ClickCare Café

Why Poor Communication with Skilled Nursing Facilities Can Ruin Patient Care & Facility Reputation

Posted by Lawrence Kerr on Tue, Jul 25, 2017 @ 06:01 AM

hand-holding-keys-1.jpgIt's easy to feel like better handoffs and better communication is a "nice to have" or something that we can resolve, as providers, once we have more time. 

We hear about tools to facilitate medical collaboration and we tend to think, "Well, that's so nice. Maybe once I get the big stuff resolved, I can move on to refining things like that."

We know from our work with ClickCare that medical collaboration IS one of the big things in medicine, very much not a "nice to have." But a recent study that looked at handoffs and communication from hospitals to Skilled Nursing Facilities (SNFs) really brought this point into relief and made the negative consequences of poor communication at discharge incredibly clear. 

More than 5 million people transition from hospitals to Skilled Nursing Facilities (SNFs) annually. The investigators in this study did detailed focus groups and interviews with SNF nurses, looking at that transition and the communication and medical collaboration that happens -- or doesn't -- and what the consequences are.

It's interesting and smart that the study looks at nurses rather than physicians. There is a lot of investigation around handoffs to physicians, but the handoffs to nurses have been looked at less. And nurses in SNFs play the primary role in managing handoffs and discharge to SNFs. 

The conclusions in this study are fascinating and are also crucial to both SNFs and to hospitals. As the study reports, “Discharge to a SNF is one of the strongest predictors of experiencing rehospitalization within 30 days.” And the study concludes, "High-quality, complete discharge communication is vital to safe and effective hospital-SNF transitions.”

The investigators interviewed 27 registered nurses from 5 SNFs in Wisconsin. Facilities ranged from urban to rural, and from 42 to 184 beds. They spoke with the nurses about handoffs and discharge. And poor quality discharge communication was the major barrier they identified to safe and effective transitions. “From the perspective of SNF nurses, difficult hospital-to-SNF transitions were the norm, and when asked to recall the details of a good transition, none were able to do so.”

The issues they identified are crucial, both because they are signficiant, specific, and also because they can be easily addressed by existing telemedicine medical collaboration technology. 

Discharge communication issues in Skilled Nursing Facilities (SNFs) that nurses identified:

  • The information they get from the hospital is inadequate, incomplete, and incorrect.
    SNFs need specific, up-to-date information about the patient including “remarkable hospital events; written orders for medications, treatments, activity level, and diet; recent and pending laboratory test results; accurate descriptions of functional and cognitive status; and pertinent social information, such as preferences and unique needs.” Both medical and social plan of care are important. And they found that when they do intake for a patient, much of this information was missing or conflicting.
  • Information is coming from multiple sources, but they are often conflicting.
    Transition information came from three sources -- the patient, the family, and the hospital -- and they had to synthesize it and try to fill in the gaps.
  • There is no good means of communication or collaboration with hospital staff.
    It is very difficult to contact hospital staff for any clarifications or to reconcile discrepancies. They don’t have contact information and don’t have the right contacts.
  • Inadequate information, presented in challenging ways, creates care delays.
    At a patient’s arrival, SNF nurses often receive “reams” of paper, sometimes exceeding 80 pages, most of which isn’t relevant to plan of care. They spend hours navigating records and often have to go through the entire printed electronic health record to figure out an accurate history. Discrepancies are often not reconciled for several days. Nurses often end up going in circles to try to get information, where no one provider actually has all of the information. SNF nurses said, “The primary states… ‘I didn’t know what happened at the hospital so I can’t give you any orders…You need to call the hospitalist or whoever worked with them.’”
  • Getting information from families is usually not a good solution.
    Nurses sometimes try to get additional information by asking individuals and families but there are three problems with this approach:
    • They often aren’t informed enough to offer quality information.
    • Asking them creates a poor impression of the SNF
    • Medical orders are legally binding so they need to reconcile what they hear with the orders.

With all of these issues, nurses say they are mostly “working blindly" when they receive a patient. And that's not a matter of inconvenience, it can be a matter of life and death. The study reports, “Missing or incomplete information resulted in care delays, which threatened individual safety and produced individual and family dissatisfaction with the transition process... In one example, an individual who had bilateral lower extremity casts was left in bed for 1 week as the SNF nurses repeatedly requested and waited for clarification of physical activity orders and cast care.”

Also, these communication issues can be a major problem for the reputation and trust in Skilled Nursing Facilities. “Care delays and implementation of an inappropriate plan of care resulting from inaccurate information produced significant individual and family dissatisfaction and made the SNF facility appear unorganized and ill equipped to care for individuals. This experience produced substantial stress and frustration in SNF nurses.”

