Minnesota Physician November 2022

PHYSICIAN

Patients and Medical Jargon

A study of misunderstandings

BY EMILY HAUSE, MD AND JORDAN MARMET, MD

Hi. I’m Dr. Emily Hause, the pediatric rheumatology fellow. Let’s discuss the results from your recent labs: your CBC, ESR and CRP were unremarkable. Your creatinine remains a bit high at 1.4, and the EKG looked good. I’ll check with my attending about discharging you from the hospital today. You’ll need to follow up with your PCP, who may make a referral to Nephrology. Do you have any questions?

Connecting Primary and Specialty Care

Improving medical practice

BY ELIZABETH SEAQUIST, MD

Advances in medical science are increasing exponentially. New methods of diagnosing and treating illness are developed faster than they can be practically incorporated into best practice. At the same time demand for health care services exceeds supply and workforce shortage issues add difficult new dynamics to the process of keeping pace with change. Physicians are expected to schedule so much of their time around seeing patients; it can be sometimes forgotten that providing the best care requires research and communication beyond what occurs in the exam room. One way this has

If you’ve graduated from medical or nursing school, this paragraph should make complete sense to you and might even mimic medical encounters you’ve witnessed at some point in your careers. Unfortunately, if you’re a patient, these brief sentences are full of enough medical jargon to be rendered completely nonsensical. When patients don’t understand their plans of care, they are not truly being included in shared medical decision-making. Connecting Primary

Patients and Medical Jargon to page 144

NOVEMBER 2022 | Volume XXXVI, Number 08

COVER FEATURES

Connecting Primary and Specialty Care Improving medical practice

By Elizabeth Seaquist, MD

DEPARTMENTS

Patients and Medical Jargon A study of misunderstandings

Emily Hause, MD and Jordan Marmet, MD

CAPSULES 4

INTERVIEW 8

Streamlining Research Access

Per Ostmo, MPA, Rural Health Research Gateway

BEHAVIORAL HEALTH 18

The Mental Health Collaboration Hub

Improving hospital bed access

By Todd Archbold, LSW, MBA

RURAL HEALTH 22

Value-based Reimbursement

A rural health perspective

By Terry J. Hill, MPA

www.MPPUB.COM

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Minnesota Physician is published once a month by Minnesota Physician Publishing, Inc. Our address is PO Box 6674, Minneapolis, MN 55406; email comments@mppub.com; phone 612.728.8600;. We welcome the submission of manuscripts and letters for possible publication. All views and opinions expressed by authors of published articles are solely those of the authors and do not necessarily represent or express the views of Minnesota Physician Publishing, Inc. or this publication. The contents herein are believed accurate but are not intended to replace medical, legal, tax, business, or other professional advice and counsel. No part of the publication may be reprinted or reproduced without written permission of the publisher. Annual subscriptions (12 copies) are $48.00/ Individual copies are $5.00.

THE HEALTH CARE WORKFORCE SHORTAGE: Facing a crisis

BACKGROUND AND FOCUS:

Prior to the pandemic, it was widely recognized there were serious workforce shortage issues facing health care delivery. Those concerns are now much worse. From physicians, to nurses, to behavioral health, to public health, to assisted living and long term care, every kind of licensed health care professional faces demand that far outstrips supply. This problem is trending steeply upward and can only manifest in serious negative outcomes. Lack of access creates higher cost, preventable increases in morbidity and mortality and systemic burnout.

OBJECTIVES:

Our expert panel will examine the root causes of the health care workforce shortage. From industry entrance barriers, to workplace dysfunction, to career satisfaction we will present examples and potential solutions. We will dissect the complex interactions between elements of health care governance and explore how industry sectors can work together more closely to solve shared problems. We will explore the numerous initiatives already underway to address these issues and share suggestions for how best to address them.

JOIN THE DISCUSSION

We invite you to participate in the conference development process. If you have questions you would like to pose to the panel or have topics you would like the panel discuss, we welcome your input.

Please email: Comments@mppub.com and put “Roundtable Question” in the subject line.

Sanford and Fairview Announce $14 Billion

Merger

Minneapolis based Fairview Health Services and Sioux Fallsbased Sanford Health have recently announced intent to combine and create a new health system. While the plan isn’t yet a binding agreement, the companies say their governing boards have both approved moving forward to organize as an integrated health system, which isn’t expected to be completed until next year. Post-merger, the system would continue to be called Sanford Health and ultimately result in Sanford president and CEO Bill Gassen retaining the same role in the combined system. “Our organizations are united by a shared commitment to advance the health and well being of our communities,” Sanford Health President and CEO Bill Gassen said in a statement. “As a combined system, we can do more to expand access to

complex and highly specialized care, utilize innovative technology, and provide a broader range of virtual services, unlock greater research capabilities and transform the care delivery experience to ensure every patient receives the best care no matter where they live.” This is the second time Sanford Health is working toward a merger with Minneapolis-based Fairview Health Services. A similar deal in 2013 did not occur meeting serious legal challenges from then Minnesota Attorney General Lori Swanson. Since then both organizations have grown considerably and it is unclear if either state or federal resistance will arise. Sanford, based in Sioux Falls, serves more than 1 million patients and 220,000 health plan members across 250,000 square miles. The system encompasses 47 hospitals and 224 primary and specialty clinics. Fairview includes 11 hospitals and more than 80 primary and specialty care clinics. Sanford includes 47,000 employees, while Fairview has 31,000.

Of those, Sanford has 2,800 physicians and advanced practice providers, and Fairview has 3,300. A 1997 affiliation agreement led Fairview to acquire the University of Minnesota Medical Center, and a new joint agreement was reached in 2018 among the university, the University of Minnesota Physicians and Fairview to create the brand M Health Fairview. The three are separate entities, however. Both agreements run through 2026, with an option for an early renewal in 2023, and discussions are underway with the university to talk about what this relationship will look like in the future.

PrairieCare and Newport Health Care Announce Service Integration Agreement

PrairieCare, one of the nation’s largest providers of premier psychiatric services in the Midwest, recently announced it has joined the Newport

Healthcare family of programs. Newport Healthcare was founded in 2008 in Orange County, California as a six-bed facility for adolescent girls. From there they have grown rapidly to include facilities nationwide offering an integrated approach designed to balance the psychological, biological, social, educational, and spiritual needs of teens and young adults, treating the full and extensive range of behavioral health concerns they may face. The leaders of PrairieCare believe that expanding access to a full continuum of care is integral to meeting the increasing demands for mental health care. Newport and PrairieCare are two very highly regarded, well-established mental health treatment providers, united in their values and dedicated to compassionate care. Together, Newport and PrairieCare will provide expanded access to care across a full continuum of services, addressing the needs of a growing number of individuals with mental health issues in

communities throughout Minnesota and beyond. The combined organizations have the capacity to positively impact countless lives, from free initial mental health assessments to residential care programs, partial hospitalization programs (PHPs), intensive outpatient programs (IOPs), inpatient psychiatric hospitals, clinic services, and continuing care programs. PrairieCare will remain as a trusted Minnesota-based psychiatric health system steadfastly committed to providing the highest quality care to patients. PrairieCare operations will continue uninterrupted. Families will continue to receive the personalized psychiatric care they need and the attentive collaboration with patients, families, and clinicians that promote optimal treatment outcomes will not change. Newport Healthcare, which includes Newport Academy, Newport Institute, Center for Families, and the Center for Research and Innovation, provides evidence-based healing centers for teens, young adults, and families struggling with primary mental health issues. Newport offers a family-systems approach with individualized, integrated programs that combine clinical and experiential therapies with academic or career support. They have 53 residential treatment sites and 13 IOP/PHP sites in 15 metro areas and 11 states including Minnesota.

