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Cardiac rehab is effective, but patient-centered care needs to actually be patient-centered

With CMS’s new Cardiac Bundle, cardiac care (especially post-acute care), is the next service line to go under the microscope. As with total joint, variations in outcomes and costs are often seen in post-acute care so looking at how that care is delivered is key. For any bundle to be successful, engaging patients and ensuring their participation in follow up is a driver of success.

I have to admit, I haven’t read the bundle specs yet, just the news on the bundle. According to Becker’s Hospital Review’s “10 things to know about CMS’ new mandatory cardiac bundle”, the bundle includes provisions to test cardiac rehabilitation services, with 36 sessions available over 36 weeks. However, according to this article from NPR, although cardiac rehabilitation is proven to be effective, most people don’t participate. If you read through the comments on the NPR article (ignoring the trolls of course), you’ll start to see the reasons: cardiac rehabilitation care is built around the needs of the people providing the rehabilitation, not the patients.

From our experiences delivering post-acute care plans, as well as talking to payers and providers we’ve learned a few reasons why patients don’t follow up with their outpatient care:

  • Distance: In cardiac cases, patients are taken to the closest hospital, but this may not be the closest to their home or work. In other post-acute scenarios, they may have gone to a center of excellence that is also at distance.
  • Time commitment: These programs often require multiple days of treatment a week. Not everyone has the flexibility to take off work.
  • Timing: Programs are usually offered during 9 to 5, to accommodate the needs of the providers. Patients might prefer evening or weekend programs. We talked to one provider that focuses on lower income patients. People in hourly wage jobs don’t get to choose when they take breaks and their breaks are usually 15 minutes, and maybe 30 minutes for lunch. It’s next to impossible for them to attend in-person sessions.
Francis Ying/Kaiser Health News

Francis Ying/Kaiser Health News

The NPR article keyed in on these within the one example of Kathryn Shiflett (a healthcare worker herself!) whose distance and work hours (4:30 AM – 3:00 PM) pose a significant barrier: “She lives an hour away and is about to start a new job. Cardiac rehab classes happen Mondays, Wednesdays and Fridays, with sessions at 8 a.m., 10 a.m. and 3 p.m.”

While the bundles are definitely driving the right behavior in focusing on patient outcomes rather than procedures, they need to go further to promote patient-centered care. In this case, that should be testing new models like mobile health or community-based rehab programs that are adaptable to the unique needs of different patient groups.

Posted in: Adherence, Healthcare Disruption, Healthcare Legislation, Healthcare motivation, Healthcare transformation, Occupational Therapy, patient engagement, Patient Satisfaction, Rehabilitation Business, Uncategorized

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This Month [August] in Telemedicine

This Month [August] in Telemedicine

Moderated by:
Jonathan Linkous
Chief Executive Officer,
American Telemedicine Association

Gary Capistrant
Chief Policy Officer,
American Telemedicine Association

This month in Telemedicine webcast was interesting because more than once was the ATA sentiment geared towards realizing the big picture of telemedicine: To help patients. Unless you are lucky enough to work directly with patients that utilized telemedicine on a daily basis, I think sometimes, including myself, we get caught up in the bureaucracy/methodological side of things. Sometimes it takes talking with patient or clinician in order to make me grasp how HIT is improving lives, my life too! So I appreciate the reminder John! At the end of the webcast he asked if you have a personal story of how telemedicine helped you or a loved one ATA needs to hear it, please email John Linkous -jlinkous@americantelemed.org

The main highlight of the first 20 minutes of this webcast focused on the positive trend of telemedicine utilization. Not surprising the younger crowd just beginning their careers in medicine strongly support the use of telemedicine; Medscape conducted a survey and found out that 70% residents had no problem consulting via telemedicine. And maybe because I am of the ‘younger’ crowd (bahaha) I think this is ingenious: the Colorado medicine board is doing away with the rule that patients need to see doctors face to face before utilizing telemedicine; ok so how many times have you gone all the way to the doctor’s office only to get a referral or need blood work done before they can give you a diagnosis/treatment?! Genius! Other interesting facts: 20% of American adults use some technology to track health care (counting steps, migraine triggers & heart rate, etc.) and 57% of households with children access one health portal per a month. Finally big employers are seeing the benefit of telemedicine to cut back on insurance costs; 75% of large employers will be using telehealth as a benefit next year.

