Category Archives: Voices from the Field
Nicole Lurie, MD, MSPH, is the assistant secretary for preparedness and response at the U.S. Department of Health and Human Services (HHS), and Kacey Wulff, MPH, is special assistant to the assistant secretary, at HHS. An alumna of the Robert Wood Johnson Foundation Clinical Scholars program, Lurie is the co-author of “The U.S. Emergency Care System: Meeting Everyday Acute Care Needs While Being Ready for Disasters,” published in the December 2013 issue of Health Affairs, which focused on the future of emergency medicine. This is part of a series of posts featuring RWJF Scholars who authored articles in the issue.
As we approach the Affordable Care Act’s March 31 enrollment deadline, data is starting to emerge about how these reforms are making care more accessible, cost less, and, ultimately, Americans healthier. As these reforms take effect, and make our day-to-day health care system stronger, they also result in strengthening communities across the country to become more resilient and disaster-ready.
The gaps that inspired and propelled health reform like untreated chronic conditions and mental illness, and health disparities plague our health care system every single day. During a crisis, like a hurricane, earthquake, or attack, these issues can become magnified. As a result, the ability for individuals and communities to prepare, respond, and recover successfully is intrinsically linked to the strength of the underlying health care system.
The Affordable Care Act expands mental health and substance use disorder benefits and federal parity protections for 60 million Americans. As a result, many Americans who previously have not had coverage for mental health care will have greater access to this and other important aspects of health care. This will help to make the tools that support recovery from injuries sustained during disasters, whether illness, injury, or trauma, more accessible.
This boost in preparedness is important for responding to disasters big and small: the biggest indicator of how a person or community will fare during a disaster is how they were doing before the crisis struck. While health insurance doesn’t guarantee that you will be healthier, it does make health much more likely.
An interview with Sara Rosenbaum, JD, the Hirsh Professor in the School of Public Health and Health Services at the George Washington University, in Washington, DC, and a Robert Wood Johnson Foundation (RWJF) Investigator Awards in Health Policy Research recipient. She is the author of “The Enduring Role of the Emergency Medical Treatment and Active Labor Act,” published in the December 2013 issue of Health Affairs, which focused on the future of emergency medicine. The interview is part of a series of posts featuring RWJF Scholars who authored articles in the issue.
Human Capital Blog: Your article discusses the past, present, and future of the Emergency Medical Treatment and Active Labor Act (EMTALA), adopted in 1986. Could you tell us a little about what moved Congress and the President to create the law, and what its purpose was?
Sara Rosenbaum: The law had several roots. To begin, it was the outgrowth of a good deal of law that came before it, embracing the notion that hospitals should provide emergency care, even without the expectation of payment. So that idea wasn’t unique to EMTALA, but by the early 1970s the expectation that hospitals would provide the community benefit of emergency services had revved up, partly because states had adopted that expectation under their own common law and statutes. So EMTALA was the culmination of a lot of legal precedent. But what prompted passage of the law in 1986 was two things: First, a substantial number of news stories about patient-dumping, particularly in California; and second, on the heels of Medicare payment reform a few years earlier, there was a lot of concern that hospitals would start discharging Medicare patients in an unstable state – sicker and quicker, as the saying went.
HCB: What are the law’s key components?
Rosenbaum: The one everybody knows best is the screening component: If somebody comes to an emergency department and requests an examination, hospitals must examine the patient to determine if there's an emergency medical condition. And if they find one, they must provide stabilization treatment. Or, if the patient has an emergency condition that the hospital is unable to stabilize, it can seek the cooperation of another hospital with more specialized capabilities, and transfer the patient. And then that second hospital has a separate obligation; it can’t just say “no.”
HCB: What’s your sense of how the law operates in the daily life of a hospital?
