QAPI From the Front Lines

One person lifts the word Compliant and others are crushed by non-compliance, as the winner follows This is the PolicyPub’s first post by a contributing author. I have recently written on the upcoming QAPI mandate included in the Affordable Care Act and the impact that will have on nursing homes – particularly those unprepared (which I am coming to realize appears to be the majority).

I am thrilled to have my Artower colleague, Terri Durkin Williams, R.N., L.N.H.A., share her practical experiences with QAPI.

The Nursing Home industry is being challenged to develop quality programs that consistently maintain regulatory compliance. This shift in continuous improvement will require organizations to self-assess their operational performance. In turn, this will move organizations from the established routine of monitoring systems to self-assessments.

The federal government has mandated a Quality Assurance and Performance Improvement QAPI standard under the Affordable Care Act. This mandate was to be established and implemented in nursing facilities by December 31, 2011. As yet, regulations implementing the QAPI program have not been released by CMS.

The purpose of the QAPI program is to develop best practice in providing services and care to nursing home residents. This should be the mission of all health care providers. Waiting for the government to lead us in our business is jeopardizing organization survival both financially and in the delivery of services and care.

QAPI is not a new concept: it has been widely used in healthcare organizations for quite some time. The nuclear power industry has embraced this process to assure quality controls, safety, maintain regulatory requirements, increase efficiency and enhance the reputation of individual power plants. Achieving these goals requires a significant commitment of organizational time and personnel.

Given the tremendous cost pressures and narrowing reimbursement, however, management often judges such commitment as an unaffordable expense. The tendency is to not proceed with an in-depth evaluation of organizational functions. This is too often unfortunate short-sightedness of executive management. It leads to undesired consequences such as, poor care resulting in litigation, staffing turn-over, declining census, fines due to regulatory deficiencies, dissatisfied customers and increase in regulatory over-sight to just mention a few potential outcomes.

A common current practice in quality assurance programs is to monitor a task that is being performed by personnel. The evaluator observes the personnel and uses a check list to determine if the standard being monitored is compliant. The pitfalls of this approach include:

  • Observers not being trained in a manner that results in the consistent application of standards used to perform the evaluation; i.e., the evaluation is based on the observer’s personal biases;
  • Personnel performing to the standard while being observed;
  • Personnel documenting what is required, but not assuring that care was delivered according to the established standard;
  • Monitoring as a snapshot observation; it does not tell the entire story;
  • Organizations using limited information that is gathered in the monitoring process to determine compliancy – this can give a false sense of success and prevent the exploration of best practices
  • Monitoring that  does not guide the organization to the root cause(s) of problems, does not allow for personnel to explain their performance and fails to obtain what knowledge the personnel have of the standard being monitored:

  • limits the beneficial involvement of all personnel in the process;
  • is often viewed by personnel as a punitive measure; and
  • creates a disconnect in communication throughout the entire organization.

Poor preforming organizations tend not to take time to complete a comprehensive assessment of their operational issues and challenges. They may feel that they do not have time for a comprehensive assessment. This causes them to guess at what the problem is and just perpetuates a poor practice.

Example Case
I was recently involved working with an 84-bed nursing home that had seven (7) “immediate jeopardy’s” for a period of six and a half months. Their approach to quality assurance was to have nursing managers spend several hours a day monitoring and documenting problems. But there was no understanding of the root cause(s) of those problems. They received fines from CMS of over a half million dollars. This organization would have benefited from a self-assessment program.

The alternative to this chaos is planning for cultural change that will lead to best practices. The embracement of the self-assessments program exemplifies this and is characterized by the following:

  • Supported by organizational leadership;
  • Involvement of personnel at all levels within the organization to promote professional growth;
  • Effective and efficient communication – a team working together and respecting each other;
  • Focus on evaluating the most important aspects of the people, process, and technology;
  • Comprehensive understanding based upon a collection of observations, record reviews, personnel interviews, benchmarking data, and other ongoing assessment information measured against specific criteria;
  • Identification of performance deficiencies and potential causes, organizational strengths and weaknesses and opportunities for improvement
  • Evaluates performance against established best practices;
  • Provides opportunities to change the culture of the organization;
  • Stabilizes daily operations, by consist expectations, policies and procedures and
  • Establishes a culture whereby organizations control their business activities based on mission and purpose.

