Preparing Nurses for Accountable Care Organizations

Worth every penny

Regular readers know that the Disease Management Care Blog has an abiding respect for nurses. It can't help it. The DMCB has watched these health care providers comfort the ill, prompt overconfident physicians to reconsider, help families, save lives and be the only source of human warmth in hospital suites swarming with expertise, technology and blood.  Little wonder, then, that the DMCB has imbued these professionals with almost mystical organizational powers that can achieve any statistically significant outcome, fulfill any level of patient satisfaction and reduce any projected cost.  They, thinks the DMCB, are the mortar that holds the system's bricks together.

So, when the Feds came up with the star-crossed concept of the "Accountable Care Organization" (ACO), the DMCB assumed that the omnipotent nurses would come to their rescue.  Yet, while that's generally true, ACO wannabes may want to check out a more disciplined examination of the topic with this succinct three page Milliman Briefing Paper appropriately titled "The Nurse's Role in Accountable Care."

Basically, it's not going to be a matter of hiring some nurses and telling them to be accountable, caring or organizational. The nurses assigned to care coordination, disease management, coaching, outreach and transition planning are going to need to step beyond a traditional focus on the individual patient and acquire skills in communication, informatics, problem solving and helping patients across a "range of resources and entities."  They'll need to be comfortable with change management, data analyses and teaming.  Not only will the right individuals need to be assigned these tasks, organizations will need to carefully invest in their professional development.

The DMCB wholeheartedly agrees. That's because the training described above is exactly what is used for years by the population health and disease management companies for their new hires.

fiction: tabloid inspired

A couple of weeks ago, the homework for my writing class was to take a headline from a tabloid and use it as a jumping off point for a more serious short story or poem. I was uninspired by the headlines in my grocery star tabloids ("Brad Gives Angie Ultimatum!" "Jennifer Lopez Fights Eating Disorder!" "Larry King Marries Again!") and decided to go to that old standby - the now sadly defunct Weekly World News. I stole a legendary headline from them. The monologue that follows is all my own.

"Bat Boy Found in West Virginia Cave!" by Bill Creighton, Weekly World News, June 23, 1992

I blame the doctor.

I wanted a baby so badly. The other doctors I'd seen wouldn't help me, so I sought this one out. The office was in a bad part of town and it was dark and smelled a bit funny but he didn't ask me many questions. He said he would help me get pregnant.

And he did. I don't know what the shots were for or what was in the medicine he gave me to drink but I didn't care. I would soon have my baby.

It wasn't a difficult pregnancy. I didn't get too sick. The last few months were hard when I had trouble sleeping but that was it, really. It would have been more fun if there had been someone – anyone - in my life to share in my excitement, throw me a baby shower or help me set up the nursery. But I didn't mind so much. Soon I would have a baby to love. I wouldn't need anyone else.

He was born right on his due date and, from the first, I could tell something was wrong. The first time I held him in my arms I felt not love but revulsion. This was not the child I was meant to have. He was not my baby.

In those first few months he cried a lot. I made sure that he was fed and his diapers were dry but for the most part, I left him in his crib. He was safe there and I did not have to look at him.

As he got older, I continued to cringe at his touch. When he tried to crawl in my lap, I would push him away. When he cried, I left him to it. No one could say that I did not take good care of him. He had food and clothes, I even bought him books and toys. But nothing could make me love him.

I don't feel too guilty about that because it soon became clear that he was a bad kid. The first time he got into trouble in school, I went in to meet with the his teacher. After that, I didn't bother answering her notes or phone calls. If he couldn't get along with the other kids there was really nothing I could do.

The first time he ran away, I called around to the neighbours. The second time, I left the door unlocked so he could come in when he decided to come home. The third time, I locked it.

The first time he was arrested, I went down to the police station right away. The second time, I let him spend the night in jail. The third time – I decided he was the state's problem not mine.

A short time after that, he stole a car from the school parking lot. I haven't heard from him since. This morning I got a call. He was found hiding in a cave in West Virginia. They want me to come to him. But what would be the point?

That child, that particular child, was a mistake. He should never have been born.

I am sad, though. I do feel a loss – not for that child but for the baby I might have had. The mother I might have been.

Maybe I should try again.

This time, I'll go to a different doctor.

Neither the Republicans Nor the Democrats Want to Face the Provider Cost Problem But Both Want to Dump the Problem on the Consumer

A key piece of Paul Ryan’s deficit reduction plan is to change Medicare as we know it. It appears his bold Medicare premium support proposal is failing to gain traction--it is dead as part of any deficit reduction deal this year. Worse, his Medicare proposal looks to be giving Democrats lots of political ammunition for the 2012 elections.What lies at the heart of Ryan’s Medicare difficulties is

Asthma Rates Are Going Up. Time to Think About Other Approaches to Care

Peak Flow Meter

According to the CDC's Morbidity and Mortality Report (MMWR), the prevalence of asthma in the United States has increased from 7.3% (20.3 million persons) in 2001 to 8.2% (24.6 million persons) in 2009.  Just over half of these individuals (52.6%) have had at least one asthma attack, and of these, 42% (or 4.6 million) have lost a day of school or work in the course of a year.  Of all persons with asthma, only 42% have been taught to use a peak flow meter and only 34% have an action plan.

