Aligning Practice with Policy: Pima Council on Aging

BY JON STONE 

This is the first installment in a serious of blog posts highlighting advanced illness innovation in action. To check out the latest posts in the series, please click here.

His mother was 87 when it happened. Her chest hurt. The pain persisted. He asked her what she wanted for her care: ‘Do you want the doctors to find why you hurt? Will you want them to treat it? Will you want them to just manage your pain?’

His sister tried to get their mother’s wishes recorded too, “but we could not get her to the place of actually reducing all of that to writing,” he said.

“She ends up going to the doctor.  The doctor ruled out heart problems, she ruled out breast cancer.”

A month passed. And another. The pain sharpened.

“She went to see her primary care doctor because she thought maybe her asthma was acting up. He sent her to an urgent care, which in turn sent her to the emergency room at a hospital in Phoenix.”

That’s where doctors diagnosed his mother with Stage Four lung cancer.

She quickly declined.

“An oncologist and pulmonologist came into her room and basically said, ‘You have to understand. We can buy you six months but it’s going to be pretty unpleasant.’”

Mark Clark wasn’t aware of it at the time, but long ago his mother had filled out a document naming him as her health care Power of Attorney (POA), which designates the person who can legally make decisions as to what medical treatment should be given. Although his mother was still competent to make her own health care decisions—and ultimately chose to live out her remaining time in hospice care—knowing the POA was executed would have saved Clark and his siblings uncertainty and heartache.

“These issues of making decisions that you can articulate to a person that you trust—I’ve lived the personal experience of what it’s like when you don’t do that ahead of time,” he said. “Trying to actually get that stuff done ahead of time in a setting where you don’t have an oncologist standing over you with a chemo cocktail in her hand is probably a better way to do that.”

Three weeks after his mother entered the hospital, she died.

On top of the personal and family torment that Clark and his family endured, is the irony that at the time, and to this day, Clark heads The Pima Council on Aging (PCOA), an Area Agency on Aging (AAA) whose scope has increasingly expanded to include promoting the use of POAs and advanced care directives (a legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves).

AAAs are public or private nonprofit agencies established by the Older Americans Act (OAA) that coordinate and offer services to help older adults remain in their homes and communities. PCOA, which serves areas in and around Tucson, Arizona, like AAAs across the country, is charged with offering a range of supports that optimize older peoples’ health, independence, and dignity.  Its mission “to promote dignity and respect for aging and to advocate for independence in the lives of Pima County’s older adults and their families” is an embodiment of the Aging Network’s commitment to improving the quality of care and quality of life of older adults and their caregivers.

Critically important for those who face advanced illness, a key component of the PCOA mission is to help clients learn of and execute the proper documents to express their end-of-life wishes.

That the CEO of an organization serving vulnerable older adults struggled to understand his own mother’s wishes shows how common and pervasive the difficulties that stem from a lack of intentional advance care planning can be. And it reinforces the value of initiating these conversations early and often.

“For us, there would have been fewer unhappy conversations between my siblings and me, and it would have meant that there was less franticness going on,” Clark says.

There are now many different resources through which families and loved ones can receive access to and guidance in initiating advanced care planning.  In addition to populating an advanced care directive, and a health care Power of Attorney, these can include a mental health Power of Attorney, which allows a trusted person to make mental health care decisions on someone’s behalf,  a living will (one kind of an advanced care directive which generally takes effect only during a person’s terminal injury or illness), and a Do Not Resuscitate Order (a doctor’s order that tells medical personnel not to perform CPR if a loved one goes into cardiac arrest).

For example, people can easily access these documents online, and many states, like Arizona, distribute them through their Attorney General’s office. Sometimes eldercare or estate attorneys advocate that their clients execute the documents as part of estate planning.

But increasingly, Area Agencies on Aging across the country are playing a stepped-up role in fueling the effort to ensure older Americans have thought through and expressed their end-of-life wishes.

This represents a significant evolution for AAAs, and a reflection of the importance of advanced care planning—emotionally, medically, financially, spiritually—in the lives of Americans.  AAAs were created to help older people and their caregivers live quality lives with as much independence and dignity as possible.  Traditionally, these efforts focused largely on easing the burdens of day-to-day living: helping older people with meals, in-home care, transportation, budgeting.

But early on, The Pima Council on Aging took steps to coordinate efforts with numerous local organizations to bring advanced care planning resources to community members and to provide clarity and order during a life stage wrought with unpredictability and imbalance.