Key components of a successful self-assessment program include:

  • Executive management and board leadership’s passion for excellence;
  • Identification of an individual that is supported by leadership as the Team Leader in championing the Art of Quality.
  • Entire self-assessment team educated on the organization’s mission and leadership’s expectations – and they are accountable for their actions;
  • Defined sequence of the self-assessment process;
  • Evidence based standards;
  • Requisite IT support that facilitates the collection of relevant data, analyzes information and provides benchmarking; and
  • An ability to have fun, learn and celebrate successes.

To explore how your organization can implement Artower’s EviQual™ Self-Assessment Program using evidence based practice contact me at twilliams@artoweradvisory.com or 216.244.2923.

  ~ Terri

Accelerate! ~ Or Be Eaten

sparkyartower:

Originally published in November 2012.

Originally posted on Sparky's Policy Pub:

John Kotter makes his latest contribution to an already authoritative body of work on organizational change management in the article,

that form the backbone of a strategy network, which he suggests should work in parallel with an organization’s existing operations. The accelerators differ from the eight steps in their being nonlinear, more organizationally encompassing and ideally facilitated independent of the traditional organizational hierarchy.

), while the other is a network framework that is able to leverage the organization’s group genius in ways that facilitate rapid strategy deployment.

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Culture Change at the Core of QAPI

This past Friday I attended the 2014 Katz Policy Lecture at the Benjamin Rose Institute. Peter Kemper, PhD, Professor Emeritus of Health Policy, Administration and Demography from Pennsylvania State University gave the lecture on Expanding Culture Change to All Nursing Homes: Challenges and Policy Approaches.

Professor Kemper acknowledged early on what is often the opening salvo of critics of culture change – that defining exactly what it is can be a formidable challenge. In fact, as he noted, it may be preferable to think of culture change as a movement instead of a model. This perception would be consistent with the concept of continuous quality improvement where it is recognized that while operational perfection is inherently unachievable, evidence shows its pursuit drives measurably better outcomes.

Cutting through the theory and research, at its core culture change is the ability to create an organizational environment in which individuals are empowered, trusted and valued: and this must be true for both patients and the workforce caring for them. What does this look like? Well, in listening to the lecture I found that we need look no further than the five elements of Quality Assessment Performance Improvement (QAPI).

Element 1: Design and Scope: Culture change can only take place if there is a shared commitment to be cognizant and aware of how each individual’s role and responsibilities support achievement of the organization’s future state vision. To accomplish this there must be an understanding and pragmatic recognition that the approach needs to be comprehensive, inclusive and constantly evolving.

Element 2: Governance and Leadership: It is the organizational leadership’s primary responsibility to create the environment by owning (without controlling) the design and scope process, while the role of governance is to ensure sustainability and accountability of that environment once created.

Element 3: Feedback, Data Systems & Monitoring: The old adage of you can’t manage what you can’t measure, however incomplete in its ability to capture the full essence of organizational behavior, nonetheless is the primary means of incenting desired behavior while discouraging unwanted behavior (i.e., accountability). This must be a fundamental element of culture change, particularly from the standpoint of sustainability.

Element 4: Performance Improvement Projects: The key concepts attributable to culture change here are prioritization and ability to impact. The important nuance that many PA/LTC organizations have difficulty understanding is that PIPs don’t have to be directed retrospectively. They can (and should) be borne out of a comprehensive design and scope process (i.e., Element 1). This is a key element of intersection between culture change and QAPI programming that must be embraced and understood.

Element 5: Systematic Analysis and Systemic Action: Socrates noted that, “the unexamined life is not worth living.” I contend that an organization committed to culture change will continuously assess and examine whether and how well it is able to achieve its vision while fulfilling its mission and always reflecting its core values. This brings us full circle to the concept of continuous quality improvement noted at the beginning of this post.