This is important because widely accepted asthma treatment guidelines recommend that a peak flow meter be made available to patients with asthma so that they can detect subtle changes in air flow which could herald an asthma attack.  In addition, a written asthma "action plan" should be prepared so that patients with asthma know what to do if their symptoms spiral out of control.  Those are two key interventions that could significantly reduce the huge number of school and work days lost described above.

Unsurprisingly, the MMWR report ignores all that and ends with a bland call for programs that "empower" persons with asthma, address gaps in access to care, support preventive measures, promote self-management education and expand reimbursement for asthma education.

That may sound good, but it ain't happening.  It doesn't take an epidemiologist to conclude that there is absolutely no chance that the current one-on-one health care system is going to educate more than 10 million persons with asthma about peak flow meters or action plans.  There are not enough physicians, physician assistants, nurse practitioners, appointments, office visit minutes, patient centered medical homes or integrated delivery systems to handle it all.

Given the rising rates of asthma, what other options are out there?  Maybe it's time to get serious about virtual clinics, turbo-charged community based organizations, remote telephonic coaching including cellphones as well as web-based interactions with monitoring. School budgets are being cut back, but asthma may be a reason to keep school nurses around as an option for children and adolescents.  Perhaps lay people can be asthma educators.  Social media such as Twitter may also be able to play a role.

The good news is that the population health and disease management industry, in partnership with insurers, primary care, the medical home community and employers, is already working on these and other new approaches to caring for asthma.  As experience with them grows, the DMCB is looking forward to reading about their positive outcomes.  They'll not only be reported on this blog, but who knows... maybe they'll even be a topic of a future edition of MMWR.

alone on mothers' day

When my spouse first mentioned that he was thinking of taking the boys to the Toronto Comic Arts Festival in Toronto, I protested, "But that's Mothers' Day week end!"

Then I stopped to think.

"Would you be taking both boys?"

"I think I'd have to."

After a moment's thought (empty house! to myself! quiet writing and reading time!), I bravely said, "I think you should go. I don't want to deprive the boys of this chance."

My spouse (clueing in) "Do you want your Mother's Day present to be a week end by yourself?"

Me shaking my head and stammering and not quite keeping a straight face, "I'll miss you."

So they went. And I have missed them. I've also slept more than 8 hours each night, done a considerable amount of cleaning, read a book, watched stuff on Netflix, had dinner with a friend and taken the dog for a run. I still have time to catch up on some writing, make soup, take the dog out again and do most of the laundry. I'll be starting the week of with far less stress than I often do.

My boys had a lot of fun this week end doing things I wouldn't have particularly cared to do (even Grandma went to see Thor last night). I felt a pang of guilt when they left but I quickly let that go. It sounds like they've had a great time. And soon enough they will be home and I will once again embrace the chaos of my family.

Happy Mothers' Day!

Allergy versus Anguish. A Scientific Look at Mrs. Clinton in the White House Situation Room

According to news outlets, Secretary of State Hillary Clinton has denied being in a state of "anguish" when she was photographed while remotely witnessing the Bin Laden raid.  She blames her appearance on  one of her "early spring allergic coughs."

Which prompted the scientific Disease Management Care Blog to ask two questions:

1) Doesn't being in an air-filtered and environmentally controlled "Situation Room"  protect against lingering allergy symptoms?

The DMCB looked at some peer reviewed literature and found that after exposure to an allergen, there is a complex cascade of cellular and chemical reactions that can play out over many hours. Check out this helpful quote:

The immediate reaction to brief allergen challenge, measured in minutes, does not fully explain.... clinical allergic rhinitis, in which symptoms last hours to days after exposure....  From 3 to 12 hours after allergic challenge, about half the subjects experience a recurrence of symptoms, most notably nasal congestion; this is termed the late phase response.

The inflammatory congestion and mucus production can lead to a "post nasal drip," which can irritate the upper airway and cause a reflex cough.  This could account for Mrs. Clinton placing her right hand over her mouth, which supports her version of events.

2) Is the news media's description of Mrs. Clinton's appearance as "anguished" correct?

The psychologically astute DMCB has witnessed plenty of anguish in its lifetime.  A recent example was the DMCB's spouse's look when the DMCB suggested that a 5 foot column topped with the bust of a Roman dead dude would be a perfect addition to the decor of our enclosed porch.  Mrs. Clinton's appearance rises to that level, but - assuming this isn't a cough - the DMCB thinks the hand over the mouth is more than just anguish.  Among body language cognoscenti (for example), that action is thought to convey the unconscious suppression of speech in response to a surprise.

Who cares, but it's a fun end-of-the-week topic.  The DMCB likes to imagine that at least one person in the White House Situation Room was connected to his or her emotions. That is doubly true for Mrs. Clinton, who has struggled with being perceived as heartless and, ironically, supposedly mastered the art of political body language.

One last thought: Mrs. Clinton would care what the DMCB and others think and would respond to a reporter's question like that if she is harboring plans for higher office. 

Stay tuned!

Photo from the White House

The Latest Cavalcade of Risk Is Up

This edition is hosted by David Williams of the Health Business Blog.  Experience the craziness of Part D trends, the suspense of deductibles, the thrill of shared decision making as well as funky financials, going "naked" and being bit by policies that may not cover dog bites and exotic pets.