of the pathways leading from certain risk factors to certain adverse effects.  Providers need to be cognisant of these, as quality of life often depends on it.

Guidelines from the UK’s Institute for Health and Clinical Excellence were issued in March 2009 in this document, entitled “Rehabilitation after critical illness.”  This is a very detailed and comprehensive document, establishing directives to enhance the “optimisation of recovery as a therapeutic objective rather than mere survival.”  The guidelines are too extensive to warrant a summary here, so you’ll have to check it out on your own if you’re interested.

Finally I’ll mention another place to go for a little bit of insight on this topic.  Here  you can find an engaging discussion from the Diane Rehm show on NPR.  Transcripts and audio from the piece are there too.  It can be dowloaded on iTunes as well.

Healthcare providers need to address ICU patient care with a hollistic approach.  There are best practice measures to be taken that will help avoid real, severe problems if the devliery system will make an effort to restore quality of life to patients as opposed to merely restoring survival without the aid of machines. 

Accountability Goes Both Ways

In the absense of a healthcare delivery system that forces such collaboration, it’s important for patients to be involved in (read: accountable for) their own care.  Below is a relevant albeit cheesy ad from the Agency for Healthcare Research and Quality (AHRQ).  This is embedded from YouTube, you can find the original video as well as others here as part of their “Questions Are the Answer” campaign.

The AHRQ website offers a wide range of tips and advice for how patients can be involved in their care, such as recommendations to:

–  Talk about your health history

–  Ask questions

–  Take notes

–  Bring a family member with you

–  Learn about your conditions

–  Talk about the services you need

–  Understand your options

It’s definitely worth your time to check out the website.

The principles discussed in this post are related to the bigger idea of “e-Patients.”  In order to give the e-Patient movement (a.k.a. participatory medicine) due credit, I’d have to create an entire blog devoted to it.  I merely want to just mention the idea, only because there are phenomenal resources out there that can teach more than I can.

One of the pioneers and spokespeople for the e-Patient movement is stage IV kidney cancer survivor “e-Patient” Dave deBronkart.  Take some time to look over his blog and find out about some of the recent goings-on in the e-Patient world, and it’s a great starting place to become familiar with the movement.  Also worth your time is Dave’s book, Laugh, Sing, and Eat Like a Pig.  It tells the story of his cancer survival, how being involved with his treatment may have saved his life, and how his experiences can help change healthcare for the better.  It’s a quick read, most of which is a compilation of online journal entries from Dave posted while beating cancer.

Something always brings me back to you…

Imagine that hospitals actually did everything they could to keep patients from turning right around, readmitted for conditions related to what they were treated for in the first place.  Lately this concept has gained interest as a means to improve quality and control costs.  While no doctor or nurse would be happy to see a patient return with problems that were just treated, some health systems have cancelled initiatives that have successfully prevented such occurences on account of losing money.

A WIHI presentation from the Institute for Healthcare Improvement (IHI) from October of 2010 (download an audio file and/or associated materials here or on iTunes) touches on the elephant in the room often associated with discussion of readmissions; the fact that  improving readmission rates may also result in lost revenue.  Listen to the WIHI to get a much more in-depth perspective on that problem than I can offer.  It seems to come down to balancing regulation and the goals of the organization to find ways to make up for any revenues lost from reducing readmissions.

How common and/or expensive are readmissions, anyway? Is it even worth focusing on this one issue in light of everything else going on in healthcare?  This study in the New England Journal of Medicine found the following, among other things:

• 19.6% of the 11,855,702 Medicare beneficiaries who had been discharged from a hospital were rehospitalized within 30 days and 34.0% within 90 days
• 67.1% of medical patients and 51.5% of surgical patients were hospitalized or died within the first year
• 50.2% of patients readmitted within the 30 day period had no proof of a bill from a physician’s office in between discharge and readmission
• Among surgical readmissions within the 30 day period, 70.5% were rehospitalized for a medical condition
• The average hospital stay for a readmitted patient is 0.6 days longer than a patient in the same diagnostic group

With this data painting a small picture of the overall problem, we can move on to investigate a couple attempts to do something about it.  The STAAR (STate Action on Avoidable Readmissions) Initiative from The Commonwealth Fund and IHI uses grant funding to attack the organizational boundaries in four states (Massachusetts, Michigan, Ohio, and Washington).  It’s a pretty unique approach, seeing as patient readmissions are usually tackled within an organization – not a statewide effort.  You can learn more about the STAAR initiative here or on the WIHI presentation I mentioned earlier.

The Affordable Care Act has taken a few measures to improve the situation.  Starting October 1 of 2012, hospitals will be penalized for maintaining readmission rates higher than the expected level, with fees increasing in subsequent years.  Many believe that the emergence of Accountable Care Organizations (ACO’s) will bring about changes that will address readmission problems.  They definitely would help with the problem, integrated systems such as Geisinger (PA) and Kaiser Permanente that spread the responsibility of patient health across players in the same system have produced low readmission rates.  However,  no one really seems to know exactly what ACO’s are going to be or how the concept will evolve.  This article in Healthcare Executive discusses the issue of readmissions and a few concepts that can guide particularly health administrators in making changes to help their organizations adapt without going into an ACO approach.

It’s almost impossible to touch on all aspects of this issue in one blog post, but my intention was to guide readers to a few resources and points of discussion currently going on in the whole debate.  There’s a lot more that could have been said, but hopefully this post is useful in identifying some of the resources that are out there.

National Patient Safety Awareness Week

Just thought I’d get the word out about National Patient Safety Awareness Week, sponsored by the National Patient Saftey Foundation.  This year’s theme is “Are you in? Committ to Safer Health Care.”

If you can’t see the video above, visit this link: http://www.youtube.com/watch?v=nDNtdLSK8Og

Patients are often harmed through the medical care they receive, and a lot of that harm is preventable.  85% of Americans know someone who has been a victim of medical error.  We need to eliminate the attitude that shrugs off errors, saying, “these things happen.”  The fact is if we were more responsible, they wouldn’t.  There are tons of reasons why errors occur, and it is not a problem that can be solved easily.  It requires a massive amount of coordination across different boundaries of healthcare delivery. 

There are organizations other than the NPSF working toward patient safety goals.  The Institute for Healthcare Improvement has taken some initiatives to improve patient safety that you can learn about here.  Also available is the transcript of a Q&A with Patricia Sokol, RN, MD, the Senior Policy Analyst for the American Medical Association’s Institute for ethics.