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Primary Care and the Next Phase of Health Care Reform

Oct 29, 2014, 11:00 AM, Posted by Martin Serota, Michael Hochman

Michael Hochman, MD, MPH, is medical director for innovation at AltaMed Health Services, the largest independent federally qualified health center in the United States. AltaMed has enrolled more than 30,000 Southern Californians in Medi-Cal and Covered California, the state health care exchange. Hochman is an alumnus of the Robert Wood Johnson Foundation (RWJF) Clinical Scholars program at the University of California, Los Angeles, and the U.S. Department of Veterans Affairs. Martin Serota, MD, is AltaMed’s chief medical officer.

Michael Hochman Michael Hochman

Although the dust is still settling, most indicators suggest that the first wave of national health care reform was a success, particularly in California.  More than 8 million Americans enrolled in commercial health plans under the Affordable Care Act, surpassing targets set by the Obama administration. Many more will qualify for plans under Medicaid expansion. As leaders at a community health center that serves a large population of low-income patients—many of whom currently lack coverage—we could not be happier about the new opportunities for our patients.

Martin Serota Martin Serota

But we also know that the work is far from complete. Health care reform will only be a success if coverage expansion results in improvements in quality and efficiency, and better health for the population. As we know from the Massachusetts experience, it took time and a lot of effort for these benefits to ensue. Only now, several years after health care reform began in Massachusetts, are residents of the state starting to reap the benefits.

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Patients Pleased With Care from Physician Assistants

Oct 29, 2014, 9:00 AM

Physician assistants (PAs) received high marks from patients in a recent survey conducted by Harris Poll for the American Academy of Physician Assistants (AAPA). Among 680 Americans (out of more than 1,500 surveyed) who have interacted with a PA in the past year, 93 percent see PAs as part of the solution to the nation’s shortage of health care providers; 93 percent regard PAs as trusted health care providers; and 91 percent agree that PAs improve health outcomes for patients.

“The survey results prove what we have known to be true for years: PAs are an essential element in the health care equation and America needs PAs now more than ever,” AAPA President John McGinnity, MS, PA-C, DFAAPA, said in a news release. “When PAs are on the health care team, patients know they can count on receiving high-quality care, which is particularly important as the system moves toward a fee-for-value structure.”

The AAPA points out that more than 100,000 PAs practice medicine in the United States and on U.S. military bases worldwide. A typical PA will treat 3,500 patients in a year, the association says, conducting physical exams, diagnosing and treating illnesses, ordering and interpreting tests, prescribing medication, and assisting in surgery.

Read more about the AAPA survey.

This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.

RWJF Pioneering Ideas Podcast: Episode 6 | What if? Shifting Perspectives to Change the World

Oct 20, 2014, 9:00 AM, Posted by Pioneer Blog Team

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RWJF's Pioneering Ideas Podcast is on iTunes! Don’t miss an episode—click to subscribe.

Welcome to the sixth episode of RWJF’s Pioneering Ideas podcast, where we explore cutting edge ideas and emerging trends that can help build a Culture of Health. Your host is Lori Melichar, director at the foundation.

Ideas Explored in This Episode

Sharing Health Care Providers’ Notes (3:08) OpenNotesTom Delbanco and Jan Walker talk with RWJF’s Emmy Ganos about why they decided getting health care providers to share their notes with patients was an essential innovation–and where their work is headed next. Here’s a hint: what if the  3 million patients who now have easy access to their clinician’s notes could co-write notes with their providers?

Rethinking How We Solve Poverty (18:46) Kirsten Lodal, founder and CEO of LIFT, talks with RWJF’s Susan Mende and shares some simple ideas with the potential to revolutionize our approach to helping people achieve economic stability and well being. In a thought-provoking conversation, Lodal connects the dots between improving the well being of those living in poverty and building a Culture of Health.

A Historian’s Take on Building a Culture of Health (27:58) – Princeton historian Keith Wailoo and RWJF’s Steve Downs discuss how deeply held cultural narratives influence our perceptions of health, and how today’s “wild ideas” are often tomorrow’s cutting edge innovations.