Our frustration in hearing about this kind of problem is huge. Not because it's a concerning public health problem, both in terms of medical provider burnout, and in terms of providing adequate care for our patients... but because we have the tools to fix this. 

Ultimately, this blog is not about advocating for iClickCare as a tool. And if you can find a better telemedicine tool for medical collaboration and communication around handoffs, you should use it. But we see several key reasons that iClickCare could be a crucial tool to support communication with Skilled Nursing Facilities, essentially fixing all of the above problems in a simple and cost-effective way: 

  • Multiple voices, in one place. 
    One of the primary issues that SNFs face is that there is information coming from multiple providers and sources in multiple institutions and they can conflict with each other. iClickCare keeps all of these voices in one simple patient record, which means that when there are conflicts, they can be resolved quickly. Also, it allows communication across the continuum of care, so that whether it is a physician, generalist, hospitalist, aide, or nurse, all of their experiences about the patient's status can be integrated and incorporated. This also helps ensure that both the medical and social and personal context for care plans can be communicated -- rather than the picture being stripped down to just "orders", leaing nurses to guess about things like cognitive condition or personal context.
  • Simple communication for busy people. 
    Nurses in SNFs identified contacting hosptial staff -- and even knowing who to contact as a key barrier to effective discharge with adequate communication. With iClickCare, you don't need to play phone tag, hunting down the provider who last saw your patient. You request a consult and the other providers can answer your questions quickly, but on a schedule that works for them, and without needing to track down contact information. Further, words, pictures, and videos can be used to clarify issues and make sure that everyone is on the same page. 
  • More efficient development of care plans. 
    It's downright dangeous to delay care for hours or even days because there is inadequate information at discharge and it takes days to resolve the issues. With iClickCare, the process becomes hours or days faster because you're using the power of telemedicine to navigate care, asking key questions to the right people, without nurses having to remove themselves from the care setting. 

If you're experiencing communication or discharge challenges in a Skilled Nursing Facility, we urge you to give a telemedicine tool to resolve them. You can try iClickCare for free, for 14 days. Download it here:

 

Try the iClickCare 14-day evaluation

 

Tags: medical collaboration, long term care, care coordination, decrease readmissions, skilled nursing facility, handoffs

The Key Ingredient in Using Telemedicine in a LTC/SNF Setting

Posted by Lawrence Kerr on Thu, Jul 20, 2017 @ 06:01 AM

takahiro-sakamoto-181476.jpg

At NewYork Presbyterian, the COO is taking on "respect."

The NEJM Catalyst published an interview with Dr. Laura Forese, who spoke about their new initiative. Their big goal was to cultivate teamwork across the continuum of care, and in surveying the clinicians and non-clinicians at their hospital, they kept hearing that individuals felt like respect was the missing ingredient to their teamwork. So the hospital, under Forese's direction, has been taking action to try to cultivate more respect across the hospital. The intention is certainly there. But when pushed for examples of how they are cultivating respect in the hospital, Dr. Forese gave one primary example: posting a respect credo throughout the hallways.

Many medical providers just gave a little internal eye-roll.

Sometimes it seems like administrators' primary strategy when it comes to almost anything is posting more signs. Not more training, not better tools, not more support, not refined processes -- more signs. 

I certainly agree with New York Presbyterian's goal. Teamwork in any setting is crucial, but in Long Term Care and Skilled Nursing Facilities (LTC/SNFs), teamwork is a matter of life and death on a moment to moment basis. Especially critical, the "team" in a LTC/SNF setting often includes providers across a broader continuum of care than in other settings -- aides, orderlies, housekeepers, families, PT, OT, specialists... the list goes on. 

What I don't agree with is New York Presbyterian's "too easy" approach to such an important topic.

So if the goal of improving teamwork, care coordination, and respect in LTC/SNF settings is valid, then what is the best approach to cultivate that?

We believe there is one key ingredient in improving teamwork in Long Term Care and Skilled Nursing Facility settings: working as a team.

Yes, it really is that simple, but it's not always easy. We get better at running, the more we run. We get better at surgery the more operations we do. And we respect each other more, and function better in care coordination and medical collaboration, when we work together as a team. 

That is precisely the impetus behind iClickCare. We believe that teamwork and collaboration has to be made efficient, fun, effortless, and efficient for healthcare providers to do it. It has to use technology that teams already have, and it has to include every care provider (even non-clinicians, when appropriate). Period.

The best way to improve teamwork is by working together as a team. And the best way to get providers and non-clinicians across your facility to work as a team is to give them the tools to do it in the course of their regular day. Everyone wants to show their colleagues respect -- the important thing is removing obstacles to that, not lecturing about its importance via laminated credos.