“A board member came to me who questioned why PCOA was involved in this,” Clark said.  “We were supposed to be all about helping people live full and independent lives.  Not about helping people die.  So, the board had had some robust conversation about that.”

In 2013, PCOA submitted an application to develop a community end-of-life coalition serving the Tucson area.  The idea was to bring together into a community coalition disparate organizations and people—faith communities, hospitals, government entities, eldercare lawyers—who are interested in-end-of- life issues.

PCOA continues to work with entities throughout Arizona which offer advanced care planning services and the people who need them. It serves as the communication help line in Pima County for the Arizona End-of-Life Care Partnership, which is anchored by the United Way of Tucson and Southern Arizona.

PCOA and its staff and volunteers are also directly involved in discussing end-of-life planning with members who bring up the topic or might benefit from learning about it. This includes one-on-one and group-based education and coaching.

Casual observers might notice these collective efforts manifesting all over town—within faith communities, in libraries and other locations. Thousands of the Arizona Attorney General’s end-of-life packets have been mailed to members of the community.

This initiative of this Area Agency on Aging focuses on the far end of the continuum of life. But as Mark Clark sees it, and personally learned from it, “having a good end of life is important to having a good life.”

Innovation in Action: Honoring Choices Minnesota

BY JON STONE 

16 times over the past five winters, an unsuspecting person took to a snowmobile or an ATV or a car, drove it onto a frozen Minnesota lake or river, broke through the ice and later died.

“I was just watching the news about a horrific snowmobile accident where the passenger on the back of the snowmobile is now in the intensive care unit and is non-communicative,” says Karen Peterson. “Decisions have to be made.”

Karen Peterson, Executive Director, Honoring Choices Minnesota

The decisions to which Peterson is referring are often literally ones of life or death.  If the patient will likely never regain consciousness, should doctors remove life support allowing him or her to pass away? Or should they do everything in their power medically to keep that person alive?  

“In the absence of all other information, we do everything possible to keep the person alive.  And so that’s the default that we fall back to if we know nothing else,” Peterson says.

But what if the patient wouldn’t have wanted to be kept alive without having any chance of recovery, or regaining any semblance of a quality of life?

Peterson is executive director of Honoring Choices Minnesota, a Minneapolis/St. Paul-based organization whose focus is on preventing anyone from being in a situation in which their end-of-life wishes are not known and acted upon.

“No one can know what tomorrow will bring,” she says. “It’s our firm belief that all adults — everyone ages 18 and older — should spend at least a minimum amount of time thinking about what they would want to happen if they could not speak for themselves.”

The way to make sure that your wishes are known – arguably, the easy way, and unequivocally the best way to stave off an otherwise agonizing process for your family and loved ones – is to have done Advance Care Planning, which has two components. The first is to talk with loved ones about goals, values and preferences, so that the people who will be involved if something happens to you will know what you want.  The second piece is to complete a Health Care Directive (HCD).  These legally-binding documents let medical teams and loved ones know who you have chosen to make health care decisions for you if can’t do so yourself (in Minnesota that person is known as your Agent; other terms used include “surrogate”, “proxy”, “substitute decision-maker” or “health care power of attorney”).  HCDs also allow you to express considerations for your treatment that reflect your goals, values and beliefs, as well as the specific medical treatments that you would want or not want. This might include receiving or choosing not to receive those that keep you alive artificially.

“It just makes everything so much smoother for the family, and for the health team,” Peterson says.

The problem: an estimated three out of four American adults have not filled out an HCD.  And this is where matters can become complicated, especially in a state like Minnesota.

Most states have enacted laws that govern the “legal next-of-kin” who are empowered to make health care decisions for a person who does not have an HCD and can no longer communicate. Generally, the succession of decision making established in these state laws is, first, a spouse, then parents, then adult children, then siblings, then other relatives, and then friends.

But by choice, Minnesota is one of several states that doesn’t have a legally-defined hierarchy of who makes health care decisions in this situation.  It reflects some concerns. For example: that a non-married partner – who would otherwise serve as the best decision-maker — would be excluded; and, that a spouse who might have been abusive and have contributed to the patient’s trauma could inherit decision-making responsibility.

So while Minnesota’s and some other states’ law might address inherent flaws in pre-determined next-of-kin decision making, it leaves, unresolved, the gaping question of “who, then, will decide”?

Honoring Choices – the advance care planning model that began in Minnesota and now exists in eleven other states –aims to address the existential implications of this question.

Most fundamentally, Honoring Choices Minnesota is attempting to inspire as many adults as possible in the state to start their Advance Care Planning and complete a Health Care Directive, and to help prepare health care teams for situations where there are ambiguities or unanswered questions. 