Sound bites

...On opening up health care providers’ notes and what’s next:

“What I would like to do is spread the responsibility for health beyond the health care system. The health care system is good; I hope that it gets better, but there are so many other parts of our lives that contribute to our well being.” – Jan Walker, OpenNotes 

“It will be a very different world in the future. And we do think that OpenNotes is kind of giving people a peek into it. It's a first glimmer that this kind of transparency, this kind of approach to things, while it's passive now, it just opens up an enormous amount of possibilities for the future. And that's what really excites us.” – Tom Delbanco, OpenNotes

...On rethinking how we solve poverty:

“People's lives are like rivers... they flowed before coming into contact with us, and they will flow after having contact with us. And so the opportunity that we have, the privilege that we have is of most positively affecting the trajectory and the velocity of that flow. But if we forget that–if we get too swept up in having to own everything that happens in a person's life–then we won't build the best solutions, because we won't build solutions that provide people with the support they need to navigate the flow of that river over the long term.” – Kirsten Lodal, LIFT

...A historian’s take on building a Culture of Health: 

“Our concern with aggregate trends is an important one in tracing the shifting demographics of health in our country, but to understand what health actually means involves actually putting the data aside and thinking about lives and thinking about individuals and thinking about what these trends mean on an individual level.”– Keith Wailoo, Princeton University

Your Turn

Now that you’ve listened – talk about it! Did anything you heard today get you thinking in new ways about how you can help build a Culture of Health? Do you have a cutting-edge idea you’d like to discuss? Comment below or tweet at me at @lorimelichar, or consider submitting a proposal. Be sure to keep the conversation and explorations going at #RWJFpodcast.

Join the Conversation

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Exploring Citizen Science

Jul 31, 2014, 11:34 AM, Posted by Christine Nieves

Christine Nieves / RWJF Christine Nieves, program associate

I remember the distinct feeling of learning about Foldit. It was a mixture of awe and hope for the potential breakthrough contributions a citizen can make towards science (without needing a PhD!). Foldit is an online puzzle video game about protein folding. In 2011, Foldit users decoded an AIDS protein that had been a mystery to researchers for 15 years. The gamers accomplished it in 3 weeks. When I learned this, it suddenly hit me; if we, society, systematically harness the curiosity of citizens, we could do so much!

This is the spirit behind our recent exploration to learn more about how citizen scientists are addressing some of the most pressing problems in health and health care.

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Choosing Wisely: Intensifying the Spotlight On Health Care of Dubious Value

Apr 30, 2014, 8:52 AM, Posted by Susan Dentzer

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“If you study the kinds of decisions that people make, and the outcomes of those decisions, you’ll find that humanity doesn’t have a particularly impressive track record,” write the brothers Chip and Dan Heath in their masterful book Decisive. Invoking research from psychology and behavioral economics, the Heath brothers demonstrate how people often make decisions by looking at what’s in the “spotlight”—the information immediately before them, sparse as it may be.

But what’s in that spotlight “will rarely be everything we need to make a good decision,” the Heaths counsel. To choose wisely, we need to broaden our focus, or “shift the light.”

That’s especially true in health care, where the consequences of any decision, poorly made or not, may be life or death.

Enter Choosing Wisely, a program that shifts the spotlight onto many of the tests and treatments that both providers and patients should question, if not abandon completely.

(Editor's note: On May 2, 2014, RWJF held a First Friday GoogleHangout to explore how Choosing Wiselysprang from critical examination of the overuse of medical care in the United States—and how it’s changing how care is delivered in communities. Watch an archived version of the Hangout, above.)

This two-year old campaign, launched in 2012 by the American Board of Internal Medicine Foundation, has identified more than 250 tests and procedures that warrant scrutiny because they are ineffective, unnecessary, unsupported by evidence, or possibly harmful. Even so, physicians and other clinicians perform them regularly, and patients sometimes request them.

Fifty-four of the nation’s premier medical specialty societies have joined the Choosing Wisely effort, and most of these have contributed to their own lists of questionable care. This week, three non-physician groups will also sign on to the campaign. Among the categories of dubious care identified on various societies’ “top five” lists are these:

  • Excessive imaging: CT or MRI scans for low back pain shouldn’t be ordered within the first six weeks of treating a patient, unless there are severe neurological symptoms, while patients with minor head injuries shouldn’t routinely get a head CT unless they have a skull fracture or are bleeding. Excessive scans expose patients to radiation that increases their lifetime risk of cancer.
  • Unnecessary medications: Antibiotics are not effective against viruses and should not be prescribed for viral illnesses such as sinus infections or bronchitis, particularly in children. But doctors say they frequently feel pressured to write these prescriptions by anxious parents.
  • Superfluous screening or diagnostic tests: Patients with no symptoms of heart disease and are at low risk of developing it are still frequently subjected to electrocardiograms when they get routine physical exams, despite evidence that this routine screening doesn’t improve patient outcomes. By the same token, hospitalized patients may have their blood drawn countless times for costly diagnostic testing that often yield little useful information, and can contribute to anemia.