If you want to see examples of how telemedicine can drastically improve teamwork in a LTC/SNF setting, click here:

Transforming Long Term Care Through Telemedicine

Tags: telemedicine, medical collaboration, long term care, care coordination, skilled nursing facility, LTC/SNF

3 Reasons Rewards and Punishments Can Fail to Advance Value Based Care

Posted by Lawrence Kerr on Tue, Jul 18, 2017 @ 06:01 AM

34811651110_9d6bb665f0_z.jpgIn Liberia, the rate of maternal mortality rates is 725 deaths in every 100,000 live births. That's almost 50 times higher than it is in the US and among the highest rates in the world, even when compared to other developing countries. 

So communities, clinics, and medical providers in Liberia are scrambling for the right solution to get those rates down. According to a New York Times article this month, the consensus seems to be that safer births come from delivering in a clinic or hospital -- under the care of a trained midwife -- rather than at home with the support of a traditional birth attendant. 

That would surprise few people -- but the way they're going about it, as well as the results they are seeing -- are surprising indeed, and are very applicable to our conundrums about value based care, how to improve compliance, and whether care coordination and medical collaboration compliance can be of value in this new climate.

In the Liberian village of Zahmboyee, Evelyn Dolo is a birth attendant who traditionally supports women in giving birth at home. Recently, however, her village created a hugely steep punishment for doing just that. If Evelyn supports a village woman in giving birth at home, the fine is 5,000 Liberian dollars (about $50), a gallon of palm oil and a tub of cooked rice.

So Evelyn, like many traditional birth attendants in Liberia, is rushing patients to clinics rather than attending them at home. The fines vary from community to community -- sometimes the fine is in cattle, or dollar amounts, or rice, or food. But they are usually steep enough to be significant or even catastrophic for a birth attendant. 

Clinics say that they do indeed see more women giving birth in a clinic. And in Liberia, it's too soon to tell whether maternal mortality has shifted significantly. But in other countries, where similar programs are in place, the results simply aren't what people expected. For instance, in India, there has been a program in place to give poor women a cash incentive to give birth in a clinic or birthing facility. Like in Liberia, dramatically more births are happening in a facility -- the number went from 20% to 49% in 5 years -- but there has been no meaningful decrease in Indian maternal mortality rate. 

Lynn Freedman, director of Columbia University’s Averting Maternal Death and Disability program says of coercive punishment or incentive programs: “I don’t think it gets countries or their populations where they want to be.” 

I found this result discouraging when it comes to maternal mortality rates, but also interesting when compared to the pattern we have in the US of creating coercive reward and punishment programs for medical providers around things like care coordination and medical collaboration. Whether it is metrics like length of stay, rate of readmission, or specific patient satisfaction scores, providers are often punished or rewarded for particular indicators -- in the hopes that the hospital system will then experience an improved ROI.

When it comes to value based care, what can we learn from programs like these in Liberia and India?  And do rewards and punishments work in supporting better outcomes and better compliance?  Or is it possible that we can see results like India's, where the behavior we're rewarding increases, but value does not?

3 Reasons Rewards and Punishments Can Fail for Value Based Care:

  1. Incentives don't always align with resources. 
    In Liberia's experience, hospitals are seeing more expectant mothers as patients but may not have more money or providers to care for them. As the New York Times points out, "If more women are coming into clinics, then those places need to have increased staffing and supplies to care for them." Similarly, providers are often told there is a new incentive for some aspect of care -- but the time to care for the patient and the support resources to make it happen remain scarce. In a value based care setting, extensive attention needs to be given to having incentives and resources align.

  2. The right incentives have to be given for the right thing. 
    Sometimes the thing that's easy to measure isn't truly the thing of most value. For instance, in the case of maternal mortality rate in Liberia, it's easy to observe whether mothers are giving births in a clinic -- so that is what is being rewarded. But in truth, maternal mortality rate may be helped or hindered in either a home or clinic setting -- so ultimately, when it comes to the end "value" to the patient -- what needs to be measured may be something much more subtle. Similarly, here in the US, hospitals are all going to be on value based care payments. But if providers aren't equipped meaningfully to provide true value (rather than sent on a wild goose chase for metrics that don't really matter), then value for the patient won't really be achieved, even if the metric is met.
  3. Providers may become disconnected from their deeper motivations and more important practices. 
    When medical providers, whether in Liberia or in the US, are incentivized for particular behaviors, they start to focus on those actions, rather than the natural things they do to care for the patient in the best way they know how. Not every provider is perfect, but almost every provider is deeply motivated by wanting to help and care for the patient in front of them. In many contexts, that means going above and beyond for the patient, collaborating creatively with other providers, and finding new and better ways to do care coordination because it can help the patient get a better result. Just as Liberian birth attendants may start to become disconnected with their own wisdom about what the patient needs, if there are too many restrictions on how they can care for the patient, the same thing is happening with US medical providers. So many of the incredible people who use iClickCare for care coordination and medical collaboration are doing so because they believe it will help their patients -- not because of any immediate reward or incentive. 