Licensure compacts. Ok guys really? Every “This month in telemedicine” webcast talks about this. What is the hold up?! It is so frustrating to me that if I get ill on vacation in Hawaii (ok dreaming, who gets sick in Hawaii?) I cannot get a consult from my doctor over the phone or the internet. This is silly people and it was clear to me that John thinks so as well. He underscored the importance that ATA supports the federation’s compacts in principal, but has some concerns… it is estimated that it will cost 300 million for the 21% of physicians that have more than one state license. Oh money, yea ok that’s the same old hold up every time. Next time they talk about state licensure compacts I am just going to put a dollar sign in my post… you’ll understand.

Circa 1934. Broadcast to Webcast; Radio Technology to Wireless Telegraphy… and now just ‘wireless’. http://www.cio.noaa.gov/rfm/index.html

Frustration was also heard in John’s voice about the FCC Telecommunications Act of 1996. The last Telecommunications act was in 1934, 62 years it took to write a revision, and it looks like it will take another 62 years at the rate they are going! ATA continues to be disappointed in the Act; the FCC estimated there would be a 400 million a year in spending on broadband linking rural healthcare, last year they approved for 200 million. They have only deployed 100 million; only spending a quarter on what the program was supposed to spend- “they need to step up.” Why John? They have 62 years to spend that!

A big note: telemedicine care for post discharge (knee and hip replacements) isn’t expanded out to Physical and Occupational Therapy for Medicare patients. CMS has waived two of Medicare restrictions: allow any Medicare beneficiary to provide services regardless of where they reside but somehow does not include health innovation- “we will be commenting to CMS” and so they did in a letter dated 9/8 strongly urging CMS “…to allow for PT and OT to provide rehabilitation by telehealth means, otherwise covered by Medicare…”

The ATA Fall Forum is next week (9/16-18) in Washington D.C. (and yes I put in D.C. being from Washington state!) with the highest registration rate ever and the exhibits have sold out. They actually have a ATA meeting mobile app for those of us that cannot make it. With a conference that has “Tele” in the name, I see this as the most logical and sensible way to attend.

Posted in: Healthcare Technology, Healthcare transformation, Occupational Therapy, Physical Therapy, Rehabilitation Business, Telemedicine

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Should Patients set SMART or MEANING(ful) Goals?

Goal setting provides incentive, improves adherence, and helps measure progress. Right? Maybe. Presenters in the session “Goal Setting in Rehabilitation: Theory, Practice, Evidence” at the annual American Congress of Rehabilitation Medicine conference in Toronto were consistent in their believe that goal setting is important for rehabilitation but also pointed out a lack of evidence and a distinct lack of consistency in application. It seems that goal setting theory in healthcare has been largely borrowed from business and sports, and while it makes sense that goal setting should help patients, there is not a lot of decisive evidence and there is a lot of debate on how goals should be set.

Does goal setting work?

A survey of the clinical research on goal-setting in rehabilitation showed that goal setting didn’t improve physical function, however it did improve patient self-efficacy. Evidence was inconclusive on whether goal setting affected motivation, adherence, or engagement. However, the overall analysis showed a statistically significant difference in favor of goal setting. The issue is how goals are set and could setting them differently improve care.

How are goals set?

Currently the usual care condition for setting goals is having healthcare professionals set them instead of patients. The problem with this is that the goals may be SMART, but they are not meaningful for the patients. There is often a mismatch between patient and physician goals: physician goals are often functional goals and patient goals are quality of life or aspirational goals. Since goal seems to have a bigger impact on intrinsic factors, like efficacy and possibly also satisfaction, it seems that patient-directed goals would be more effective.

The following are “SMART goals” adapted to apply in rehabilitation. However, the speakers adapted them slightly to apply more directly to rehabilitation. (Assignable rather than achievable.)

Specific, measurable, assignable, realistic, time bound
 
 

How should goals be set?

Goals that help a patient connect with their care plan are preferred, for example, goals that fit the following criteria.