As Professor Kemper also noted during his lecture, there is nothing necessarily innovative or revolutionary about culture change in PA/LTC. My observation is that it is really a matter of borrowing – or adopting – proven best practices of organizational behavior from other industries and research that dates back to the early 1900s. But going from theory and research to realized benefit takes the type of leadership that isn’t as easy to import. That’s where a lot more work needs to be done before either culture change or QAPI can achieve meaningful and lasting improvement in patient outcomes and life enrichment of the individuals served.

Cheers,
  Sparky

 

 

Picture Credit: Provider Magazine

WARNING: Paradigm Shift Ahead

In light of the passage last Thursday by the Senate of S. 2553, the Improving Medicare Post-Acute Care Transformation Act of 2014, I thought I would re-share this post from July. 

If you are responsible for leading a post-acute/long-term care organization, I believe you should take note of two recent regulatory and legislative initiatives that provide a rather clear vision of where the post-acute/long-term care industry is headed – and it’s going to be disruptive to traditional thinking (if you want to survive).

ITEM 1: VBP in Home Healthcare
Earlier this week, CMS issued propose rule,
CMS-1611-P, which proposed to update Medicare’s Home Health Prospective Payment System resulting in an over all 2.5% reduction in rates when consideration is given to rebasing adjustments and sequestration. Importantly, included with that rule was a solicitation of comments regarding a home healthcare value-based purchasing (HHVBP) model.

Section 3006(b)(1) of the Affordable Care Act directed the HHS Secretary to develop a plan for implementation of a HHVPB program for home health agencies and to issue an associated report to Congress. Key concepts of that report included building upon existing measurement tools and processes, the alignment with other Medicare programs and tying payment to performance.

As currently contemplated, beginning with CY 2016 in five to eight states participating in an initial demonstration, average Medicare payments would be increased or decreased in a rage of 5% to 8% based on quality performance as measured by both achievement and improvement across multiple quality measures. The belief is these incentives/disincentives would encourage better quality via improved planning, coordination, and management of care.

 

ITEM 2: Broad Spectrum Reform Targeted
Last week, leaders of the Senate Finance and House Ways and Means committees introduced bipartisan legislation (H.R. 4994, S. 2553) that would have the type of disruptive influence that Clayton Christiansen has researched and explained leads to
disruptive innovation. Being referred to as The Improving Medicare Post-Acute Care Transformation Act of 2014 (or, IMPACT Act of 2014), it would require data gathering and reporting standardization across different types of PA/LTC settings to facilitate better comparisons of quality and resource utilization among those settings and to improve hospital and post-acute care discharge planning.

The data collected and analyses completed would then be used to develop new payment system(s) that could be site-neutral and reflect various forms of bundling and/or at-risk capitation. Anticipated quality measures include functional status, skin integrity, medication reconciliation, major falls and patient preference. If enacted, SNFs, IRFs and LTACs would begin reporting some of these measures as early as October of 2016, with confidential feedback sent the following year and public reporting of the measures occurring in 2018.

Taken together, these two initiatives – even if neither is ultimately implemented – reflect the long anticipated but now swiftly emerging paradigm shift away from fee for service in the PA/LTC industry. They also reflect the migration toward a view of PA/LTC that encompasses the patient’s overall and entire experience after an acute care stay. Owning only a piece of the puzzle, without being able to seamlessly and economically integrate with healthcare providers holding the other pieces, will not represent a sustainable business model.

To reinforce this, simply look at the strategy of Kindred Healthcare. Writing in Forbes Magazine recently, colleague Howard Gleckman noted that,

“as recently as 2010, half of Kindred’s business was generated by its skilled nursing facilities. This year, only one-fifth of its revenues will come from its nursing and rehab centers. In a major strategic shift, Kindred is betting the company on in-home care, hospice, care management, and fully integrated care services.” [my emphasis added]

Ironically, PACE models – whose genesis dates back to the early 70s – are well ahead of the curve in successfully providing comprehensive, integrated services and care, though their positioning platform has primarily been a means of serving low income seniors. That road hasn’t been easy, as development and execution is fraught with financial, operational, clinical and regulatory challenges. But the overall long-term programmatic success demonstrates the value created from integrated care delivery under a fully capitated payment model (as in, see above).