Robert Atkins, PhD, RN, is associate professor of childhood studies and nursing at the Camden campus of Rutgers, the State University of New Jersey, and director of New Jersey Health Initiatives, a statewide grantmaking program of the Robert Wood Johnson Foundation (RWJF). He is an alumnus of the RWJF Nurse Faculty Scholars (NFS) program.
Human Capital Blog: Congratulations on your position as director of New Jersey Health Initiatives (NJHI). What is RWJF’s vision for the program and for the state?
Robert Atkins: Thank you. As the largest philanthropy in the country devoted specifically to health and health care, the vast majority of Foundation resources are, of course, targeted outside of New Jersey. However, New Jersey is the Foundation’s home state. Consequently, the Foundation has a history and connection to New Jersey that is distinctly different from other states and reflected in the kinds of grants made by the Foundation that benefit individuals, communities, and institutions in New Jersey. Although NJHI is only one facet of the Foundation’s philanthropy in the state, as the only national program office of the Foundation that focuses on a state, NJHI is “the face of the Foundation in New Jersey.”
The Foundation’s vision for NJHI and its other New Jersey or “backyard” grants is that they reflect the very best of what the Foundation can do to improve health and health care. I think this tradition of meeting the Foundation’s highest standards of excellence is evident in the legacy of NJHI, and it is a tradition that I feel privileged to sustain and improve upon.
Shreya Kangovi, MD, is an assistant professor of medicine at the University of Pennsylvania Perelman School of Medicine, executive director of the Penn Center for Community Health Workers, and a Robert Wood Johnson Foundation/U.S. Department of Veterans Affairs Clinical Scholars program alumna.
“What do you think will help you stay healthy after discharge?”
Mr. Manzi, a soft-spoken man in his early 60s, paused to consider. No one had asked him this question before. He had come to the hospital because of blurry vision and thirst too severe to ignore. The doctors told him that he had severe diabetes and hypertension, and that he needed to adhere to a long list of new medications, tests, and appointments.
“Not just medical stuff,” Anthony, the community health worker, continued. “Talk to me about anything. Dealing with shut-off notices, housing issues, whatever you think you need to stay healthy.”
Mr. Manzi opened up. He explained that he was originally from Ghana but had been living and working odd jobs in Philadelphia for 20 years as an undocumented immigrant. He had not had a job in six months and twice, his home had gone into foreclosure. Mr. Manzi was uninsured and had not been able to get outpatient care before coming to the hospital.
“I’m willing to do whatever it takes to stay healthy,” he concluded. “But I need to make sure I can pay for all of these medications and a doctor. And I need some help with the foreclosure—I can’t take care of myself if I lose my home.”
Mr. Manzi’s answers became the basis for his tailored intervention. IMPaCT (Individualized Management for Patient-Centered Targets) is an innovative model of care in which community health workers (CHWs) provide tailored support to help patients achieve individualized goals. Anthony, an IMPaCT CHW, shares socioeconomic background with patients like Mr. Manzi. He and other IMPaCT CHWs are selected for traits such as empathy, active listening, and reliability.
About 19 in every 100,000 American children under the age of five suffers from an inflammatory illness called Kawasaki Disease (KD) that can cause irreversible damage to the heart. If diagnosed early, it can usually be treated effectively, and children can be returned to health in just a few days. But between 10 and 20 percent of treated patients suffer from a persistent fever, or one that recurs after treatment, and they are at elevated risk of developing coronary artery aneurysms. A new study, led by Robert Wood Johnson Foundation (RWJF) Harold Amos Medical Faculty Development Program Scholar Adriana H. Tremoulet, MD, MAS, and published yesterday in The Lancet, offers new hope for patients with KD.
The symptoms of KD include prolonged fever associated with a rash, swollen neck glands, red eyes, swollen red lips, a condition physicians call strawberry tongue, and swollen hands and feet with peeling skin. Current treatment is infusion of intravenous immunoglobulin (IVIG) and aspirin. The IVIG carries the pooled antibodies from the blood plasma of more than 100,000 donors, and in the KD patient, it decreases the inflammation that causes heart damage. The treatment usually works, but some patients’ IVIG-resistance puts them at greater risk and in need of further treatment.