Marshfield and Essentia Explore Merger

Recently, the Marshfield Clinic Health System and Essentia Health signed a written agreement to explore the logistics of forming an integrated health system. The health systems have complementary geographies and capabilities. If combined, the merged health system would include 3,500 providers, 150 care sites and 25 hospitals. Around 1,600 of those providers would come from Marshfield Clinic, along with 11 hospitals and 60 clinics. Essentia, meanwhile, has 70 clinics and 14 hospitals. Brian Potter, senior vice president of finance and chief operating officer for the Wisconsin

Hospital Association, said there are many reasons health care systems merge. “There’s the basic economic reasons of scale and efficiencies and cost savings,” he said. “You can learn from each other. Different systems have different expertise and services. Some may have specialists that the other system had a hard time getting, so now they can coordinate that coverage.” Essentia CEO Dr. David Herman said, “I am truly excited to work together for the benefit of our patients and our colleagues. Through a new partnership, we can support the care models, services, research and technologies to ensure sustainable and thriving rural health care.” Marshfield Clinic CEO Dr. Susan Turney said, “This is an exciting opportunity for both our organizations and those we serve. These are two of the premier health systems in the country, looking to come together to serve rural communities and beyond. When I

MINNESOTA’S MEDICAL CANNABIS

Approved health care practitioners can certify patients for Minnesota’s Medical Cannabis Program, which provides a treatment option for people who are facing debilitating medical conditions.

For more information on how to enroll, qualifying medical conditions, and more, visit mn.gov/medicalcannabis.

O ce of Medical Cannabis 651-201-5598 1-844-879-3381 (toll-free) health.cannabis@state.mn.us

CAPSULES

MDH Creates Chronic Pain Resource Guide

The Minnesota Department of Health (MDH) has recently created a new tool to assist residents statewide who deal with chronic pain. An online resource guide, the NO PAIN MN map, features several services that have been demonstrated to reduce chronic pain and improve quality of life, including psychotherapy, acupuncture, yoga, massage therapy, chiropractic care, and physical therapy. These alternative pain management options can provide treatment with no risk of substance misuse, while improving quality of life. The new resource will make it easier for Minnesotans experiencing chronic pain to find safe, opioid-free treatments, to help with healing, working, socializing and managing daily tasks. Chronic pain can be debilitating and affects about 20% of U.S. adults, according to the CDC. An important goal of treatment for people

experiencing chronic pain is to provide options to help improve quality of life and function. “There are many ways to effectively manage pain that do not rely on opioids, but many people don’t know what those options are or how to access them,” said Minnesota Commissioner of Health Jan Malcolm. “This statewide map is a great step to increase awareness about the safe and effective alternatives that are available in Minnesota.” Directing people to alternative pain management strategies could address the reliance of opioids in Minnesota. Data released earlier this year shows overdose deaths in Minnesota involving opioids increased from 685 deaths in 2020 to 924 deaths in 2021. The website is intended for both health care providers and patients. Providers can find a menu of patient care options and can make referrals to practitioners of non-pharmacological and non-opioid pain management. Patients can locate providers, identify resources for self-management and

discuss treatment options with their medical providers. Each listed service includes contact information, addresses and descriptions so anyone can explore treatment options and contact providers directly. “The listed treatments are evidence-based and found to be effective in reducing chronic pain,” said Jennifer DeCubellis, CEO, Hennepin Healthcare. “This is a useful tool to both patients and providers looking for treatment methods that are safe, reliable and effective for managing pain and healing patients.” Explore the MDH Non-Narcotic Pain Management Mapping and Demonstration Projects page to learn more about resources near you. Visit the NOPAINMN.org to learn more about this mapping project.

Mayo Research Shows AI-Screening Use Improves Cardiac Care

Recent research from the Mayo

Clinic shows artificial intelligence can improve diagnosis and treatment for cardiac patients, but first the AI-enabled clinical tools have to be easily available and used. A study showed that clinicians who were high adopters of an AI-enabled clinical decision support tool were twice as likely to diagnose low left ventricular ejection fraction as low adopters. The study, published in Mayo Clinic Proceedings, found wide variation in the rate of adoption of AI recommendations. Clinicians who were high adopters tended to be less experienced in dealing with patients with complex health issues, but age, gender, years of experience and number of patients cared for were not significant factors. “It was surprising to see the significant difference in the rate of diagnosis between high adopters and low adopters,” says David Rushlow, M.D., a Mayo Clinic physician and chair of Family Medicine for Mayo Clinic in the Midwest. “The tool is extremely helpful, but we did

not expect to see a full doubling of the diagnosis rate of low ejection fraction as compared to low adopters.” Ejection fraction measures the percentage of blood that leaves the heart each time it contracts. Low ejection fraction can be caused by heart muscle weakness, such as cardiomyopathy, as well as heart valve problems, uncontrolled high blood pressure or damage caused by a heart attack. Early diagnosis and treatment in patients with low ejection fraction is critical to reduce the risk of symptomatic heart failure, hospitalization and mortality. “AI decision support tools have the potential to be very effective in aiding the diagnosis of serious health conditions before the onset of usual clinical symptoms, and may outperform traditional diagnostic approaches,” Dr. Rushlow says. Clinicians at 48 Mayo Clinic primary care practices in Minnesota and Wisconsin participated in the randomized controlled trial, which involved 358 physicians, nurse practitioners and physician assistants. “Clinicians who were most likely to follow through with the recommendations of the AI decision aid tended to be less experienced in dealing with complex patients,” says Dr. Rushlow. “This demonstrates the importance of AI systems that integrate seamlessly into the workflows of clinicians. Given the technical nature of AI in health care, it often is initiated and developed in academic specialty practices. To maximize AI’s benefits, more collaboration is needed between specialty practices and primary care.”

Allina Opens New Heart Surgery Center

Allina Health is recently opened Minnesota’s first cardiovascular ambulatory surgery center. Located in the Centennial Lakes Medical Office Building in Edina, the new Allina Health Minneapolis Heart Institute (AHMHI) Surgery Center provides cardiovascular procedures in a convenient, outpatient setting and features two operating rooms equipped with state-of-the-art imaging, diagnostic and interventional

equipment. Physicians from the Allina Health Minneapolis Heart Institute will provide Interventional Cardiology, Electrophysiology and Vascular procedures, including Right Heart Catheterization, Coronary Angiography, Implantable Pacemakers, Endovascular Ablation, and more. “As our population ages, the incidence of cardiovascular disease is growing,” said William Katsiyiannis, president Allina Health Minneapolis Heart Institute. “We are proud to bring this unique offering to the Twin Cities market to provide more access to procedures for the diagnosis and treatment of cardiovascular disease in our community. The AHMHI Surgery Center gives patients another option for their surgical care needs in a high-quality, convenient, outpatient setting.” The AHMHI Surgery Center is grounded in Allina Health’s commitment to significantly expand its ambulatory surgery platform to enable efficient, cost-effective, and high-quality consumer-centric care. Increasing its surgery center offerings is part of Allina Health’s organizational vision of a high value, integrated complex care coordinator for the community. “Our investment in ambulatory surgery centers, which has rapidly grown from one center to nine centers over a short period of time, is part of Allina Health’s larger population health strategy and Whole Way to Better journey,” said Dave Slowinske, senior vice president of Operations at Allina Health. “The Allina Health Minneapolis Heart Institute Surgery Center solidifies our commitment to deliver surgical care in all settings from complex surgery in a major metropolitan hospital to same day surgery in a community-based setting. Providing accessible and affordable care that is closer to home is aligned with our value-based care strategy to lower the total cost of care for our communities while maintaining the superior quality our patients have come to expect when they entrust Allina Health with their health care needs.”

Streamlining Research Access

Per Ostmo, MPA, Rural Health Research Gateway

Please tell us about the mission of the Rural Health Research Gateway.

The Rural Health Research Gateway (Gateway) is a research dissemination program funded by the Health Resources and Services Administration’s Federal Office of Rural Health Policy (FORHP). The primary purpose of Gateway is to share the work of the FORHPfunded Rural Health Research Centers (RHRCs). There are several of these research centers housed within different universities across the United States, each with their own research teams, areas of expertise and websites. Gateway streamlines the process of accessing research by making all research across all RHRCs available in one place.

The Gateway website is a free, searchable online repository for FORHP-funded rural health research. Users can browse research by topic, date, research center and author. Gateway also disseminates research through webinars, exhibiting and presenting at rural health conferences, posting key findings on social media and notifying subscribers when new research is published.