The Robert Wood Johnson Foundation is supporting Choosing Wisely with a $2.5 million grant to extend the influence of these lists beyond medical specialty societies and into communities. State medical societies in Texas, Oregon, Minnesota, Tennessee, Washington, and Massachusetts have undertaken steps to promote the lists, including developing continuing medical education courses for doctors. So have ten regional health collaboratives, such as Maine Quality Counts and the Washington Health Alliance outside Seattle (both are among RWJF’s Aligning Forces For Quality communities as well).

Consumer Reports and AARP are among organizations that have taken the lead in publicizing the lists for consumers. All told, these efforts have reached an estimated 170,000 or more physicians and 16 million-plus consumers. There’s even a Wikipedia page for the campaign, with the lists of tests and procedures curated by a “Wikipedian” in residence.

Caveats: Although more than 200 articles have been written about aspects of the campaign in medical journals, there is as yet little hard evidence that is has reduced superfluous care. A recent perspective in the New England Journal of Medicine noted that the specialty societies’ lists “vary widely in terms of their potential impact on care and spending”—and suggests that some societies omitted lucrative elective procedures, such as knee replacement surgery, that also aren’t appropriate for many patients.

The bottom line: As a nation, we need to shine a spotlight on an even broader range of questionable health care in the future. But for now, the Choosing Wisely campaign is illuminating plenty of “care” that we can clearly pass up with impunity as we pursue our real objective:  better health.

 

How Can Health Systems Effectively Serve Minority Communities? Improve Medical Literacy, Take a Holistic Approach.

Apr 28, 2014, 2:45 PM

To mark National Minority Health Month, the Human Capital Blog asked several Robert Wood Johnson Foundation (RWJF) scholars to respond to questions about improving health care for all. In this post, Cheryl C. Onwu, BS, a public health graduate student at Meharry Medical College, responds to the question, “What are the challenges, needs, or opportunities for health systems to effectively serve minority communities?” Onwu is a Health Policy Scholar at the RWJF Center for Health Policy at Meharry Medical College.

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A doctor informed an African American male that he has diabetes mellitus, and medication was prescribed. However, the doctor did not mention the extent of the dangers involved in having diabetes, or “the sugars.” Additionally, the doctor did not explain the detrimental effects if the patient failed to follow the prescription regimens and other recommendations.

Some of the challenges faced by minorities include lack of medical literacy, which can affect their overall health. Clear communication between a health care provider and his or her patients is important, so patients are cognizant of their health status, the importance of maintaining a healthy lifestyle, potential threats to well-being, and how to control health problems.

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From Trauma to TED: Boston Marathon Survivor Adrianne Haslet-Davis on Recovery, Care, and Collaboration

Apr 21, 2014, 12:30 AM, Posted by Shaheen Mamawala

Boston Marathon survivor Adrianne Haslet-Davis performs at TED2014 Adrianne Haslet-Davis (photo by James Duncan Davidson)

Last month, I attended my first TED conference in Vancouver, Canada. Though inspiring, it was also overwhelming—in a sea of over 1200 guests, it can often be challenging to make meaningful personal connections. However, when I saw Adrianne Haslet-Davis step onto the stage and dance a beautiful rumba while wearing her prosthetic leg, I knew she was someone I wanted to meet.

While Adrianne and I had just a quick exchange of hellos in person at TED, I was further inspired by the message she wrote when she stopped by our RWJF Culture of Health Café. There she offered her own vision of a Culture of Health, framed within her personal experiences as a victim of the 2013 Boston Marathon bombing. Adrianne graciously offered to expand on her personal Culture of Health vision in a brief interview with me.

Shaheen: You recently returned from TED2014 in Vancouver, where you gave a powerful dance performance. Tell us about that experience.