Tremoulet, a pediatric infectious disease specialist at Rady Children’s Hospital in San Diego, conducted a Phase III trial in which a synthetic antibody called infliximab was added to the standard IVIG and aspirin treatment. While the protocol did not affect the patients’ resistance, it had important positive results. “In our study,” Tremoulet said, “we demonstrated that a single dose of infliximab is safe in children with Kawasaki Disease and that this treatment reduced the inflammation in the body overall as well as in the arteries of the heart faster than just using standard treatment with intravenous immunoglobulin.”
Sue No, RN, BSN, is a fellow in the Robert Wood Johnson Foundation Nursing and Health Policy Collaborative at the University of New Mexico (2013-2017). She is working toward her PhD in nursing with a concentration in health policy. This post is part of the “Health Care in 2014” series.
Every New Year brings New Year’s resolutions. It is a time for reflection on years past and to develop actionable changes needed for a hopeful and productive new year. Clearly 2014 is no exception. With the New Year already in full swing, I encourage people—yes, this also includes you, Generation Y—to enroll in a health insurance plan and take advantage of the Affordable Care Act’s (ACA) current and new coverage opportunities in an effort to advance our nation’s culture of health.
You might be asking yourself a few questions such as: Who is Generation Y and why are they important? I am happy to provide answers.
The largest generation, Generation Y, or Millennials, consists of young adults born between 1977 and 1994. This important demographic is key to obtaining a sustainable health care exchange system with affordable insurance plans. Healthy Millennials must enroll in the marketplace to offset the high costs acquired by the disproportionate number of Americans with high medical costs. Unfortunately, only a small number of young adults have participated in the health care exchange since open enrollment. This isn’t surprising.
An Interview with Julie A. Fairman, PhD, RN, FAAN, co-director of the Future of Nursing Scholars program, and Nightingale Professor of Nursing and director, Bates Center for the Study of the History of Nursing, at the University of Pennsylvania.
Human Capital Blog: What is the goal of the Future of Nursing Scholars program?
Julie Fairman: The Robert Wood Johnson Foundation launched the Future of Nursing Scholars program to create a large and diverse cadre of PhD-prepared nurses who are committed to long-term leadership careers that advance science and discovery, strengthen nursing education, and bring transformational change to nursing and health care. It is vitally important that we meet the growing need for PhD-prepared nurses, not only to ensure that we address the shortage of nurse faculty members, but because nurse researchers make valuable contributions to practice and policy. The program will fund schools of nursing to provide scholarships, and it will provide mentoring and leadership development activities to build the capacity of a select group of future nurse leaders. The program’s call for proposals launched this week, and scholars will be selected by the nursing colleges and universities that submit successful program proposals.
HCB: Congratulations on the release of the program’s first call for proposals! As schools begin applying to participate in this program, what would you like them to keep in mind?
Fairman: We are very excited about this program. The major requirement for participation is that research-focused schools of nursing must be ready and able to graduate PhD students in three years. We understand that acquiring a PhD in nursing in three years is not the norm and that many schools have not previously graduated students within that time frame. So, schools are not necessarily ineligible if they have never operated this way, but they will need to provide a thorough description of how they will meet this obligation. We are asking applicant schools to provide information not only about their curricula, but also about their mentoring activities and faculty engagement with research. We also ask that they provide a discussion of interdisciplinary engagement in their institutions, and details about their admission, retention, and graduation of PhD nurses.
Schools that are chosen for the program will be responsible for selecting the scholars who will participate. Schools should select scholars who understand and accept the challenge of completing their PhD degrees in three years. To succeed, the scholars they select will be goal-directed, focused, and committed to long-term academic careers with a focus on science, health policy, and/or innovation. They also should be interested in health policy formulation or in the development of new evidence-based solutions to address health care problems.