As the program director what does your work entail?

My primary focus is maintaining the Gateway website, ensuring that new research is archived and made easily accessible in a timely manner. When a new publication is added to Gateway, an email notification is sent to our subscribers that includes a brief description of the research, key findings and a direct link to view the full publication. Keeping the Gateway library up-to-date with new research from nine RHRCs and additional policy analysis initiatives requires careful coordination with the research teams.

As a research dissemination program, it is important that research findings are presented in ways that are easily understood by a broad audience. Gateway isn’t just for researchers. Our users include policymakers, educators, public health employees, hospital staff, students and more. Rural Health Research Recaps have been developed by Gateway as a point-of-entry to the

research world. These one-pagers identify key findings from all the RHRCs on specific rural health topics. For example, in the past five years the RHRCs have produced 42 research publications on mental and behavioral health. That’s both impressive and daunting for readers. Our new recap, Rural Mental Health “Rural Mental Health,” is a succinct and easy-to-understand starting point.

Dissemination is also about stakeholder engagement. We want our stakeholders to be wellinformed on critical rural health issues, but we also need to know which issues our stakeholders care about most.

Rural Healthy People Initiative, looking back at key findings from Rural Healthy People 2010 and 2020. At that time, the Rural Healthy People 2030 survey was ongoing, and our audience could choose to complete the survey.

Gateway also exhibits at various rural health conferences to share new research with attendees. The National Rural Health Association’s Annual Meeting is an excellent place to get engaged. At the 2022 Annual Meeting, researchers from the Maine RHRC were presenting early findings from a research project on ambulance deserts. The research lead was discussing how their team currently had data on 44 of the 50 U.S. states, with hopes of acquiring data for the remaining states within the next year. That’s when an audience member spoke up and said, “I can help you get that data.”

We also field questions via phone or email. I frequently hear from students looking for resources, journalists seeking key findings for stories they are working on and from aspiring researchers hoping to begin a career in rural health. If our team can’t answer a question directly, we’ll point you in the right direction.

Please tell us about some of the research projects you and your members are working on now.

Gateway webinars are an opportunity for attendees to engage with researchers directly during the Q&A portion, and these discussions often highlight additional research needs. Last year, the Southwest RHRC presented on the

Each year, FORHP assigns new research projects to the RHRCs. Between the larger research centers and the smaller policy analysis initiatives, we see approximately 40 new research projects per year. All ongoing and completed research projects and their related publications can be viewed on Gateway. The size and scope of projects vary. Some result in single page data briefs while others result in 40-page chartbooks, publications in peer-reviewed journals, case studies, policy briefs or any combination of these final products.

The University of Minnesota RHRC is currently investigating differences in health and health care access for LGBTQ+ adults. One key finding is that rural LGB adults reported the

How do you engage with rural health stakeholders?

Rural for one population may not look the same as rural for a different population. “...”

“...”

highest rates of depression and anxiety disorder diagnoses, as well as the highest levels of depressed feelings, compared with urban LGB and rural and urban heterosexual adults. Rural LGB adults also reported the lowest levels of having their social and emotional needs met.

The Washington, Wyoming, Alaska, Montana and Idaho (WWAMI) RHRC specializes in the health care workforce. WWAMI’s current project examining trends in behavioral health workforce supply in the rural U.S. has found that while the per capita supply of psychiatrists declined over the past decade, the supply of psychologists, psychiatric nurse practitioners, social workers and counselors increased in both rural and urban counties.

What are ways physicians and clinics can utilize your research?

There is a tremendous amount of freely accessible research on Gateway, but not every publication will be relevant to every user. If someone wants to stay up to date on a wide variety of rural health topics, then they should subscribe to Gateway’s research alerts. These emails highlight key findings when new research is published and only take a minute to read.

Other users might prefer a narrower focus. In that case, browsing Gateway by topic is best. DEA waivered physicians may want to browse “opioids.” A study by WWAMI RHRC found that over half of physicians with a 30-patient waiver were not treating any patients with buprenorphine. Psychiatrists might browse “mental and behavioral health.” Research conducted by the Rural and Underserved Health Research Center found that, in 2019, 32.4% of non-metropolitan and 35.7% of metropolitan adults with serious mental illness received no mental health treatment in the prior year. Administrators may be more interested in the topics of “health care financing” and “workforce.” Another study by WWAMI RHRC found that between 2010 and 2016, the nurse practitioner workforce in the U.S. grew at an annual rate of 9.4%, while the overall physician workforce grew at 1.1%.

Gateway makes it easy to find research relevant to any rural health stakeholder. We hope that our users share research with others, cite it for their own research projects, implement findings into practice and get engaged with the rural health research enterprise.

What are ways physicians in out-state areas could contribute to your projects?

I have two recommendations. First, physicians who are interested in getting involved in rural health research should reach out to Gateway. If someone has a particular research topic of interest, then I can help connect them with an RHRC that specializes in that topic. Second, if physicians want to become more “tuned-in” to the general field of rural health, I recommend checking out the Rural Health Information Hub (RHIhub)–another FORHP-funded program. While Gateway is specifically focused on research, RHIhub covers rural health more broadly. Users can find funding opportunities, news stories, a calendar of rural-oriented events and a huge library of resources. Like Gateway, RHIhub is 100% free to use.

What are the biggest challenges facing rural health care delivery today?

Access to health care services is a perennial issue facing rural health. According to the North Carolina RHRC, 183 rural hospitals have closed

Research Access to page 104

Streamlining

since 2005, 140 of which have closed since 2010. Of these 183 closures, 99 have been complete closures, where facilities no longer provide any health care services. 84 have been converted closures, meaning facilities no longer provide in-patient care, but continue to provide some health care services, such as primary care or skilled nursing care.

When a rural hospital closes, the travel burden to receive care increases for that geographic area. The Southwest RHRC examined travel burdens to receive care and found that in 2017, rural residents traveled, on average, more than twice the distance for medical/dental care than urban residents, (urban 8.1 miles one-way; rural 17.8 miles one-way). Rural residents also spent more time in travel (urban, 25.5 minutes one-way; rural, 34.2 minutes one-way).

Telehealth services can help alleviate some of the challenges related to health care access. However, telehealth comes with its own set of challenges. Large swaths of rural America lack broadband internet service. South Carolina’s RHRC found, in 2016, only 61.4% of rural and

78.0% of urban American Indian/Alaska Native households reported having broadband internet service. By comparison, 82.5% of rural and 89.1% of urban non-Hispanic White households reported having broadband.

alternatives to complete closure of a critical access hospital, while long-term care facilities were rated as the least viable alternative. The North Carolina RHRC is also studying Rural Emergency Hospitals, which were established by the Consolidated Appropriations Act of 2021, but it is too early to tell how many rural hospitals might convert to this new designation. Of course, all the various hospital designations have workforce requirements, and it can be difficult to attract new health care professionals to rural areas. We can look to the University of North Dakota and the University of Minnesota Duluth as exemplars in rural training tracks for physicians and other health care professionals.

What are some solutions to these challenges?

The North Carolina RHRC explored alternatives to complete closures by conducting a national survey of critical access hospital executives. Conversion to a Rural Health Clinic, Urgent Care Center or a Federally Qualified Health Center were considered the most viable

Expansion of broadband infrastructure is one possible path toward increased access to health care services, but the existence of infrastructure alone does not guarantee household access. South Carolina RHRC found that income and education level of the household are major predictors of broadband access. When considering telehealth implementation, health care facilities should be cognizant of populations that cannot afford or do not know how to operate a smart device needed for telehealth services.

Since Gateway started in 2007, you have completed over 600 research projects. What were some of the most dramatic findings?

The Rural Health Research Gateway was launched in 2007, but our oldest archived research publication was published in 1996. The RHRC program is even older, having been initiated in 1988. As that program grew, it became more important to have one centralized place to access all the research across all RHRCs. Thus, Gateway was born.