MEANING goal setting

 

While presenter Kath McPherson from the Auckland Institute of Technology argued that patient goals could be vague and also asked why goals had to be realistic: wasn’t it better that the patient continued to hope and work towards something, William M. M. Levack the concept of helping patients set “fiduciary” goals. That is, guide the patients goals based on the situation more initially and less as the patient gained autonomy. To illustrate this he used the example of Mr Roberts a blind diabetic amputee who had a goal of going home to live. If Mr. Roberts’ goal were the only thing taken into consideration, it would ignore the realistic factors that might not make this possible, for example, his wife’s ability to care for him. As such, a better approach for goal setting for Mr. Roberts was to consider a number of factors including:

  • The values and preferences of the patient
  • Clinical judgment of the healthcare professional
  • Time and resources required for the goal
  • Likely consequences of pursuing the goal

For Mr. Roberts, this approach would look like this:

value pluralism in goal setting

The takeaway from these sessions was the necessity to link the clinicians small functional goals with the patients big aspirational goals. Functional goals are necessary and will measure progress but aspirational goals are what drives patient self efficacy which is so important for recovery.

 

We think a lot about goal setting and patient reported outcomes at Wellpepper. Patient reported outcomes are great tools to show progress and also validate clinical efficacy but they must be linked to patient’s goals for real impact. We’re working on some interesting ways to do this through our technology and are excited to be able to share this with the rehabilitation medicine community.

Posted in: Adherence, Behavior Change, Healthcare motivation, Healthcare transformation, Occupational Therapy, Rehabilitation Business

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APTA Session Recap: What We Say Feeds White and Grey

“Brain‐Enhancing  Strategies for Effective Therapeutic Communication”

Speaker: Karen Mueller, PT,DPT PhD

Therapeutic outcomes are as affected by the therapist’s ability to effect behavior change in their patients as by their clinical skills. However, many healthcare professionals don’t understand the basics. This session by Karen Mueller, PT, DPT, PhD focused on strategies to help improve patient care by examining principles from positive psychology and mindfulness to develop empathy for patients.

We know from research that feeling empathy from the healthcare provider is one of the key factors in patient satisfaction. We also know that a positive relationship between patient and provider is a key factor in improving patient adherence to treatment plans. How much do we think about the impact of the provider on the patient in daily care? Does a more positive and mindful healthcare provider get better results with patients?

The session started with some background research on positive psychology and mindfulness, with reference to renowned happiness researcher Martin Seligman, Director of the Positive Psychology Department at the University of Pennsylvania, in particular the impact of positive psychology in healthcare outcomes.  Unfortunately, our brains are naturally wired towards negativity, which may have been a primitive self-protection mechanism, and it takes a 3:1 ratio of positive thoughts to overcome negative thoughts so we need to actively cultivate positive thoughts to overcome this bias.

Why is this important? Positive emotions appear to create enduring personal resources including creativity, resilience, social relationships, and overall health and well-being.

“The way we choose our words can improve the neural functioning of the brain, in fact a single word has the power to influence the expression of genes that regulate physical and emotional stress” Andrew Newberg, MD

Next the session explored mindfulness, defined clinically as the “cognitive process of directing and redirecting focused attention on an internal physiologic process” and in layman’s terms of focusing and noticing the current experience without attachment, often by using the breath as a tool. Mindfulness has been studied for its impact in healthcare, particularly for managing chronic pain but patients using mindfulness techniques have also seen improvements in fatigue and depression.

Mindfulness has also been proven to be effective in therapeutic practice when used by healthcare providers. A study by Beach et all in 2013, showed that clinicians who practiced mindfulness had an easier time building patient rapport, more patient centered communication, and ultimately more satisfied patients.

Finally the session provided practical advice for people wanting to practice mindfulness when caring for patients:

  • Understand how you are feeling before you meet with a patient. Your negative emotions can have a big impact on them. If you are stressed or burned out, help yourself so you can better help your patients.
  • Speak wisely: express appreciation, speak slowly (slower speech enhances trust and reduces anxiety), speak briefly, check for understanding
  • Listen wisely: paraphrase, don’t interrupt, look at the patient, ask questions

The session provided a comprehensive high-level survey of the topic, and pointed to a wealth of information and research studies for those wishing to explore the topic further to improve their patient care.

Posted in: Aging, Behavior Change, Healthcare motivation, Occupational Therapy

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