Elizabeth Dickson, MSN, RN, is a fellow in the Robert Wood Johnson Foundation (RWJF) Nursing and Health Policy Collaborative at University of New Mexico. Earlier in her career, she worked at a school-based health center (SBHC). This post is part of the “Health Care in 2014” series.
As a public health nurse, I have worked with children in schools for much of my career. From 2009 until 2013, I worked at a SBHC in New Mexico that was located in an alternative high school in southern Albuquerque. Although small, many students at this school came from families of mixed immigration status and had experienced high levels of street violence, alcohol and drug abuse and overdose, suicide, poverty and food scarcity, minimal health care access, and high teen pregnancy rates.
These kids saw and experienced more than many outsiders of the community could have imagined. The SBHC was open one day a week during school hours and employed a staff that included a nurse practitioner, a physician assistant, public health nurses, administrative staff, and mental health counselors. I worked with an incredible team that provided many health services and screenings, including mental health support, in the limited time that we had.
Jay Himmelstein, MD, MPH, is a professor of family medicine and community health and chief health policy strategist at the Center for Health Policy and Research at the University of Massachusetts Medical School (UMMS). He serves as a senior advisor to the UMMS Office of Policy and Technology, and is a senior Fellow in health policy at NORC, University of Chicago. Himmelstein is an alumnus of the Robert Wood Johnson Foundation Health Policy Fellows program, where he worked on the health staff of Senator Edward Kennedy. This post is part of the “Health Care in 2014” series.
The nation's attention has focused in recent months on the politics and challenges related to the roll-out of state and federal health insurance marketplaces created by the Affordable Care Act (ACA). Despite website technical woes, significant numbers of Americans have already gained access to affordable insurance plans through the marketplaces and other provisions of the ACA, and it appears likely that the ‘marketplace’ concept will be successful over time in connecting consumers to health insurance and significantly decreasing the ranks of uninsured.
The better functioning marketplaces currently allow consumers to: 1) determine eligibility for subsidized health insurance, 2) use basic online shopping tools to compare and purchase health insurance plans based on four different "metallic tiers" (i.e., the platinum, gold, silver, and bronze tiers), and 3) make side-to-side comparisons between these plans on features such as deductibles, out-of-pocket cost limits, and number and proximity of doctors and hospitals. A few marketplaces also offer information about plan quality, the ability to search for health care providers and hospitals associated with specific plans, and rudimentary ‘cost calculators’ which estimate the total cost of plans inclusive of premiums, deductibles, and out-of-pocket costs.
Carli A. Culjat, BSN RN, is a staff nurse in the Emergency Department at Bryan Medical in Lincoln, Neb., and an alumna of the Robert Wood Johnson Foundation New Careers in Nursing program. She graduated with her BSN from the Creighton University School of Nursing. This post is part of the “Health Care in 2014” series.
As a new graduate and a young person, I am very eager to see what will happen to my country, my career, and my own future with the changes taking place in the U.S. health care system. As I walked across the stage receiving my diploma, my emotions developed and they included excitement, relief, and fear of the unknown. I believe our county is facing similar emotional complexity. As a new graduate and new employee – change can bring forth so many emotions, especially on the large scale that is taking place in health care today.
The media covers the controversy of the situation and as a former student, my class still uses social media to reach out and develop opinions on the changes and their possible effects. Fear creates controversy and with this, we see so many different perspectives and reactions. Even still, I believe our country is excited for a change and ready for the health care system to evolve into a system that we can be proud of and utilize.
There are many who are relieved, myself included. I am relieved that employment is an option at this time in this changing system, I am relieved that our country has taken the initiative to address a need, and I am relieved that I have an education and position that I can use to assist, in the best way a single person can, in health care reform—as a frontline person, a staff nurse in an Emergency Department.