So if you’re one of those individuals I referenced at the top of this post, what I would do if I were you is spend some time understanding the PACE model – and a crash course in organizational change management might not hurt either.

Cheers – and Happy Independence Day!!
  ~ Sparky

 

 

America’s Housing Crisis

Warning-Challenges-aheadLast week the Joint Center for Housing Studies of Harvard University released a new report, Housing America’s Older Adults: Meeting the Needs of An Aging Population. Funded primarily from a grant provided by the AARP Foundation, it concisely and comprehensively depicts the fissure of disconnect characterizing the burgeoning need for affordable senior housing as contrasted against the nation’s ability to accommodate that need.

As reported on there, a myriad of overlapping demographic and socioeconomic components are advancing unabated to create a perfect storm in the form of a national housing crisis that represents one of the most vexing domestic policy issues we will face over the next two decades.  Despite the growing enthusiasm for home and community-based services as a more preferable and lower cost alternative to institutionally-based care, the stark reality is that individuals in need of services and support, as well as long-term care, need a physical location at which they receive that assistance – and a place to sleep to boot.

With all of the media attention that has been given to healthcare reform it’s not surprising that housing, services and support and long-term care for the elderly and disabled is characterized by those intimately familiar as a social time bomb, ticking away without the attention it needs or deserves. In good part this deference is also due to the political reality that it’s a minefield of tough choices, which upon further survey frightens even the most stalwart politician into a stasis of self-preservation (yes, more so than usual).

Friend and colleague, Rob Hilton, President & CEO of the A M McGregor Group in East Cleveland, Ohio has long held a personal and professional passion for addressing the affordability of housing, services and care for seniors. In June of 2012 I interviewed Rob for a Pub Chat: Affordable Housing Key to Long-Term Care. Rob was originally responsible for my getting interested in the concept of Affordable Housing Plus Services. LeadingAge’s Center of Applied Research headed by Dr. Robyn Stone has some very good resources on the background and research surrounding AHPS.

That interest spurred my thinking about how taking a holistic approach to the development process could result in more affordable product offerings. Real estate development is by its nature both a risky and capitally intensive endeavor. Being able to use a process that effectively manages that risk while reducing unproductive expenditures can – in the aggregate – have a major impact on affordability. The graphic below is one that we use at Artower to help explain key concepts of this approach.

chart_061914

I also wrote about this approach a few years back in a white paper on Mission-Driven Development that further describes some of the key concepts.

Depicted below is a strategic development planning matrix that was developed collaboratively by me and Rob Hilton over the past decade (i.e., many iterations reflecting our learning). In some fashion this represents the holistic, circular process shown above being flattened into a linear representation that can better accommodate process tracking and accountability. I realize this image is too small to read, but please contact me if you are interested learning more.


Visio-Affordable Housing101013-page-0

So while I don’t claim to have all of the answers to the housing crisis that is facing us, I have spent considerable time undaunted by the aforementioned policy minefield thinking about solutions. I would be more than happy to share what I have learned with others who are interested in tackling this challenge head on – while there is still time.

Cheers,
  ~ Sparky

Blog picture credit: Power By Choice, Colorado Springs, CO 80904

QAPI: A Steep Learning Curve for Many

Compliance Conceptual MeterI am becoming increasingly concerned that many, if not most, post-acute/long-term care organizations are poorly prepared to embrace the requirements of the looming Quality Assessment Performance Improvement (QAPI) reporting requirements mandated by the Affordable Care Act. I base that conviction on how much I have learned over the past few years working with my colleague, Nathan Ives, of Strategy Driven Enterprises, LLC.

A graduate of the United States Naval Academy, for over two decades Nathan has been immersed in the world of quality assessment, performance improvement and regulatory compliance as each has applied to the nuclear power industry. He has held several influential positions at the Institute of Nuclear Power Operations (INPO) and has led teams of nuclear operations professionals in the performance evaluation of over 24 nuclear electric generating stations from 20 utilities in the United States, Canada, and Japan. He also led the nuclear industry’s effort to redefine performance standards in the areas of organizational alignment, managerial decision-making, plant operations, and risk management.