Ultimately, the simple act of trying to care for your patient to get the best possible outcome is the most true act of value based care that can exist. Certainly, hospital systems need to find ways to improve on the value dimensions that are dictating hospital funding. But we advocate for finding a way to do so that doesn't risk alienating medical providers from their most powerful outcome based approaches.

Why not incentivize through enrollment in true understanding of what works and what doesn't in the end outcome, rather than through sticks and carrots linked to simplistic actions? We tend to think that the US is different from a country like Liberia or India -- but we can ignore their learnings at our own risk.

You can use telemedicine to improve performance in value based care. Try it for free here:

Try the iClickCare 14-day evaluation

 

Photo by 149720488@N03 on Flickr, used under Creative Commons rights.

Tags: value based care

Population Health aids Coordinated Care Initiatives

Posted by Lawrence Kerr on Wed, Jul 12, 2017 @ 06:19 AM

samuel-schneider-222889.jpgPopulation health initiatives are nothing new -- but I'll be the first to admit that I was floored by the results that some projects are getting, and this may aid our efforts toward coordinated care. 

As you likely know, population health initiatives are projects that look at the health of a group -- for instance the health of everyone in a state -- including the distribution of those outcomes.

CareOregon is one example -- a nonprofit that increases access to healthcare services for patients on Oregon’s Medicaid programs. As their CEO tells it, their goal is to make hospitals all but unnecessary by limiting the need for that kind of care.

The surprising results? Since it launched in 2011, CareOregon has seen a statewide 23% drop in unnecessary emergency department visits and admissions have decreased as well.

As providers, we may not be population health practitioners in name, but it's our responsibility to look at these determinants of health as well. And we've identified three crucial takeaways from population health that any provider can use.

CareOregon is a great example to look at when it comes to population health. It's broad-based enough to carry takeaways for all kinds of health initiatives. Its results have been substantial in a short period of time. And they've generously shared their initiatives and results so others can learn. 

4 Takeaways from Population Health That Every Provider Can Use:

  • Focus on health, not just healthcare.
    For instance, with CareOregon, a child with severe asthma might be cared for with air conditioners or air filters -- not just medication or even emergency care. This full picture of the "social determinants of health" is something we're passionate about at ClickCare -- and a big reason that the case method of iClickCare is flexible, holistic, multimedia, and includes providers across the continuum of care.

  • Value people -- including the patient and the family -- across the continuum of care.
    CareOregon focus on teams, not events. So whether that means a specialist, an aide, or even a professional outside of medicine, if it will help the patient's overall healthcare, it's part of the picture. As they say, "Sometimes protecting your health means we’ll help you find other agencies that can help you access non-medical support." They also prioritize improving teamwork and communication over advancing specific tactics to improve care. If the team is working well, the results will be good. Finally, they use a “bottom up, top-enabled” approach -- so that the folks who are in most contact with the patient are driving the care (the day-to-day providers), in ways that are enabled at the top (administrators). Valuing people strongly supports our belief that healthcare collaboration and coordinated care are also crucial initiatives -- and telemedicine is one way to make them practical, efficient, and easy.

  • Use simple, inexpensive solutions. 
    This approach is about using technology to work smarter, not harder. Sure, videoconferencing telemedicine systems are fancy (and expensive) -- but we believe that the best medical camera is the one in your pocket already and that the technology should be deeply intuitive. Sophisticated technology doesn't need to be expensive -- and that usually means investing in software, not hardware that is rapidly outdated. 

  • Look at holistic data.
    Fierce Healthcare quotes Karen DeSalvo, M.D., former national coordinator for health information technology at the the Department of Health of Human Services, as saying that we need to break down data "silos that prevent providers from seeing the full picture of a patient's, or community’s, health. Having the full picture allows for a 'system that wraps around people and supports them."  Electronic health records (EMRs and EHRs) are just one piece of the puzzle. All of the other parts of patient data -- that anecdote from a nurse, the self-reported weight changes, etc -- need to be taken into account in systematic ways. Sure, the data in EMRs and EHRs can be codified, but we think that a big reason that CareOregon has seen such dramatic results is because they use the data that helps, even if it's not able to be put into a spreadsheet.

We applaud the pioneers of CareOregon, and the work of every provider who has been courageous enough to try something new as part of it. 

Maybe your medical context is not one where these principles are being used -- but that doesn't mean that you can't apply them, even in small ways, today. 