I don’t think I could pinpoint the most dramatic findings coming out of the RHRCs, but there are three general themes that I would like to mention. First, as rural health stakeholders, we should be cognizant of dual disparities in health. Location (living rural vs urban) is only one dimension of analysis. The RHRCs also examine health disparities by race/ethnicity and other social determinants of health. Rural for one population may not look the same as rural for a different population. Second, health care solutions for urban areas do not necessarily work in rural areas. The U.S. is vast and diverse. Accordingly, there are different environmental and cultural factors that influence health status and need. Third, the phrase

“older, sicker, poorer” is often used to describe rural populations. This is unfortunate, because rural populations are also resilient, diverse, generous and community oriented. A more well-rounded view of rural that includes these positive aspects is needed to attract investment in infrastructure and workforce.

With so many publications freely accessible through Gateway, do you have a favorite that you’d like to recommend?

I am particularly enamored with a few publications. First, the University of Minnesota RHRC published a chartbook, in 2020, titled “Rural-Urban Differences among Older Adults.” It examines demographics, socioeconomic characteristics, health care access and use, and health characteristics across rural and urban older adults. Key findings are represented across 44 easily understood charts. When it comes to disseminating research, a simple chart or figure is hard to beat. This chartbook from Minnesota is a masterclass in representing data graphically without being complicated.

Another favorite of mine is a 2019 project from South Carolina’s Rural and Minority Health

Research Center, titled “Social Determinants of Health Among Minority Populations in Rural America.” The project is comprised of four policy briefs examining American Indian/Alaska Native, Asian American/Pacific Islander, African American, and Hispanic populations. This is the research that I would share if someone asked me, “What exactly are social determinants of health?”

Per Ostmo, MPA, is the Program Director of the Rural Health Research Gateway (Gateway) is housed at the Center for Rural Health at the University of North Dakota School of Medicine & Health Sciences. Gateway is funded by the Federal Office of Rural Health Policy (FORHP) to disseminate research conducted by the FORHPfunded Rural Health Research Centers. He earned his Master of Public Administration degree from the University of North Dakota.

manifested is seen in the process of connecting primary and specialty care. While there is no question that this kind of collaboration can create more effective care and ultimately improve the practice of medicine, the pathways to this communication have become more difficult than ever.

Specialty care is sought by primary care providers in situations where assistance is needed to make a diagnosis or develop a treatment plan. It may also be utilized to confirm the diagnosis and ensure the developed plan is optimal for their patient. Most often, the primary care provider will refer a patient to a specialty provider for an evaluation, though sometimes a primary care provider may not be sure a specialty care provider needs to be seen. While it is always better to err on the side of caution, improved methods of communication can not only provide support in decision-making, they can help avoid unnecessary visits to a specialist. Confirmation by a specialist that the plan developed by the primary care doctor builds the level of trust in the physician patient relationship. Sometimes an appointment with a specialist is not possible on a timely basis. Researchers estimate that up to 40% of specialist referrals might be avoidable. Improving communication between primary and specialty care can address these issues, as well as improving both patient relationships and the primary care knowledge base.

Given the challenges of improving communication and the benefits of the resulting improved outcomes there are an emerging number of new tools and approaches that can be utilized to address these issues. One promising example is the electronic consultation or eConsult. Pioneered in 2005 at San Francisco General Hospital and through the San Francisco Health

Network, the idea seemed to produce more efficient and effective care. eConsults are asynchronous exchanges initiated by a primary care provider (PCP) between that provider and a specialist colleague. They differ from synchronous communication such as in-person, video or phone consults. An eConsult can be initiated through a secure HIPPA compliant message that can share lab reports, images and other medical record data. Within three days a response can be received that will provide recommendations.

This model proved so successful that it spread to academic medical centers and to commercial and Medicaid payers.

The Association of American Medical Colleges (AAMC) became one of many organizations to adopt the eConsult concept and quickly became a leading force in addressing the many challenges that eConsults face. By 2014 the AAAMC had launched Project CORE (Coordinating Optimal Referral Experience) to build on the promise of the eConsult and in five years had helped improve patient care for more than 2 million patients. It was during this period that the University of Minnesota Medical School became a participant in and contributor to the project.

Initially, institutions participating in eConsult development saw an 84% increase in timely access to specialty care, avoiding nearly 7,500 unneeded referrals. As the process of fine-tuning the new model evolves, several important benefits are emerging. Patients experience shorter wait times to get a specialist appointment and communication is streamlined. This results in the specialist encounter yielding a higher-value in person visit and leads to better documentation and communication between providers. Though the majority of eConsult visits do not require an in-person specialty visit, when one is necessary the process helps triage patients, improving safety and outcomes.

Another benefit is that, within a specialty practice, the level of subspecialization is increasing. There is often great variation in the knowledge base and expertise between practice members. The eConsult speeds the process of getting an opinion from the doctor most qualified to respond.

How it works

These exchanges use structured templates within the electronic medical record to create a seamless, point-of-care pathway that facilitates highquality coordination and communication between providers. For appropriate questions, which are typically about straightforward and low-acuity issues, eConsults allow for significantly more efficient specialist input and more costeffective care delivery. At any time, a specialist can convert an eConsult to a referral, and patients have the option to request an in-person visit rather than an eConsult. Perhaps the most difficult issue eConsults faces revolves around embedding the option into the electronic medical record (EMR), especially considering the large number of EMR providers and existing compatibility problems. This may entail some customization and IT resources, however the end result is well worth the investment. It’s important to note eConsults are not a way to expedite face-to-face consults or inquire about logistics of care. They’re also not meant for patients who are established within the specialty practice. Additionally, eConsults should not be about issues easily answered by consulting a textbook or clinical guidelines.

This model can optimize the use of specialty care for primary care providers and their patients. This provider-and-patient-centered intervention creates advantages for these stakeholders:

Elevate everyday the

Sanford Health East Interstate Avenue Clinic has doubled down on its commitment to building hope through better mental and behavioral healthcare by reconfiguring three neighboring practices into more accessible, wellness-driven environments that preserve patient dignity. The JLG-designed new Behavioral Health practice gives patients privacy with an exclusive waiting area and entrance while giving providers a place of refuge in the centralized core, open gym, and outdoor courtyard. This is healthcare design that elevates the everyday — bridging the gap between silence and seeking help.

To learn more about JLG, contact Todd Medd, tmedd@jlgarchitects.com or Kristine Sallee, ksallee@jlgarchitects.com

Jargon Oblivion

Working in a hospital setting, we’ve heard examples of when “patient and family-centered rounding” goes well and when it goes poorly, in part, due to this jargon use. Why do health care providers continue to use medical jargon in patient encounters, despite knowing they shouldn’t? Our research team at the University of Minnesota Medical School hypothesized this was largely due to what’s been coined “jargon oblivion.” This concept is that doctors and nurses spend so much time training and being immersed in the medical world they forget which words and phrases are commonly understood by the general public. Medical professionals have invested years in learning the foreign language of medicine, designed to specifically and efficiently communicate with one another, though not intended for communicating with our patients.

Born out of frustration in hearing technical, jargon-filled sentences used at the bedside or in a clinical setting, our research team set out to answer some very clinical questions: What is the lay public’s understanding of common words or phrases typically encountered in medical settings? What about common abbreviations we hear used regularly? What’s their understanding of technical words or disease names—words like afebrile or

myocardial infarction? Do patients understand the medical roles and titles we use when introducing ourselves in a clinic or hospital-based practice?

We began with a literature review, seeking answers to our clinical questions. We found articles that addressed some of those questions, but there were still large gaps in our understanding of the lay public’s knowledge and perceptions about medical jargon. Previous studies reported that technical terminology, abbreviations and acronyms were the most common types of jargon utilized. Some studies were performed in doctor’s offices, some in other medical settings like emergency department waiting areas. However, we felt these could mismeasure the public’s understanding by cherry- picking from a cohort of people already seeking care under a given specialty, resulting in an anchoring bias. There are also context clues present in a medical setting that may point people in one direction or another in terms of an answer.