For the past two years, Nathan has been working with my Artower colleague, Terri Williams, RN, on developing EviQual™, a turnkey regulatory compliance solution that PA/LTC organizations can use to create a QAPI program. Terri has nearly 30 years of experience as a practitioner, educator and advocate for quality improvement and patient safety at PA/LTC facilities. Now, as a I have neither an operational engineering nor clinical background, for me it has been a fascinating learning experience. And what I have learned primarily is that QAPI – as understood from how it has been applied in other industries – is an entirely different approach to outcome quality and patient safety than what most PA/LTC organizations are currently familiar with.

Whereas historically those organizations have focused a great deal of attention on observing, recording and diagnosing the cause(s) of adverse events, the whole point of a quality assessment program is to proactively diagnose existing practices, policies and performance to create an environment in which such events don’t happen in the first place. It is a paradigm shift in thinking and approach that for most organizations must be accompanied by changes in organizational culture.

That’s why in creating EviQual™ we have sought to leverage the already existing knowledgebase of what has been proven effective in improving quality and safety in an industry that has many parallels with healthcare. In fact, Nathan and I collaborated on a white paper  some time ago on the applicability of lessons learned in the nuclear power industry to aligning healthcare organizations via quality and performance improvement.

The Centers for Medicare and Medicaid Services has made available QAPI at a Glance, a step-by-step guide focusing on 12 core elements ranging from organizational sponsorship and leadership to tactical  program implementation. A very well written accompaniment to that guide was just recently completed as a series of articles for Long-Term Care Magazine by Nell Griffin, LPN, EdM. Both are wonderful resources if you are new to understanding QAPI and the important ramifications it will have on PA/LTC organizations.

The first step in the 12-step process for implementing a QAPI program focuses on leadership, responsibility and accountability. What this requires is the active and committed sponsorship of the QAPI process by senior executives and board members. So when I hear leadership teams at PA/LTC organizations say they are confident their clinical teams are proactively addressing the QAPI requirements, I can’t help but fear those organizations have already stumbled out of the gate.

Cheers,
  ~ Sparky

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Moving Away From Sick Care

There is a saying that goes, “America doesn’t have a healthcare system – we have a sick-care system.” I don’t know whether that quote is attributable to an individual or not, but the connotation is that what for decades has served as a healthcare delivery system belies the underlying premise that the individuals benefitting from that system’s value proposition are, indeed, healthy.

Of course, they are not – at least at the time service is required.  They are sick, ill or afflicted by a myriad of chronic diseases and conditions. Whatever we want to call it, a system that addresses the needs of these individuals is critically important. But the study in ironic contrast serves to raise awareness of the need to address population health as the best hope of reigning in the unabated march of healthcare’s gobbling up the nation’s GDP.

Last week a new Health Policy Brief, The Relative Contribution of Multiple Determinants of Health, was released by Health Affairs and the Robert Wood Johnson Foundation that looks at factors and considerations impacting individual and population health. These are commonly referred to as health determinants and can be summarized into five major categories: genetics, behavior, social circumstances, environmental and physical influences and medical care.

Researching and understanding how specific factors and considerations within these categories impact individual and population health is very challenging because of complex, interdependent, bidirectional relationships – and because the timeframe over which meaningful measurement must take place can often be decades. But if the US delivery system is to make a paradigm shift away from having a sick care system, efforts must continue to understand whether and how health policy interventions and choices, as well as the efficient use of limited resources, can achieve better outcomes.

This, in turn, requires the adoption of a more holistic understanding of health: the roles social and environmental (i.e., nonclinical) determinants play in impacting individual health. Human behavior, for example – a primary concern in understanding poor health outcomes – must be understood and assessed, “according to multiple dimensions and at various points of intervention.”

Despite the challenges, progress continues on understanding the role nonclinical determinants play in individual and population health outcomes. The continued advancements in Big Data should accelerate these efforts. The policy brief referenced above provides a nice overview of these efforts with resources that should be noted by healthcare providers wanting to better understand how their competitors are seeking to become strategically aligned with population health management.