And if you want a medical collaboration tool like iClickCare as part of that effort, try it for free:

Download iClickCare from the Apple App Store

 

 

Tags: medical collaboration, coordinated care, care coordination, healthcare collaboration, big data

Sweet Potatoes Help with Care Coordination

Posted by Lawrence Kerr on Wed, Jul 05, 2017 @ 06:01 AM

Medical Collaboration depends on different communication.jpgSometimes medical providers have a tendency to focus on the seriousness and sophistication of care. 

When we're about to give a shot, we emphasize that it might hurt. When we prescribe a medicine, we don't always explain the pathway simply -- sometimes we use jargon that makes sense to only the other providers in the room. 

We get most excited about care plans that are cutting edge. 

But a recent study caught my eye as evidence that we might be better off focusing on the simplicity, ease, and fun of a care plan, rather than the more rigorous or medically important aspects.

A recent article in JAMA Internal Medicine looked at the trend of emphasizing the health merits of foods. We see things advertised as high protein, high fiber, or farm-fresh -- and we assume that these descriptors are attractive to people.

As the study reports, "Ironically however, health-focused labeling of food may be counter-effective, as people rate foods that they perceive to be healthier as less tasty."

So the researchers created a study to see whether health-focused labeling is better or worse than just a neutral label -- and better or worse than how junk food is described.

Researchers watched 27,933 students (with some staff) in a dining hall over 46 days. Each day, the researchers offered the same vegetables, but named them differently. For instance, the sweet potatoes might be described as "zesty ginger-turmeric sweet potatoes” instead of just “sweet potatoes." That change, in fact, resulted in 25 percent more people choosing the vegetable. And, as the New York Times summarizes, "35 percent more customers chose the zesty label than the health-positive 'wholesome sweet potato superfood,' and 41 percent more chose it than the scolding 'cholesterol-free sweet potatoes.'"

Across all of the vegetables, the study concludes that vegetables were most likely to be chosen when they had "flavorful, exciting, and indulgent descriptors" rather than neutral ones, or (even worse), descriptors touting their health benefits.

It's a simple study, with results that may seem obvious. But the implications for how you talk about care plans could be significant. It's human nature to want to choose fun things over healthy things -- and there's no reason we can't frame care the same way we frame sweet potatoes. Care coordination is more than assuring appointments are kept; it is about ensuring a good attitude and thus good compliance for improving health. If the patient buys into your recommendations, you are making value, and you will get paid (telehealth with value based care and MACRA).

For instance, your heart patient might need to lose weight so he'll add years to his life. But is it possible that losing weight could also make his August vacation more fun and active? That might be the component to focus on. The shift also makes us reflect on the continuum of care, as different people on the team should be collaborating on things as seemingly mundane as the verbal phrasing of a care plan -- and that requires strong medical collaboration and care coordination -- and a medical collaboration tool. 

Care is far more than how we describe it, of course -- but if subtle changes in verbiage can benefit your patient's outcomes, it could be worth experimenting with.

For stories of collaboration and innovation from around the world, get our free guide:

ClickCare Quick Guide to Medical Collaboration

 

Image: Carol Mitchell

Tags: good medicine, care coordination, value based care, medical collaboration tool

Why Treating The Patient as Part of the Solution Gets Better Results

Posted by Lawrence Kerr on Wed, Jun 28, 2017 @ 06:01 AM

16751926184_8843b3c4ef_z.jpgThe Wong Baker Scale has become universal and is required by the Joint Commission (formerly JCAHO) to be present at every patient's bedside. Most often it is on the wall where it is unavoidably seen whenever the patient's eyes are open.

This visual pain scale was actually developed in a smart, caring, rigorous, innovative way. (More on that story here.) Wong and Baker created the scale visually by asking children to draw pictures of how they felt at different levels of pain. They then made a composite of those pictures, which became the scale. It was a smart approach because it circumnavigated literacy limitations (which can affect children but also adults with literacy challenges or who speak another language) -- and it was developed in partnership with the patients themselves. 

Sadly, the common usage of the pain scale is very much in conflict with this original approach. The scale is hung so prominently, with so little context, and with such a focus on pain, rather than healing, that the original intention is lost. We will look at the effects on a patient's healing (how badly does it hurt vs. how do you feel?) in a future post. However, we wish to focus on another aspect of the imagery: one that builds a schism between provider and patient.

Of note, is that the images portray not only a description of pain, as intended, but also an element of anger. When the patient is continually oriented toward a literal picture of pain -- with the doctor positioned as the gatekeeper or arbiter of treatment -- then the provider and patient are in opposition when it comes to care. Of course, then a patient with a difficult problem becomes a "difficult patient."