The key is education.  The organization spans the far reaches of the state to help numerous entities – health systems, community centers, religious institutions, local clinics – with their Advance Care Planning efforts. In addition, it trains health care professionals to have the skills and confidence to hold challenging conversations with patients and their loves ones.

Central to this effort is a process of sharing information, technology and best practices that Honoring Choices Minnesota established with the Twin Cities’ largest health systems a decade ago when they each decided to incorporate the model and work together to execute it.

“From the very beginning that’s been our base that we built on, that in this one area of health care we are not competing.  We are working with each other and we are helping each other,” Peterson says.

This non-competitive collaboration has since expanded well beyond the Twin Cities area.  As patients increasingly switch doctors, specialists, health insurance companies and geographies, migrating from one health system to another, it’s becoming easier for their electronic medical record (EMR) to be accessible to their new health care team in any participating system.  If a patient’s HCD is included in their EMR, the health care team can quickly access and understand the patients’ wishes for their care.

But one of the most potent contributions which Honoring Choices Minnesota makes to the HCD movement is guidance in training health care teams on how to make the correct decisions.

This is a formidable process with correspondingly high stakes.

Sometimes, it involves locating and talking with the agent named in a patient’s HCD, if that person is not physically present and, when notified of the situation, had no awareness of being chosen for that role.

“There would need to be a discussion of ‘why do you think your uncle picked you?’ and exploring the relationship”, says Peterson.  “The attempt would be to spend some time really talking with that agent. Maybe if you can get the nephew talking, he may all of a sudden remember, ‘oh my gosh, you are right.  I did talk to Uncle John and we talked about being on a respirator and he said he never wanted that.’ So a well-trained advance care planning communicator would probe for that kind of information to facilitate the best decisions for the patient.”

More frequently, the health care team finds itself needing to navigate a waiting room full of relatives in the absence of an HCD or a named surrogate. 

“If there’s no disagreement, if a physician comes in and says ‘this is what we think we need to do for your mother, or sister, or brother-in-law, and they present their recommendation to the group of caring people who are in the hospital, and everybody says, ‘Absolutely, let’s do it,’ then you can move forward,” she says.

“It’s when the physician presents a status report and makes a recommendation, and you have five people in the room and five different reactions to that recommendation, that’s where we have to figure out, ok, how do we come to agreement?  Because if you have five people and five different opinions, how are you going to determine what the patient would have wanted if you don’t know who the patient trusted above all others to make those decisions?”

 “Sometimes one of them is a really strong, forceful personality, who overtakes the power of the group, and ends up making decisions.  Then, later, you find out that in fact, the patient’s preference would have been the quiet and thoughtful cousin, but it was never written down legally,” Peterson says.

Educating health teams throughout the state on how to gather facts and nuances, and “read the room” full of well-meaning loved ones, has converted the uncertainty surrounding undeclared health care wishes into more confident decisions on what type of care to administer.

“They talk with the family, they look who is there, they look at the interaction, they look at the legal and relationship connections,” Peterson says. “Most of the time, the vast, vast majority of time, they land on the right person.”

A pre-existing HCD avoids this need to troubleshoot in the first place. The most recent data in Minnesota, based on a self-reporting phone survey conducted by the state’s Department of Health in 2017, showed that 36 percent of the state’s adults had successfully completed an HCD – higher than the national average, which is around 25 percent.  Participation is lower among young adults and far higher among those who are older; some Minnesota health systems report that 90 percent or more of their patients who are 65 and older have filled out an HCD.

“People think about it for a long time, they come to our info sessions, they hear about it, they get the document, take them home, they put them on their desk, they get covered up by other papers, and a year and a half later, they’re looking for something else and they come across it and they go ‘oh – yeah, I guess I should really do something with this.’”

Statistically, the health care wishes of the two 60 (+) year old people who recently broke through the ice and died in Minnesota, were likely expressed through a Health Care Directive.   Those of the four people between 18 and 29 who suffered that fate, were likely not.

“We’re making progress,” Peterson says.  “It’s not going as fast as we like, but we are definitely making a difference.”

Priority Health: High-Quality Care Through Communication

Numbers are foundational to the algorithms and actuary science which contribute to the creation of healthcare payment models. But increasingly, organizations that are trying to promote optimal care for Americans with advanced illness insist that four words are essential to these equations: What do you want?

When people living with advanced illness are asked what they want, their answer, and the discussion it prompts, yields insight that promotes effective and efficient care.