There are currently a lot of major healthcare providers touting in the press their foray into population health, as if the opportunity for impact is ripe for harvesting. But having recently become more educated and aware of the myriad issues and complexity of population health, I do have to wonder if their strategies are too narrowly focused on how to creatively redeploy existing assets and resources – rather than making a candid and honest assessment whether either can be productively leveraged in the context of a holistic approach to healthcare.

Cheers,
  Sparky

Population Health Needs A Brand Positioning Strategy

Population Health (PH) is a term that has become ingrained in the Healthcare Reform lexicon over the past decade. It’s one of those politically gravitational conveniences that allow candidates from different parties to embrace a common goal with little risk of being criticized for holding beliefs different than their opponent. And that is precisely because it is difficult, if not impossible, to prove someone believes in something that does not have a consistent and agreed upon definition.

Just What is Population Health?
What PH enjoys in broad political support it lacks in definitional credibility. A good treatise on variations of contemporary definitions can be found in Academy Health’s Population Health in the Affordable Care Act Era by Michael Stoto, Ph.D. Without wanting to deliberately adulterate that work, Stoto highlights conceptual commonalities and differences in definitions from several sources that I will try and very briefly summarize below.

A focus on health outcomes – the subjectivity of which notwithstanding – and the distribution of outcomes (i.e., how do outcomes vary across comparative stratifications, such as geographic residence, ethnicity, age, etc.)

The impetus of achieving healthier outcomes is through encouraging healthier lifestyles, better nutrition, preventative care, avoiding behavioral risks, etc.

Measurement of health status indicators as well as the factors that are correlated with those indicators (e.g., socioeconomic conditions, physical environments, childhood development, etc.)

Utilization of data and analytics to develop a conceptual framework for understanding and explaining differences in population health indicators – and how that knowledge impacts research agendas, resource allocations and public policy.

Often discussed (or confused, depends on your perspective) with public health, though the latter also typically connotes a governmental influence of some type (e.g., a municipal health department).

Policy Perspectives
From a policy perspective, there are two ways to look at PH: altruistic and pragmatic. From an altruistic perspective policies that promise to improve population health are most often framed in cost—benefit analyses: the benefits, if achievable, are easy to agree upon (who doesn’t want to be healthier?). The ROI is the challenge and most often the subject of political contention.

From a pragmatic perspective – particularly as PH has been manifested in the Affordable Care Act – what we are really talking about is cost control. Healthier people demand less healthcare services. Individuals with chronic conditions that more effectively manage those conditions need less healthcare. Economics 101: if we can reduce demand while maintaining or increasing supply, costs should decrease.

Parallel to this latter perspective is the growing base of knowledge that indicates improving the quality of care can achieve both lower costs AND better care. So if population health is a vehicle through which quality can be improved, it benefits from that additional policy advocacy.

Population Health Perceptions
Population Health means different things to different people. A good part of that difference can be explained in the inherent subjectivity of the concept of health outcomes. Some other portion can be explained by academic exercises seeking to cut the Gordian Knot. Still another by political extrapolations that seek to gain favor by equating improved population health with an appreciative electorate.

Whatever the feasible explanation(s) may be, Population Health suffers from an identity crisis. Beyond just a definitional problem, however, it fundamentally lacks in having been able to achieve a shared understanding of its meaning and purpose at a level that resonates with the very “population” whose health is of concern. In short, PH could use a brand positioning strategy.

Perceptual Positioning of Population Health
One of my favorite books on branding is Brand: It Ain’t the Logo: It’s what people think of  you™ by Ted Matthews. Matthews argues that,

“a brand is the sum total impression and memory of every remarkable, every so-so and every negative experience with any and all pieces of an organization. A brand is the personality of [that organization] . . . and is judged and assessed a value by everyone it touches, whether inside the [organization] or outside. These perceptions of value may, or may not, be what you want them to be. Which suggests a fact that may surprise you: your brand isn’t really yours (emphasis added). You don’t own it – all the people thinking about you do.”