It's not surprising that provider burnout is at an all-time high. Almost all healthcare providers went into the field because they want to help people -- and the subtle message that they are on "the other side of the table" from the patient will wear at compassionate caregivers. Further, this type of positioning starts to make the patient the enemy as well -- the provider begins to focus on "fixing the patient and getting her out the door" rather than embarking on a course of treatment in a journey taken together. 

With similar motivations and implementation as the pain scale, satisfaction surveys also help to manage the patient, but simultaneously shift the focus from success to failure. The surveys have even been found to fuel the opioid epidemic by creating adversarial incentives. Besides contributing to burnout, low satisfaction scores can correlate with low pay with unintended consequences. Again, this isolates the patient from the provider to the detriment of both.

The schism is at odds with current value-based care initiatives. If providers and patients are both looking for an outcome that is truly one of better health, the provider and patient are certainly on the same side, moving forward. Rather than the model of fixing the patient, managing the pain, and getting a good satisfaction score, would it not be better to keep the patient in the loop and keep their assessment as part of the solution?

Healthcare and medical collaboration is finally being recognized as a way to improve our health care system. We must design tools that at low cost and high effectivity include everyone irregardless of degree, title and position. We believe that when it comes to telemedicine, medical collaboration, and telehealth, it's absolutely essential that the patient be deeply involved as a part of the solution. In iClickCare, one of the simple four buttons to be clicked is “Invite Patient”. The true meaning of "invite patient"? Perhaps the button should really say, "invite the patient and family to add to the discussion of the patient's care, as providers of all types work together to come to the best possible approach to care". Further collaborative thoughts among all members of the team, can then be rapidly assessed and appropriately integrated into the patient's care.

Whatever tools you use for the patient, we hope that you make the choice to engage the patient in the solution. It may be action that is "against the tide" but it won't be for long -- you're just a pioneer in making it a reality. 

To experiment with including patients in care discussions, click here to use iClickCare for free:

Try the iClickCare 14-day evaluation

 

Image from osseous on Flickr, used under Creative Commons rights.

Tags: medical collaboration, communication with patients, healthcare collaboration, improving patient satisfaction

Your Patient's Roommate May Have a Bigger Impact Than You Do

Posted by Lawrence Kerr on Wed, Jun 21, 2017 @ 06:03 AM

roomates.jpgAs healthcare providers, we believe we're doing everything we can for our patients. 

We're providing the standard of care, always looking for better medicines, better protocols, better surgical techniques, better ways of caring. 

But I recently stumbled upon one factor in patient outcomes that very few providers are aware of -- and the effects of it can be staggering. Even if this finding doesn't apply to your practice directly, I think there are important lessons to be learned for all healthcare providers, across contexts.

A recent article in the American Journal of Health Economics, looked at the effect of the health or sickness of a patient's roommate on that patient's health. They found that there is significant "spillover" of health from healthier roommates to less healthy roommates. In fact, patients with healthier roommates needed less care during hospitalization, lower rates of readmission, better condition at discharge, shorter length of hospital stay, and lower hospitalization costs.

As the New York Times reports, "a patient who rooms with the healthiest roommate has a hospital stay that is about eight hours shorter, requiring 27 percent less medical attention, and costing about $840 less."

Crucially, the study controlled for the factors that nurses used to assign patients to rooms, including diagnosis and specific room assignment. Even looking at one room, patients with healthier roommates had better outcomes than those with sicker roommates. 

In terms of appropriate action based on the findings, it’s not 100% obvious what might be implied. For patients, it could be worthwhile to advocate for themselves, requesting a different roommate if they find themselves with a sicker one. 

But for providers, the findings are much more applicable. With Length of Stay such a crucial metric for providers, these findings are astounding. A stay that's shorter by 8 hours and almost one-third less medical attention is powerful -- and hard to beat. 

There may be specific ways to approach the assignment of patients to rooms that will optimize around this dynamic. But more interesting to me are the higher-level takeaways that the study points at. 

Two takeaways from the findings that patients have better results if they have healthier roommates:

1. Peer influence is crucial.

The study seems to point to the influence that peers can have on patient progress. In fact Peer Support is a burgeoning part of the field, with significant positive consequences for health outcomes. This is one reason that we made iClickCare so accessible and powerful for collaborations among people across the continuum of care, including providers not traditionally included in many care decisions, like occupational therapists, teachers, family members, social workers, and aides. If peers are on one side of the continuum and super-specialists are on the other side, then we advocate for including as wide of a spectrum of care as possible, in the acknowledgement that -- as in the case of roommates -- the rewards can be significant.