Seven Deadly Sins

Drs. Mike Pitt and Marissa Hendrickson, two collaborators on our new research project, had previously published on their proposed classification system of medical jargon (“Journal of General Internal Medicine,” 2019, cited with the authors’ permission), which divided jargon into seven categories. They defined technical terminology as words learned in medical school. This would include disease names, tests and anatomical names. Alphabet soup represented acronyms and abbreviations. Examples of these are CBC, NPO, EKG, MI and PCP. Medical vernacular are words that may be familiar to the public, but are not universally understood, for example, sepsis and steroids. TV medical dramas have exposed the public to a lot of these types of terms, without giving them a complete understanding of what they mean. Medicalized English is the category of words which have a well-understood meaning in common usage but often have a different meaning in medicine, sometimes even the exact opposite meaning. This includes words like negative and positive. In most contexts, negative typically indicates something bad, such as negative feedback or negative implications. However, in the medical context, negative typically has the opposite meaning; a negative test result is favorable, implying that you don’t have the disease or condition screened. Other examples would include words like tenderness or phrases like “I don’t appreciate a liver edge.” Unnecessary synonyms are overcomplicated terms used in medicine even though there are readily available alternatives. This includes saying upper extremity instead of arm, or erythematous instead of red, which overcomplicates the message. They defined euphemisms as words or phrases that health care workers might use in trying to make their concept more understandable, when in fact it may open the door to more potential misunderstandings. An example of this would be telling a patient they have bugs in their urine when trying to explain a UTI. Another example would be when a care provider mentions a spot on the lungs when trying to say there’s an unexplained finding on a patient’s chest x-ray. This also applies to times when a physician is trying to lighten the tone of their language, for example substituting died with expired. Finally, judgmental jargon was coined to indicate phrases which may be perceived by the public as derogatory. Doctors may write in their notes about a patient’s chief complaint or document that their patient denies

drug use. In today’s world of OpenNotes, giving patients access to all their medical records, it’s not a stretch to imagine patients reading this in their provider’s notes and becoming angry: “I wasn’t complaining about my back pain,” or “I haven’t been using drugs, why didn’t they believe me?”

Developing the Study

Using this paradigm of different jargon types, we felt the medical literature fell short of testing the public’s knowledge of medical jargon. We sought to answer novel questions with nuanced layers. To do this kind of research, we didn’t need to collect any body fluids, manipulate test tubes on a benchtop or even collect any protected health information (PHI). We needed to survey the lay public, but how to go about it while avoiding the anchoring bias of prior studies? We opted to conduct our surveys at the Minnesota State Fair, where we’d be more likely to get a cross-sectional look at the Minnesota public. By 2019, attendance at the state fair reached a record high, making it the highest per capita attendance of any state fair in the U.S., with approximately 20% of the state’s population in attendance.

The University of Minnesota operates its Driven to Discover (D2D) research building throughout the run of the state fair and allows selected projects to be conducted there with a voluntary audience. The building sees foot traffic across a typical year’s 12-day fair of about 60,000 people, with over 20,000 enrolling in various research projects pre-pandemic. This provided

us a forum to engage with the Minnesota public, and some of the necessary tools, for example, tables, chairs and iPads. First, we formed a team to develop our research questions, including alignment with a UMN statistician. We next embarked on some self-learning in how to design effective research surveys. We designed our anonymous surveys, using a combination of multiple-choice questions and fill-in-the-blanks, allowing both quantitative and qualitative analysis. We laid out our intended research protocols and applied to the UMN Institutional Review Board (IRB), obtaining their exemption that this did not fall under formal human subject research. Applying for a small grant enabled funding for our limited expenses, primarily covering the cost of our giveaways and research costs, totaling just a few thousand dollars. Before performing our study at the fair, we opted to break up our larger survey into three smaller ones to keep volunteer participant time down to a maximum of five to ten minutes. We also adapted the survey to an electronic tool, REDCap, which enabled us to collect data via the D2D iPads. This platform also stored the de-identified information for later analysis.

Results and Takeaways

Ultimately, we found many interesting findings, some of which have already been published and others which are still getting drafted for submission.

and Medical Jargon to page 164

People had the misconception that an occult infection had something to do with witchcraft.

Patients

One of our biggest takeaways is that the public remains confused by many of the medical roles, ranks and specialty names commonly discussed with patients in medical settings (“Journal of Hospital Medicine,” Sept. 2022).

Twelve percent of our sampled public could place physicians in the correct order of their medical ranks: medical student, intern, senior resident, fellow, and attending. Most (44%) believed the senior resident is the most experienced; only 27% placed the attending there. The public also lacks understanding of many medical specialty names.

We asked participants to answer questions like: “Pulmonologists are doctors who take of what.”

The least understood four fields were nephrologist (20%), internist (21%), intensivist (29%), and hospitalist (31%). Our qualitative analysis of the free-text responses also uncovered some fascinating misconceptions. For example, four percent of respondents thought that a nephrologist is a doctor specializing in death.

The top five most understood fields we surveyed in our study (which was not inclusive of all medical specialties) included: dermatologist (94%), cardiologist (93%) and a tie between pediatrician (89%), neurologist (89%) and gastroenterologist (89%).

We futhermore found most participants knew that “negative cancer screening” results meant they did not have cancer, but fewer people

understood that the phrase “your tumor is progressing” was bad news or that “positive lymph nodes” meant the cancer had spread. Our representative sampling found the public did not understand the words afebrile, NPO, or occult infection. In fact, more people had the misconception that an occult infection had something to do with witchcraft than correctly understood it implied a hidden infection in their bodies. More participants understood “Your blood test showed me that you do not have an infection in your blood” than those who were told “Your blood culture was negative.” Most understood that an unremarkable chest x-ray was a good thing, but much fewer knew that a clinician describing a finding in their chest x-ray as “impressive” was generally bad news.

We also learned some interesting things about conducting this type of survey research about jargon. We learned that the people at the state fair who were willing to participate in jargon-based research were generally older, more educated and female-predominant. This presumably represented those who were more willing to step away from the food, shopping and entertainment at the state fair to take a survey to enhance medical knowledge. If anything, we measured a group that was more likely less than a perfect cross section of the public to answer correctly about our surveyed medical terms and phrases. That said, this method of surveying the public at a state fair was a statistically reasonable means of sampling the public’s knowledge and was an efficient way to enroll a high number of study participants over a short time period. We screened out any would-be participants who were less than 18 years old and anyone who had personal medical or nursing training. Just like a sampling of the public, people had variable personal experience with the medical system or with family members in healthcare or allied health fields.

Our research team hopes that a medical audience will take away some key lessons. We advocate for physicians to describe their role to their patients in addition to saying the name of their medical specialty. In place of saying, “I’m an Internist” and assuming that patients understand that word, instead introduce yourself as “an internist, a doctor who cares for all general needs for adult patients.” Instead of telling patients, “Your blood culture was negative,” avoid jargon and insert emotion words to help people understand better: “I’m glad to see your blood culture did not grow bacteria.” Avoid leading questions, like “Do you have any questions?” which asks a binary yes/no question. People may feel pressure to say what they think we want to hear, “No.” Instead, substitute: “What questions do you have?” This is a more open-ended question, which implies that we assume they do have questions and we’re ready and willing to answer them. We hope to continue our research into physician-patient potential communication pitfalls and better ways to get our messages across our patients.

Emily Hause, MD, is a pediatric rheumatology fellow at the University of Minnesota. She is also known as “a pediatrician training to be a specialist in joints and conditions of body inflammation”.

Jordan Marmet, MD, is a pediatric hospitalist (aka “a hospital-based pediatrician”) and associate professor of pediatrics at the University of Minnesota.

We opted to conduct our surveys at the Minnesota State Fair.