Adrianne: It was no question at all where I wanted to dance [publicly] again for the first time.  It was important for me to do it at TED because I so strongly believe in TED’s message of getting people to think outside the box about issues that maybe we don’t know we’re interested in. I think it’s really eye-opening in that way.

I went into the project with Hugh Herr, director of the Biomechatronics Group at the MIT Media Lab, who came to me and said “Adrianne, I think we can make this [performance] happen but I’m not going to guarantee it. Are you in?” I said yes because it really helped me have a goal.

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The World’s Biggest Expert In Me

Mar 24, 2014, 2:03 PM, Posted by Anne Weiss

Flip the Clinic Graphic for Advances

I've worked at the Robert Wood Johnson Foundation for almost 15 years, and it’s still thrilling (and a little intimidating), working with some of the world's leading experts, thinkers, and innovators, not to mention colleagues who are brilliant, passionate, and kind. While I’ve never admitted this before, as a long-time fan of television medical dramas the people from clinical backgrounds, the “white coats,” especially fascinate me. The doctors, nurses and other health professionals I work with seem part of some mysterious club, survivors of years of arduous training who have the ability to improve peoples' lives in a way I simply can't.

But it turns out that I am an expert, something I learned from a new Robert Wood Johnson Foundation initiative called Flip the Clinic. Flip the Clinic aims, quite simply, to help patients and their doctors (or other providers) get more out of the medical encounter: that all-too-short office visit that leaves both parties wishing for more time, more information, more of a relationship. You can learn more about the history of Flip the Clinic, including its intriguing name, here.

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Creating a Knowledge Map with Stanford Medical School

Mar 24, 2014, 1:00 PM, Posted by Michael Painter

Mike Painter, senior program officer Mike Painter, senior program officer

Why should I be in the same room with these people?

That’s one of the many smart questions participants posed at a Stanford Medical School meeting I attended last weekend.  If I had been daydreaming (I’d never do that), I might have thought the question was for me. You see, the participants were a handpicked set of national medical education experts, folks nominally from the status quo medical-education-industrial complex—the very thing we’re trying to change.

You might think that they embodied that dreaded status quo.  I’m happy to report they did not—not even close.  I’m also relieved to tell you that the question (in spite of my paranoia) wasn’t for me. Instead, it was one of many challenges these thoughtful, passionate teachers tossed at each other.

“Why are we in the room?” was a challenge to each other. Why and when should teachers be in the same room with the learners?

When you think about it, that’s actually a central question if you’re attempting to use online education to flip the medical education experience.  It’s also a brave one if you’re a teacher: justify the time you spend with your students.

Read the rest of this post on The Health Care Blog

This commentary originally appeared on the RWJF Pioneering Ideas blog.

‘Teamwork Works’: Lessons Learned From the Front Line of Team-Based Care

Mar 14, 2014, 9:00 AM

As the patient-centered medical home (PCMH) has emerged as a model for providing effective team-based care that can help offset the impending primary care provider shortage, so, too, is there a growing need for educational strategies that promote interprofessional collaboration. A short report published online by the Journal of Interprofessional Care describes the strategies in place at the VA Connecticut Healthcare System Center of Excellence in Primary Care Education (CoEPCE) and indicates promising results in just one year: doubled productivity in patient care delivered by faculty providers, and a marked increase in same-day clinic access for patients receiving care from an interprofessional team.

The Connecticut CoEPCE, like four other program sites funded through the U.S. Department of Veterans Affairs Office of Academic Affiliations, builds on the VA’s system-wide PCMH model, known as Patient Aligned Care Teams (PACT). It seeks to develop exportable models of interprofessional education and patient care, according to the report, “Moving From Silos to Teamwork: Integration of Interprofessional Trainees Into a Medical Home Model.” The CoEPCE sites share four core curricular domains—shared decision-making, sustained relationships, interprofessional collaboration, and performance improvement—and the Connecticut center groups together physician, nurse practitioner (NP), pharmacy, and health psychology trainees.

The trainees divide their time evenly between interactive educational sessions and caring for patients, guided by faculty who provide supervision, mentorship, and collaborative shared care. Additionally, the Connecticut center incorporates a one-year post-master’s adult NP interprofessional clinical fellowship, to further enhance clinical proficiency and teamwork experience for NPs.

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