2. Care is more than just medical intervention, and there are rewards for addressing the full picture.

When we look at Length of Stay metrics, we are trained to look at "hard" factors, like the disease, intervention, skill level of the practitioner, etc. What surprised me about this study is that it almost takes on the issue from "peripheral vision" -- it's looking at a soft, often ignored, almost irrelevant-seeming factor in outcomes. iClickCare is made to facilitate inclusion of precisely this kind of variable, and to keep all the factors in one place. Whether it's a patient's hobby, where he/she lives, his/her interests or fears, or details of behavior or presentation that only the aide would notice -- you should choose a medical collaboration tool that captures the whole picture. 

 

Certainly, the factors influencing the roommate phenomenon haven't been completely explored yet. And there certainly aren't easy answers for room assignments based on the results. But we're grateful to the researchers for their creativity in exploring the issue. And we encourage you to use the same kind of creativity in applying the findings.

 

Use a healthcare collaboration tool that takes all the factors into account. Get iClickCare free for 2 weeks:

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Tags: medical collaboration, healthcare collaboration, decrease readmissions, decrease length of stay

5 Things Healthcare Should Steal From Hyper-Elite Concierge Medicine

Posted by Lawrence Kerr on Wed, Jun 14, 2017 @ 06:01 AM

conciergeaccess.jpgWe’ve talked about concierge medicine in this blog before, but there are new services that take this subscription-based, elite model to an extreme.

For instance, The New York Times reports that Shlain Private Medical has annual fees that range from $40,000 to $80,000 per family. House calls (or visits at the FBO of the patient’s private jet) are an option; visits are deeply unrushed; and any coordination of specialists is done by the provider, not the patient.

Many are debating the ethics around these models. When the wealthy can pay to access care that is fundamentally different than what everyone else is getting, it’s a valid question as to whether or not something is wrong.

These concerns aside, we think there is a lot to be learned from these models, for all providers, regardless of pay rate.

5 Things We Think Healthcare Can Learn From Hyper-Elite Concierge Medicine:

  • Some patients need to “cut the line.”
    As the article reports, waits to see the doctor are increasing. "It takes 29 days on average to secure an appointment with a family care physician, up from 19.5 days in 2014."  Long waits to see providers isn’t a problem for all patients, at all times. But for some situations, an instant answer is what is required. In the medical system at large, we certainly can't get every patient in to see another doctor fast. But we can use a healthcare collaboration tool like iClickCare to get key answers fast -- so patients don't even have to visit that second (or fifty-second) provider.
  • Care coordination is fundamental to care.
    The medical system has a way of looking at care coordination as something extra, or special. But a big part of the reason these concierge models are so valuable is because they willingly coordinate specialists and other providers on the patient's behalf. Fee systems are beginning to reward care coordination in the same way. The more we understand that care coordination is fundamental, the more we can support it institutionally. 
  • The context of a patient's life matters. 
    These concierge providers understand the familial, occupational, and societal context of their patients -- and work within that. People pay top dollar for that service, not necessarily because it feels good, but because it works. That's why iClickCare lets you collaborate with several other providers on a single case, using multimedia -- and it's all archived. The therapist's opinion, specialist's opinion, and that of the family doctor can all be integrated -- on each person's individual schedule. 

iClickCare makes it easy and fast to provide the standard of care that concierge facilities do. Try it for free:

Try the iClickCare 14-day evaluation

 

Tags: care coordination, healthcare collaboration, concierge medicine

The Outcomes of Older Doctors and Female Doctors May Differ -- But Does It Matter?

Posted by Lawrence Kerr on Wed, Jun 07, 2017 @ 06:01 AM

olderphysicians.jpgOur least favorite type of research is the observational study. Think: eggs are good for you, eggs are bad for you; eat meat, don’t eat meat; statins cure everything, statins cause everything; and on and on.

However, observational studies can be a first step into deeper understanding. An example is Jenner’s observation that milkmaids who contracted cowpox did not get smallpox. In the current "publish or perish" environment, the necessary deeper inquiry (Jenner tested vaccination, albeit in a crude way as we look back) often does not happen. Public media grabs and grasps the story, disseminates the story, and the story disappears and is gone within less than 24 hours. Another publication is notched for institution and researcher. Big data is thanked. Rarely do we find someone who goes on to ask why.

Certainly, inquiry into what works and what doesn't is extremely valuable. That said, two recent studies also beg for a deeper answer. Both are by the same author. The first study by lead author Yusuke Tsugawa observes the female physicians have fewer patients die or be readmitted. They speak of adherence to clinical guidelines  and “patient centered communication." 

The second study concludes that younger physicians have fewer patients die while the readmission rate is the same. It pits older physicians against younger physicians. Medicare patients formed the sample. Policy implications concluded that medical education and its maintenance of certification is important.