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The Mental Health Collaboration Hub

Improving hospital bed

BY TODD ARCHBOLD, LSW, MBA

access

Several recent news articles have highlighted the mental health crisis in our state—where children and youth are boarded in emergency departments while they await appropriate treatment in inpatient facilities and/or safe living environments. One Minneapolisbased hospital system reported as many as 20 children are boarding in its hospital emergency departments or pediatric units while awaiting inpatient beds where they could receive the more specialized care they require. This hospital, which would normally experience one or two children per month brought in for mental health reasons, ended up resorting to developing a makeshift holding unit in an ambulance bay when they had taken in nearly 145 children over a nine-month period between September 2021 and May 2022. Most of these children stayed approximately 15 days while awaiting treatment, though one had boarded 97 days. In addition to costing the state a tremendous amount of money for having children and youth in inappropriate and costly settings for prolonged periods of time, there is also concern that these prolonged stays will have devastating longterm effects on young people and may impact willingness to seek treatment in the future.

In response to the boarding crisis, the Metro Health and Medical Preparedness Coalition, in partnership with AspireMN, launched a Children’s Mental Health Services Coordination pilot in August 2022. They invited key community stakeholders to attend bi-weekly video calls to monitor communitybased services for children and facilitate the sharing of information between health systems and mental health providers. In the state of Minnesota, there are over 800 beds for mental health treatment and substance use disorders for youth. Over 200 of these beds are in hospital settings, and over 600 are for longerterm residential care. Nearly 80% of the hospital beds are in the metro area, specializing in treating acute conditions or those in crisis. Interestingly, only 27% of the longer-term care beds are located in the metro area. Unfortunately, accessing the right kind of bed at the right time has proven challenging and has been a major contributor to boarding situations.

Understanding the variety of mental health treatment programs that exist and the changing criteria for admission are two of the most common problems in making a successful referral. For example, some facilities are only licensed to treat certain ages, conditions, and even genders. Others may lack capabilities of treating more complex conditions such as medical comorbidities, eating disorders, or co-occurring substance use disorders. The vast majority of youth in boarding situations are described as being aggressive, which can be a trigger for a declined admission. Understanding the nuance and reason for aggressive behaviors is important for successful placement and to avoid running into barriers. An isolated incident of aggressive behavior or aggression toward a specific person (e.g., parent or caretaker) is very different than chronic general aggression. Understanding the reason behind these behaviors is critical, and misunderstanding them can lead to exclusion from a treatment center. Lastly, most treatment centers have limitations on the acuity of cases that change based upon staffing and current patient population or milieu. This wide gap in understanding the landscape of mental health treatment settings needs to be eliminated. This is where technology and open communication can help.

A New Partnership

Leaders within this pilot project stakeholder group have partnered with the Psychiatric Assistance Line (PAL) to develop an online Mental Health Collaboration Hub (MHCH) so hospitals and mental health providers across the state can connect 24/7 in real-time to help individuals get out of boarding situation and into safe therapeutic treatment settings. The MHCH matches cases of youth boarded in hospitals, emergency departments or any other inappropriate setting to a safe mental health treatment provider who can meet their needs. Both parties (i.e., hospitals and mental health providers) have profiles in the hub that allow collaborators to better understand their care settings and exchange key contact information. When an individual is either in a boarding situation or an anticipated boarding situation, the case is submitted in real-time to the hub. Once submitted, the case appears on a centralized dashboard for registered users to view, and the treatment centers that are a good fit and have capacity are notified. The information is de-identified and

shows only pertinent data required for admission criteria. The system also ensures consistency of semantics and what information is collected. For example, if the case is reportedly aggressive, the system will ensure the nuance of that is captured in a meaningful and objective way for assessment. A case can be reviewed and accepted by any of the treatment centers, and the hub then facilitates real-time exchange of information through messaging and secure records exchange facilitated directly between the providers.

In addition to the case submission hub, a core component of MHCH is to continue to catalyze ongoing live discussion between providers to nourish relationships and monitor trends. For example, changes in staffing patterns, licensure and even patient acuity can be discussed in advance, and often troubleshooting between partners can occur. Providers can also use this time for anonymized case review and workshops as a part of professional development. The mantra adopted by this team is “Getting to yes!”

Making Connections

Another incredibly valuable component to the MHCH is the automated tracking of cases on an aggregated level. While some health systems track their own data via electronic health record or manualized reporting (especially during the last two years), the cases that are most often reported in the media are the extreme outliers. They sway the narrative and can lead to a misrepresentation of the majority of boarding cases. The MHCH will track key components of every case, the barriers that exist and the eventual care pathway. For example, we will better understand the most common boarding cases themselves. We will monitor and track ages, genders, diagnosis and locations. In addition, we will better understand the precipitating events

that resulted in a boarding situation and the desired treatment setting. From there, we can determine which treatment settings are in the highest demand or have the most barriers in accessing them. By grouping case profiles, we will better understand what the most successful placements have been and what to expect in the referral process. For example, a 14-year-old with a major depressive disorder and a suicide attempt may most often need an acute care hospital bed and should expect to wait three days for admission. Or a nine-year-old female with autism and aggression towards caregivers may need a group home and likely wait 45 days for placement. This data will help us better design our mental health systems and care pathways connecting children and youth to care faster and even work towards preventing the situations from occurring at all. This is data which does not exist in an aggregated way between providers today.

The work of the MHCH focuses on the following objectives:

• L everage an online portal to track and monitor cases of children and adolescents boarding in hospitals and emergency departments.

• I nteract across the state in real-time to facilitate prompt review of cases.

• Through ongoing data collection, identify trends and opportunities to improve access to care for children and adolescents experiencing crisis.

The MHCH exists in an online virtual environment that leverages a secure portal and regular video calls. The online portal is a tool to help facilitate information exchange, and the live facilitation of the

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The Mental Health Collaboration Hub from page 19

meetings is critical in connecting providers with the primary goal of reducing the number of children and adolescents boarding in hospitals and emergency departments. The meetings can identify optimal care pathways in real-time.

Through the use of this online portal and ongoing communication between hospitals and mental health treatment settings, Minnesota will be better able to monitor trends in boarding as well as identify opportunities for improving access to care. We will be better able to understand if there are key characteristics in children and youth who are waiting extended periods of time for care (i.e., aggression, co-occurring developmental concerns, etc.) and then use those findings to help advocate for increased availability of treatment services in the community. The work of the pilot team is ongoing, and the full online Mental Health Collaboration Hub will be launched in early 2023 and accessible to all health care providers in Minnesota.

Building a Stronger System

Mental illness is real, it is common, and it is treatable. More people today are facing challenges with their mental health, yet less than half of those with a diagnosable condition will receive treatment. This disparity is much greater for those underrepresented communities where the social determinants of

health often have an amplified impact. Our mental health system has been shaky, fragmented and largely unbuilt for decades. Rates of suicide have been increasing since the early 2000’s, record numbers of individuals are boarding in hospitals and emergency rooms and a majority of parents report concern about their children’s mental health. It is well-documented that the pandemic has exacerbated these problems, introducing new levels of angst into family systems combined with added barriers to accessing care. One of the most notable trends in the treatment setting is the increased prevalence of trauma—adding complexity and the need for longer-term— and often deep psychological healing. The study of adverse childhood events (ACEs) is robust, and the disruptions of the COVID19 pandemic exacerbated concerns about youth mental health and suicidal behavior. The most significant events are changes in economic stability and parental relationships or divorce.

The rate of individuals in psychiatric crisis boarding in hospitals and emergency departments has increased sharply in recent years. Emergency departments have become the most common entry point for those in crisis, and that number has grown by nearly 40% in the last 20 years, even more for youth. The most common medical reasons for an ED visit are chest pains,

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The Mental Health Collaboration Hub to page

Cases that are most often reported in the media are the extreme outliers.

Value-based Reimbursement

A rural health perspective

BY TERRY J. HILL, MPH

Dr. Don Berwick, head of the Institute of Health Improvement (IHI) in 2008, coined the term, Triple Aim. He proposed American health care reform based on:

• Better patient care.

• Improved community health.

• Smarter spending.

To achieve these three goals, a new type of payment system was designed within the Center for Medicare and Medicaid Services (CMS), based on value rather than the traditional payment for medical procedures.

The pay for procedures reimbursement system that emerged from the passage of Medicare and Medicaid in the 1960s resulted in American health care cost increasing at a rate far exceeding general inflation and resulting in American health care becoming far more expensive than any other country in the Western World. Unfortunately, the high costs did not result in better quality, as the United States consistently ranked low in the World Health Association’s annual quality ranking.