It’s not a leap to borrow or migrate these concepts of perceptual brand positioning to PH. Many proponents of PH take an interventional approach as a means to advocacy. Their focus is on modifying individual behaviors, inducing health screening, creating artificial employment incentives and imposing restrictions and/or impositions on environmental elements. This is not a sustainable approach to PH brand positioning simply because it fails to recognize that the perception of PH is owned by the individual – and not the advocate.

What to do Differently
When I was giving presentations across the country a few years back on the newly passed Affordable Care Act, I made it a point to say that I believed if we were somehow successful in increasing access to healthcare services, in improving quality, in lowering costs, in enhancing efficiency and productivity – that none of that would matter long-term because the forecasted demand from an aging demographic would atomize those gains.  The only escape from a tragic gap between demand for quality healthcare and the ability to meet that demand will come from lowering innate demand.

Population health, however one wants to define it, is therefore a critical component of any strategy that seeks to address the looming care gap. But the underlying concepts of what make improving population health mutually beneficial cannot be thrust upon individuals for their own good. Nobody ever bought a Macintosh computer because Steve Jobs told them they should. If you are an advocate of PH, then it’s time to start looking at how to perceptually position its brand benefits differently.

Look at the most valuable brands in the world, and look at how they were built: such as Apple, Microsoft, Coca-Cola, IBM, Google, Disney. Marketing and advertising played important roles, but it has ultimately been each organization’s ability to offer something of value to individuals that drove sustainable perceptions. What can be learned from the branding strategies of organizations like these that can turn the perceptual positioning of Population Health on its head to achieve the long-term benefits that we believe can be achieved?

Cheers,
  Sparky

Depression, Addiction & Mental Health Policy

Pic For BlogThe last time I remember feeling as badly about a celebrity passing has to be December 8, 1980. I remember exactly where I was and what I was doing when a radio disk jockey (people that used to play and broadcast what were known as records on electronic turntables) broke the news over a song that John Lennon had been shot. About two minutes later, the music was stopped – and the sad news announced that he had been shot – and killed.

Queue up round the clock Beatles music and millions of tears across the world.  The next day in the Rock n Roll capital was damp and dreary. A cold mist just seemed to hang in the air. One of those days where ironically it would feel warmer if it would have just snowed. There are a lot of days like that in early December in Cleveland, Ohio. But this one so fit the mood.

Nobody saw that one coming. Whereas we all know now what only a few knew all to well before Monday: that Robin Willams’ mental demons were probably always only a few steps behind. Shadowing him like the inescapable darkness of a night in the forest, depression is a disease that lurks, pounces, retreats and then stalks – taking in turn at random how it chooses to haunt its victims.

Addiction, on the other hand, despite the cultural shift in attitudes over the past few decades, is not a disease. Writing in the Psychology Today blog a couple of years back, Dr. Lance Dodes explains how addiction has little in common with other diseases and cannot be explained by any disease process. But as he also astutely points out, neither is it the purview of individuals lacking in discipline and morality,  just being selfish and self-centered.

But to understand addiction is to understand the mental state of an individual leading up to and perpetuating its hold on that person.  Dr. Lance writes, “addictive behavior is a readily understandable symptom, not a disease.” In Williams’ case the connection between depression and resulting behavior leading to addiction is something that should continue to build awareness and understanding.

I realize it’s a sensitive line here because the last thing we want to do is roll back the progress made fighting stigmatization and the barrier and obstacles that has created in affecting treatment access. On the other hand, from a public policy perspective it is crucial that we continue to dig deeper: to understand mental health – and mental illness – as a critically holistic element impacting all varieties of personal well being, not just as a precept to alcoholism and addiction.

Robin Williams’ wife has asked that we remember her husband by not focusing on his death, “but on the countless moments of joy and laughter he gave to millions.” As the emotional pain subsides I am certain we will be able to do that. Before we get to that place, however, it is natural to question and seek answers on how this tragedy might have been avoided.

For millions of Americans suffering from, or affected by a loved one suffering from, a mental illness, alcoholism or addiction, Robin Williams’ death is a painful reminder of the fear and vulnerability they live with every day. And they are right to be questioning what might be done to help address that suffering. Yesterday, Rep. Tim Murphy (R-Pa) noted that, “Williams’ greatest gift to us, if we choose to accept it, is a focused determination to help those with brain illness and finally take real action to stop the loss of one more precious life.”

