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On May 10, 2018, Nightingale commented on How do you maintain culture during rapid company growth? :

Hi Dana. Thank you for your feedback. We have started to implement many of these suggestions: improved on-boarding, videos, enhanced training materials, a retreat – planned for this fall, bi-weekly email blasts from the CEO and a new HR Director that has this on her agenda. I was curious, do you knew what kind of background, experience and training a Chief Culture Officer would possess? See you next week!

On May 9, 2018, Nightingale commented on Communicating Test results :

I think it is a combination of building in time (in the schedule) for providers and staff to review and discuss results with patients as well as leveraging technology for benign results.

My concern with an auto-push of results using technology would be the potential lack of personalization. Patients may feel they are just a number and ask themselves “did my provider really review these results?” “What does this mean?” It does not give the patient the ability to ask questions. It dehumanizes the process and relationship and potentially diminishes compliance. Also, many older adults may lack the access or technologic savvy-ness to use a portal or receive electronic results.

How do you effectively communicate complicated results and incidental-omas? I fear confusion, worry and frustration with results that may be received electronically and misinterpreted by a lay person. The situation would have been avoided if the provider could explain, answer questions and reassure.

On the flip side, we are a “on demand” generation that doesn’t want to wait and I totally agree I would want my mammo results without having to wait a week. There has to be a middle ground.

Idea: Delivering results electronically in real time with canned explanations on how a lay person can interpret with an opt in/out follow up visit for in-person discussion. So if the result was completely negative and the patient did not have any follow up questions, they could opt out, saving time and resources. However, the patient that prefers face to face interactions or had questions, they still can schedule a follow up. I believe this would satisfy both worlds.

On May 9, 2018, Nightingale commented on Ageing Population – a global problem :

Not only will the population shift with the aging world but the costs associated with the care of the elderly will also markedly increase. It is well known that the highest costs of care are incurred in the last stages of life. Therefore, we have a two fold problem that I believe needs a multi-pronged approach to tackle.

There are a few innovative ideas that I feel are starting to address this particular problem:

– Senior Emergency Department Care: Seniors have special needs, especially in a time as vulnerable as an emergency. Specially trained staff in the care of the aging population with environmentally tailored and designed rooms (non-slip flooring, special lighting) to help create a peaceful healing environment for both patients and caregivers. This particular hospital system (which I am not affiliated with!) has a similar approach with the Senior Surgery Center and a Senior Behavioral Health program.

– Home Based Primary Care – Keeping elders at home to ‘Age in Place’ and meet their healthcare needs without the need for facilities (or overhead), specifically in chronic disease management. The Independence at Home Pilot (frequent primary care visits for chronically ill seniors) in 2016 yielded great results and improved outcomes: $10M in healthcare savings, 10% fewer ED visits, 9% fewer hospitalizations and 27% few SNF stays. Source: Effects of Home-Based Primary Care on Medicare Costs in High-Risk Elders; Journal of the American Geriatric Society; July 2014.

– Mobile Acute Care home delivery platforms: Innovative approach to treat minor emergent, urgent complaints in the home with Advanced Practice Providers equipped with sophisticated technology and care delivery equipment (mobile lab, supplies and procedural capabilities).

– Telemedicine: Improving access to care without the overhead of brick and mortar facilities

– Mobile lab and imaging capabilities: bringing advanced imaging and lab draws into the community, improving access without the need for hospitalization or office visit

– EMS MIH/Paramedicine programs: Using 911/Emergency Medical Systems to see and treat L.A.N.E. (Low Acuity Non Emergent) patients with advanced paramedics under remote physician supervision

– Case Management, Palliative and Hospice care expansion and team development to address end of life decision making relative to quality of life and goals of care.

I cannot recall the genesis of this statistic, however, I thought I would share it anyway (so take it with a grain of salt). It is estimated that by 2024 that approximately 28% of of all hospital/facility care will be delivered in the home. I think there will continue to be a shift from the highest level of care (the hospital) into the community. It will be up to everyone to think outside of the box and further develop the above models of care delivery, particularly to address the aging population.

Coming from a much smaller organization we are doing the exact opposite! We are currently on an annual review/comp adjustment basis which is significantly time consuming and causing issues with the budget all at once. We are therefore transitioning to anniversary date evaluations.

As far as how to transition: I would suggest significant planning (including front-loading the budget) and convert or transition to new plan early as not to delay anticipated raises. This obviously would incur increased costs initially. In your example, nursing staff, would likely appreciate an early cost of living raise and you would prevent grumbling about any delays. I would use it as a “we value our team” move. At the same time I would introduce the new strategic KPIs. I love the idea of aligning the staff with organizational goals, this can often foster teamwork. I would not phase it in, as the “old” employees may feel under appreciated if the newbies have “extra” incentives or benefits. Transparency and fairness go a long way.

My two (or three) cents.

On May 4, 2018, Nightingale commented on Prevention vs Treatment to reduce the cost in healthcare :

I love that you are asking this question! Evidence has shown that better results on Social Determinants of Health screenings are associated with better health outcomes. Delving into and identifying social, environmental and and behavioral health domains and gaps – and offering resources and teaching, can dramatically impact health and disease.

One approach would be a multidisciplinary outreach team. Specifically, local cultural or spiritual leaders in the community paired with nursing, case management and educators (volunteers?). Having the ability to make referrals (dental, nutrition, social) for the identified gaps in real time would be necessary. I would suggest setting up basic health screenings and consistent drop in “clinics” (outside of the traditional office set up), in the community centers or gathering places. Bringing the resources to the patient may help overcome access and cultural barriers.

On May 4, 2018, Nightingale commented on Addressing unnecessary emergency department (ED) use :

Hi Lisa. I totally agree that this is a widespread problem that needs a sustainable solution. One innovative model in the DC area is Nurse 911 triage. See NPR link:

This may be a way to decrease unnecessary 911 utilization AND direct LANE patients to UC or clinics. Even better would be to direct patients to their medical home, specifically if the patient cohort is a managed care group. I look forward to finding out if the 911 triage decreases ED utilization. Hoping that patient outcomes are positive too.

Another model (which is dear to my heart!) is the DispatchHealth model. On-demand acute, minor emergent care in the home. We have had significant success in 911 diversions and decreased ED utilization with estimated health care cost savings of nearly $80M to date. We are expanding our EMS partnerships and getting hospital system buy in to further develop our program. Happy to discuss more.

A third option, would be EMS MIH programs. Paramedicine is an expanding arena that uses advanced paramedics through the 911 system to treat and release low acuity patients (under MD supervision) rather than transport.

Lots of options! I believe to truly tackle this issue there has to be a multi-pronged approach. The hard part is convincing the government and payers that it is worth reimbursing for these services.