There is no doubt that the younger physician is a better coder and understands the value of coding maybe even over outcome. Could this be the education that is required? 

But, let’s not quibble over reasons and explanations. Above all, what matters most is how we can improve medicine. 

Assume the conclusions are correct, and that there are indeed differences born of gender and age. Why not encourage, support, and demand collaboration and communication? Bring the old to share with the young, the young to teach the old. The style of the female to mesh with the style of the male.

Regardless of whether these studies are strong and solid and show true causality between these physician demographics and their outcomes... Why not work together, rather than focus on controlling the parts?

 

These stories of medical collaboration show that you can take outcomes into your own hands:

ClickCare Quick Guide to Medical Collaboration

Tags: collaboration, good medicine, collaboration leadership

3 Key Obstacles to Care Coordination and Why to Surpass Them

Posted by Lawrence Kerr on Thu, Jun 01, 2017 @ 06:02 AM

carecoordination-1.jpgOne of the bizarre paradoxes of being a healthcare provider in 2017 is that we are asked to do many things... that are made increasingly difficult to do.

For instance, patient satisfaction is the watchword, but our time with the patient is chiseled down, year by year.

Or we are pushed to ensure care coordination happens -- and our pay depends on it -- but it is made increasingly impossible for us to actually do it.

A recent article by Medical Economics really brought this point home for me. They thoughtfully laid out many of the most pressing obstacles to care coordination -- while also highlighting how crucial this kind of collaboration has become in today's medical setting.

As the articles author, Sweeney, describes, “Virtually all primary care physicians engage in coordinated care to some degree, but the extra emphasis placed on it now by healthcare policymakers, along with new reimbursement models and reporting requirements, has primary care doctors looking for new ways to improve how they coordinate care.”

This article highlights several important obstacles to care coordination, but these three resonated with us the most: 

  • Most technology doesn't support it. The article quotes a doctor as saying “Nothing beats doctor-to-doctor communications, ” but he goes on to say that he gets that communication through phone or text. As we often talk about, texting medical information about patients through a regular phone is never HIPAA compliant and can be subject to huge fines for the provider. But we understand why providers resort to this. The alternatives for communication and collaboration are dwindling. That's precisely why we created iClickCare, giving every provider access to a healthcare collaboration tool that is simple enough to solve the problem without creating further workflow challenges.

  • Confusion about roles in care coordination. 
    One of the issues that was highlighted in the article is that not all healthcare providers are excellent at coordination and collaboration. Whatever the discipline, some providers feel it's "not my job" to coordinate care, outside of the medical visit. Especially when providers are having to improvise, get creative, and work with complex patient histories and contexts, a reluctant collaborator can make it very difficult to coordinate care effectively.

  • Provider burnout. The final obstacle that really stood out to us in the article was an overwhelming, underlying sense of frustration, despite good intentions. The cry that each provider quoted seemed to have was, "I want to do it right, but I'm being foiled at every turn!" This frustration and burnout is pervasive in the healthcare field right now (up to half of healthcare providers are burnt out.) And it creates a vicious cycle in which providers become unwilling to collaborate -- and when they do, they're met be resistance and obstacles. 

 

All of that said, we believe there are significant and overwhelming reasons that care coordination is a smart choice for providers to make: 

  • It's increasingly rewarded with payment. 
    As the Medical Economics article highlights, payment systems have lagged behind care coordination, but as pay-for-performance becomes the standard, and care coordination is increasingly valued, it will become the smart financial thing to do. “It’s been an unofficial mandate for decades, and it’s only now that the primary care physician is being recognized for all the work they do in coordinating care,” says Emily Briggs, MD, who has a primary care practice in New Braunfels, Texas.
  • It helps with burnout. 
    Ironically, when we become burnt out and overworked, we tend not to do healthcare collaboration -- but healthcare collaboration can be one of the most satisfying routes to beating burnout and feeling good about the work we did that day. 
  • Care improves. 
    Of course, we know that care coordination improves the care that a patient receives. The complex issues within a case, or the contextual "human" factors,f are only appropriately addressed when multiple healthcare providers are working together. “It’s all based on the patient’s sociological situation at the time. If you’re not looking at those things, you’re not a [primary care] physician,” says Briggs.


Care coordination can't happen in a vacuum and it can't happen without giving healthcare providers the proper tools, payment, and support to do it. But it doesn't have to be all-or-nothing. If you can collaborate on behalf of one patient today, you may not have changed the healthcare system, but you did change healthcare -- and maybe health -- for that patient. 

 

You don't have to wait for healthcare to change. Know your options for using telemedicine to do care coordination today: 

ClickCare Quick Guide to Telemedicine

Tags: medical collaboration, care coordination, healthcare collaboration

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