In December of last year, in response to the 2012 elementary school shooting in Connecticut, Murphy – a clinical psychologist – introduced H.R. 3717, The Helping Families in Mental Health Crisis Act. One of the most important initiatives in the bill is to address the Institutions for Mental Disease (IMD) Exclusion, which limits Medicaid coverage for inpatient mental health and addiction treatment.

The bill is complex, comprehensive and has faced a significant amount of criticism. Good coverage of this can be found in a blog post from Gary Earles, LICSW, writing last year for the Morning Zen on the Children’s Mental Health Network. Very doubtful that even with this latest tragedy the bill will move anywhere before the next Congress is installed. But what might now happen is the debate will move from the purview of policy wonks, trade groups and special interests into the real world where those aforementioned suffering can have a voice. We can only hope.

Cheers,
  Sparky

Healthcare’s Disruptive Innovator

Disruptive Innovation is a term widely attributed to Harvard Business School professor, Clayton Christensen. Often used interchangeably with the term, disruptive technology, there is an important distinction: the former represents not just advancements in underlying technology but the innovative application of that technology.

Disruptive innovation is something that concurrently, though at varying speeds, creates a new market while disrupting an existing market in ways that essentially had not been anticipated. Examples frequently cited include the introduction of personal computers and the impact that had on mini and mainframe computers; cellular phones’ impact on fixed line telephony; the iPod’s impact on the music industry; and most recently – retail medical clinics’ impact on traditional physician offices.

Enter The Clinic at Walmart.

Writing in the Healthcare Finance News, Contributing Editor Anthony Brino writes how Walmart is now wading into physician territory. Having already opened over 100 walk-in clinics across the country that provide access to medical care through collaborative agreements with local hospitals and/or physicians, this latest move – directly employing nurse practitioners – is part of a longer term strategy for Walmart to be self sufficiently ingrained as a primary care provider.

And of course, it’s not just Walmart that is seeking to capitalize on the increasing demand for primary care coupled with the escalating cost of that care: according to a 2013 report from Accenture Research the number of retail health clinics is anticipated to double over the next three years from 1,400 to 2,800. The core value proposition is increased access and greater convenience at a substantially lower cost than a visit to a doctor’s office.

What we are really looking at here is the commoditization of Medicine. The underlying premise is that a wide swath of fundamental and routine aspects of primary care can be automated and standardized: treatment of simple acute conditions, preventative care (e.g., vaccinations), wellness screening, diagnostic testing, etc.

There are substantial reasons to be concerned with the promulgation of retail clinics, particularly where they serve in lieu of primary care physician relationships. For starters, nurse practitioners – which undoubtedly must be a critical element in expanding primary care – simply do not have the same level of training and experience as a board certified physician. Their ability to assess, decipher and act upon the nuances of a patient’s conditions are – in general – not going to be the same.

The historical relationship of a patient and his or her physician becomes over time an invaluable knowledgebase that the physician relies upon to identify changes in a patient’s condition that may warrant investigation. And convenience can be a double-edged sword. Being prescribed an antibiotic for a virus that someone then confidently carries with them to their work environment not only prevents that individual from staying home and getting needed rest – it unwittingly exposes coworkers to that virus, which the antibiotic does nothing to control (or treat).

But what disruptive innovation is without its unintended consequences? Look at how much time we now spend in front of computers instead of outside exercising. Cell phones migrated to smart phones that people now use to text their way to oblivion: in 2012 over 3,300 people were killed in distraction-related crashes. Whether the paradigm shift in the music industry is a positive or negative I think depends a lot on  your age – but as with all other such innovations, nothing will ever be the same.

That is true for the healthcare industry and the practice of medicine: nothing will ever be the same – except our resistance to change – that won’t change.

Cheers,
  Sparky

Policy Prescriptions ®

The Evidence-Based Health Policy™ Experts

ChangingAging.org

By Dr. Bill Thomas

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