A basic problem was that a payment system designed on payment for procedures, without an accompanying reward or penalty for quality, often led to overproduction, waste, inadequate care coordination and quality breakdowns. With the DRG system that emerged in the 1970s as a method of containing health cost inflation, providers of excellent care were paid the same as providers of substandard care, and duplicate tests and medical procedures became common. It was not until 2017 that most physicians were placed into a modest type of pay for performance system called the Merit-Based Incentive Payment System (MIPS). This, however, did not include rural physicians who were doing a minimal number of medical procedures in their practice.

In 2010, the Balanced Budget Act was passed, and within its provisions was the authorization of a new type of value-based payment model: the Accountable Care Organization (ACO). The ACO was designed to move Medicare payments into a shared savings model, thereby giving providers an incentive to contain medical costs. In this model, hospitals and physicians took on the responsibility of providing comprehensive care to an assigned group of Medicare patients—5,000 patients being a minimum number in each ACO. Patients were assigned to the primary care physician who have provided them the most care during the previous year. The providers continued to be paid under the normal fee for service schedule, but CMS built in financial incentives to lower the cost of over-all patient care. If the hospital or organization of physicians could lower the total cost of care for the assigned group of Medicare patients during the program year, then the total savings would be divided equally between CMS and the hospital and/ or group of physicians in the ACO.

For example, if a hospital and its physicians took on responsibility for the cost and care of 5,000 Medicare patients, with their total cost to Medicare the previous year being $50,000,000, and during the subsequent year, the total cost of care for these patients was $48,000,000, there would be a total savings of $2,000,000. If that hospital and physicians met certain quality measures during the year, the savings would be divided equally between Medicare and the hospital, producing a bonus check of $1,000,000. If the cost of caring for these patients was higher than $50,000,000, initially there was no penalty; however, recently the new ACOs have incorporated financial penalties into the payment formula and have placed hospitals and providers in what is termed a “risk” situation. In other words, if they don’t save money but rather cost Medicare more money, these ACOs can be fined an additional amount at the end of the program year. This, as may be expected, is particularly threatening to small rural hospitals with limited cash reserves.

The number and size of ACOs have grown steadily since their introduction in the early years of the previous decade. Today, ACOs cover over a third of the entire Medicare population, and CMS has announced a goal of getting all Medicare payments into some type of value-based models in the next few years. Through three U.S. presidential administrations and multiple directors, CMS’s commitment to value-based payment has not

waivered. In addition, many state Medicaid programs have moved into their own forms of ACOs, and private insurance providers appear to be initiating value-payment programs as well.

Rural hospitals and clinics generally lack the necessary 5,000 Medicare patients, so multiple rural hospitals and clinics have had to come together into ACO partnerships to gain necessary volume, share costs and to acquire needed ACO expertise. For example, ACOs need to be able to access comprehensive patient information and employ experts to both manage and interpret the data. They also need education on how best to implement the new model, as well as how to set up care coordination and wellness programs.

ACO Critical Success Factors

There is a growing body of ACO knowledge based on evaluation and the experiences of ACO leaders during the past decade. The following are critical success factors generated by more than a dozen ACO leaders and evaluators.

Rural hospitals and clinics have often outperformed their urban counterparts regarding both quality and cost.

The largest ACO in America, Caravan Health, started as a small group of rural hospitals, but has grown to include hundreds of hospitals and clinics throughout the country. Caravan leaders report that rural hospitals and clinics have often outperformed their urban counterparts regarding both quality and cost. Being small is usually a liability in payment models, but when motivated, small health care organizations can change their processes and culture faster than large institutions. Since a great deal of ACO success depends on primary care physician referrals, rural ACO organizations also have an advantage with primary care physicians at the core of their medical staffs. Consequently, rural ACOs have often been able to achieve institutional

It is important to complete a comprehensive assessment of an organization’s readiness and capacity to deliver value-based care. For hospitals, the education of boards, leadership and medical staffs should be an important priority. After the initial exploration is completed, potential ACO leaders should then develop a strategic plan that lays out, on a step-by-step basis, the initiatives and resources necessary to achieve success. The transition to eventually having all an organization’s payment being based on value will require a transformation in both culture and service delivery. Culture change takes years to accomplish, so being realistic about a transition timeframe is advised. It’s going to take time and enlightened leadership.

Physicians have the greatest impact on ACO success or failure. They have the most influence with their patients, and their referrals and advice will represent the best opportunity for ACO cost savings. All too often in the past, hospital leaders have failed to sufficiently engage physicians in the early stages of ACO formation.

Value-based Reimbursement to page 244

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3 Value-based Reimbursement from page 23

Physicians brought in after initial decisions have been made has undermined the buy-in of the ACO’s most crucial players. Physician employment, ACO leaders have learned, does not necessarily ensure physician engagement. The necessity of educating and engaging medical providers in the earliest stages of planning and development, therefore, has been a painful lesson learned for many ACOs.

One of the primary benefits of ACO participation has been gaining access to comprehensive Medicare patient data. For the first time, providers can see the complete picture of their Medicare patients’ medical experiences during the previous year. A physician might learn, for example, that a patient to whom he or she prescribed an opioid medication received similar prescriptions from a half dozen other clinics. ACO leaders can also access information on the cost and quality of care provided by skilled nursing facilities, rehab centers, mental health providers and various other medical providers. And hospitals can gain information as to how many patients (and how much money) are leaving the local service area for services available locally. Given the importance of this information, it’s imperative that ACOs invest in sophisticated information systems that can manage the data, analyze the data content and issue reports that enable the ACO leaders and providers to make the data actionable.

At the heart of the value-based models are care-coordination teams, wellness initiatives and chronic illness management. These all become strategic priorities, as a shift is made from reimbursement for sickness care to achieving financial rewards for a more holistic version of health care. For rural hospitals, services such as home care, often deemed unaffordable due to care providers traveling great distances, can now be implemented, resulting not only in better care for the patient, but also a wise financial investment for the ACO. In other words, managing chronic illnesses today prevents expensive emergency and hospital care tomorrow. Since saving money, while still providing excellent patient care, are two of the three goals of valuebased payment models, the ACO, the providers and the patients benefit.

When the inter-organizational changes have been made—education completed, patient care processes redesigned, wellness programs initiated, care coordination teams in place, patient information systems operating— it’ll be important to turn the emphasis of value-based programs outward toward the third goal of the Triple Aim: improving the health of the entire community. This can best be accomplished by assessing community needs and then working in partnership with the community to address the highest priority health needs. Even the most outstanding clinical care cannot, by

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Physicians have the greatest impact on ACO success or failure.

itself, produce healthy people. The social indicators of health—poverty, lifestyle, nutrition, housing, addiction, hunger, etc.—play an even bigger role in a person’s health than does access to clinical services. A larger scope of attention is necessary, and care coordination must expand from the hospital and clinic out to the entire community. This new initiative is often termed “community care coordination”, and it grows to include emergency care, primary care, acute care, rehab, long term care, mental health and home care providers all working together in an unduplicated care continuum. In addition, social service agencies, public health, aging service providers, businesses, schools and even churches are enlisted to play a role in the community-wide effort to improve the health of local citizens.

While this transition to community health care coordination may, at first glance, seem impractical and unaffordable, in many rural communities this transition to value and population health is already taking place. An accountable care organization of rural hospitals in Michigan, for example, has placed its primary strategic focus on population health improvement, and has hired a health coordinator to help it address the social indicators of health in its region. Rural hospitals throughout the country are working with schools, and many have established primary care or mental health clinics within the schools. Others have developed nutrition programs for hungry children, and still others have made investments in housing for the homeless. Small size has enabled many of these rural hospitals and clinics to more rapidly establish community partnerships and, in the process, enhance community trust and loyalty.

Conclusion

Hospitals and clinics participating in value-based payment models have brought a new energy and badly needed resources to population health improvement initiatives. In rural communities across the country, hospitals have assumed an important new role that is consistent with their mission statements. In addition, the quality of clinical care has been improved and, in most cases, access to services has been expanded. Emphasis has been placed on prevention and chronic illness management, and transitions of care have been improved. Finally, the overall cost of care for the Medicare patients has in many cases been reduced through better patient management and wiser spending. For these reasons, value-based payment models hold great promise. Myriad problems, however, remain to be addressed in virtually all these payment models (too many to be fully addressed here), and hundreds of hospitals and clinics have been unsuccessful in their transition to value. Physicians, as earlier noted, have frequently been left out of initial planning and decision-making processes, even though they are key players in these initiatives. Still, the goals articulated by Dr. Don Berwick in his Triple Aim are worthy of pursuing, and value-based payment models may well be the best method of achieving them.

Terry J. Hill, MPA, is the executive director at Rural Health Innovations. He also serves as senior advisor for Rural Health Leadership and Policy at the National Rural Health Resource Center.

• Patients: Improved access to care, greater convenience, and fewer unnecessary visits, tests and out-of-pocket costs.

• Primary care physicians: Timely access to specialty input, clearer roles in patient co-management, and improved continuity and comprehensiveness of care for patients.

• Specialist physicians: Structured approach to consults and referrals, improved access for high-acuity patients and new patients, and more efficient referrals.

• L eadership: Improved quality, reduced costs, improved access in high demand specialties, opportunity to extend referral network, increased provider alignment, better position for negotiations with payers, and improved patient and provider satisfaction.

• Payers: Reduced referrals and associated costs and improved access for beneficiaries.

To date, there is significant variation nationwide in terms of approaches to eConsult implementation and management. There are also a range of issues pertaining to reimbursement. The recent establishment of CPT codes by CMS is a promising step toward easier industry-wide access-from large systems such as the Mayo or VA to small rural clinics. As the volume of

data grows from an expanding variety of users it is clear that eConsults are improving outcomes and reducing costs. Primary care physicians, specialty care physicians and patients all report a high level of satisfaction.

Care Maps

Care maps is a generic term and can be used in several ways. Care maps can be developed for nursing applications, for direct use by patients, either discharged from a hospital or with chronic conditions, and more. Specific to physician use, they represent another effective method to enhance PCP/Specialty communications and deliver the best quality care. They are a relatively simple but innovative tool and were originally developed around six common diseases Sometimes called a care pathway, they incorporate several elements, such as evidence-based medicine guidelines, standard workflows, disease management and reduction of gaps in care in order to support consistency of care for patients. Care maps were designed to efficiently and effectively improve quality of care, reduce total cost of care and improve patient experience. They provide a valuable resource for knowing when to initiate contact with specialty care and take into account the variation of health care provider knowledge and experience.

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Care maps are generated by a collaborative group of stakeholders, including primary care and specialist providers, quality experts, and information technology specialists. They are designed to review the clinical data associated with a patient and make recommendations on patient care with respect to characteristics related to the patient. Once a diagnosis has been made, an appropriate care map can be embedded into the medical record. These maps should be simple to follow, short and user-friendly.

For example, a care map has been developed that improves referral and recognition of chronic kidney disease. While chronic k idney disease (CKD) is fairly prevalent, we aim to identify those patients at highest risk for progression using a risk calculator and prioritize early referral for this population. We aim to improve the care of CKD patients through collaboration. We have designed a provider alert which will prompt providers to acknowledge a decreased glomerular filtration rate and document a diagnosis of CKD. Appropriate diagnosis will then afford the opportunity to use a smartest, which prompts referral criteria, labs, and medications that may be appropriate for CKD. Within health maintenance, regular lab work will be ordered based on “Kidney Disease Improving Global Outcomes” guidelines for CKD 3, 4 and 5 patients.

In some cases, patients are not referred to nephrology for early education and possible intervention. We aim to partner with primary care to increase awareness of CKD with the goal of slowing progression of CKD and avoiding acute kidney injury episodes. Improved referral processes and protocols can accommodate patients and optimize the opportunities for early interventions.

Studies of results from care map utilization that include quality of care improvement and provider use satisfaction are in early evaluation stages, however initial research indicates they are an effective tool. Further research is underway to expand the range and use of care maps, which, beyond enhancing PCP/Specialty communication, will consider how they can lower morbidity, mortality, readmission rates, and more.

Next steps

The need for communication between primary and specialty care is a critical part of health care delivery and one with ongoing challenges. The key to successfully addressing them is in working together. We must all share responsibility for identifying the areas that are most ripe for standardized improvements and then implement them.

Considering the challenges of coordinating physician schedules to allow time to review patient data, it is important to develop new solutions to meet these needs. These solutions must be timely, accurate and available to every physician and patient, regardless of location or employment status.

Not only will this improve outcomes and lower costs, it will lead to better professional camaraderie and improved physician job satisfaction. When we can lower the barriers and streamline the process of sharing knowledge, everyone wins.

Elizabeth Seaquist, MD, is the chair of the Department of Medicine at the University of Minnesota Medical School and an endocrinologist practicing at M Health Fairview.

Primary Care

We are an independent physician-owned multi-specialty practice with 180 providers located across 13 sites, and-state-of-the-art facilities. Recently voted one of the 14 coolest urban spaces in America, Mankato is a short drive from the metro with abundant nearby recreation opportunities, safe, charming and affordable neighborhoods, outstanding schools and a thriving arts community.

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contusions, infections and broken bones, most of which can be addressed immediately with a clear plan for follow-up care. According to the CDC, nearly 2.3% of all ED visits result in a transfer, yet in the case of a psychiatric crisis, independent studies have shown it is closer to 15%. The odds of a psychiatric patient waiting for care in an ED are nearly 5 times greater than for any other health condition – oftentimes resulting in days in an ED awaiting the appropriate care for their condition. The wait time to access psychiatric care can range from several hours to several days. A robust study conducted in 2014 showed that over 40% of psychiatric ED visits resulted in discharge, presumably without any meaningful treatment other than ad hoc medication administration and outpatient referrals, which are rarely followed up upon.

In addition to triaging an increasing number of individuals in psychiatric crisis, hospitals are now finding themselves housing children with severe behavioral problems or chronic conditions, such as autism and developmental delays, for months at a time. Much-needed access to group homes, foster care settings and residential treatment settings has proven difficult, and at times impossible, for severe cases

We have all the tools, components and intelligence we need to build a strong mental health system. Solving these problems requires creativity, cooperation, humility among providers and a strong sense of grit. PrairieCare is the region’s largest provider of youth psychiatric services and is currently undergoing a 40% expansion to its inpatient service. They recently joined the Newport Healthcare family of mental health services to expand its

continuum-of-care with a national platform, making PrairieCare and Newport the nation’s largest provider of specialized mental health services for youth and young adults. The health system has also partnered with Children’s Minnesota to launch a new 22-bed inpatient mental health unit that is among just a few in the nation to treat children with complex medical needs, while allowing parents to stay the night. The Minnesota Department of Human Services has also re-tooled the psychiatric residential treatment facility (PRTF) model. The changes break down both licensing and financial barriers that have plagued growth of this critical service in Minnesota.

The statewide Psychiatric Assistance Line (PAL) provides thousands of free consultations and trainings to medical professionals for better care of mental health conditions in the primary care setting. This model has garnered recognition locally by the Minnesota Hospital Association and on a national level by the American Psychiatric Association. The service is supported by grant funding from the MN Department of Human Services and the MN Department of Health. This is a unique and effective partnership between the provider community and state administration.

A robust and effective mental health system can be built when we work together across care settings. In this context, the term care setting must be expanded to include not only hospitals and mental health treatment settings, but also services from counties, the state, social services and more. We are stronger together

Todd Archbold, LSW, MBA, is the chief executive officer at PrairieCare.

Some physicians rely on Nura for assistance pinpointing the cause of the pain. Some look to us for specific treatments, while others turn to Nura for total pain management of complex cases. In every case, our message is the same: We’re here for the long-term, with the resources and commitment to make a genuine difference in the lives of patients.

Sofia Lyford-Pike, MD