This is how Dr. Greg Gadbois, Medical Director of Priority Health, a Michigan-based Medicare Advantage (MA) plan sees it. As an MA plan, Priority Health receives a per member per month reimbursement from the Centers for Medicare and Medicaid Services to provide its members with health insurance.

5 percent of Medicare beneficiaries are in their last year of life and they account for 28 percent of Medicare spending. This care is expensive because of the frequency with which Americans with advanced illnesses are hospitalized and receive services they did not necessarily want in their last year of life.

Consider how this overall end of life experience and its corresponding costs would change, if earlier and along the way, a doctor, or nurse, or chaplain, or social worker, or a trusted family member would ask their patient, “what do you want” for yourself at this point in your life?

If that person wants to focus on living the highest quality of life with the lowest degree of pain possible, a caregiver might likely suggest introducing advanced illness management, which provides services to relieve pain and improve the quality of life. Just under half of Priority Health’s members who are living with advanced illness are actively involved in an advanced illness management program.

Dr. Gadbois recounts what a colleague told him of his experience after asking a terminally ill patient what he wanted most for himself at this final stage. “He said ‘My daughter is getting married in three months. I want to walk her down the aisle. That’s what I want to do’. So we said, ‘Alright, let’s set a plan up, so that we can get you to that.’”

An interdisciplinary care team, which contributed to this patient’s clinical, psychosocial and spiritual needs, helped him reach what to him was this most important life milestone.

“He was able to walk her down the aisle. That’s what he wanted,” Gadbois recalls from the conversation. “It really comes down sometimes to some of the simple things. In many, many cases, what’s important to them is how do I move from this stage in my life to the next, wherever it might lead me, with as much dignity and grace as I can.”

But providing team-based advanced illness management to stimulate such solutions, faces problems. Medicare’s fee-for-service payment model does not cover the full range of medical, psychosocial, and spiritual supports which people who live with advanced illness need, if they’re not enrolled in a hospice program.

“Your ability to financially support the team that needs to be in place to do this, even if you were able to find up-front funding to do it, still wouldn’t be sustainable long term,” Gadbois says. “The money is just not there from a reimbursement standpoint.”

As an MA plan, Priority Health is required to provide its members with a defined, baseline level of coverage, but any additional covered services offered remain unreimbursed by CMS, and the plan incurs the cost.

Despite this upfront expense, Priority Health provides its members who could benefit from advanced illness management with a full suite of coordinated services and resources, to address their pain and improve their quality of life.

“It’s worth it because we’re doing the right thing for the patient,” Gadbois says. “Your goal is to improve patient outcomes, improve their experience, and also lower the cost of care.”

Gadbois and other healthcare leaders are working to change the way CMS pays for care to incentivize these types of programs. In March, a panel of experts convened by the U.S. Department of Health and Human Services (HHS) supported two alternative payment models which would promote the full use of care teams to provide advanced illness services to people who need them.

C-TAC and the American Academy of Hospice and Palliative Medicine (AAHPM) submitted the models and are working to secure HHS approval for a combined and funded Medicare payment demonstration project.

HHS’s payment demonstration for an advanced illness management program could be many months away. But concurrently, C-TAC believes it’s imperative to convene stakeholders to make sure they are prepared to implement the model. The organization’s 2018 National Summit on Advanced Illness Care, October 9 – 11 in Denver, will bring together healthcare organizations from around the country to, among other front-burner topics, focus on advanced illness clinical and payment models.

Gadbois hopes to receive from the Summit gathering, greater insight on implementing both advanced care planning and end of life discussions across the broader healthcare community. He also expects to learn how C-TAC’s policy advocacy is making a difference to promote end of life care.

“C-TAC stands as one of the strongest advocates for promoting Advanced Care initiatives,” he says. ‘The Summit gives me the opportunity to hear from national thought leaders.”

The Summit will also address other pressing issues in the movement, such as person-centered care programs, caregiver support, policy reform, state and community organizing, healthcare technology, and indicators of success.

Gadbois’ gauge of success is whether his members receive from their healthcare experience what they want. And when that happens, he says, other stakeholders win as well.

“We see significant savings in the long term,” he says. “Someone has to pay for this care. But when you get better outcomes and better experience, isn’t that what we want to do?”

Aligning Practice with Policy: The Carolinas Center

Forty-three years ago – before Medicare funded hospice as a benefit, before for-profit and non-profit hospice organizations proliferated through the country – a small organization in North Carolina tried to do what it could to make what was available to people in the last stages of life, better.

What is now called The Carolinas Center cobbled together grants and volunteers to figure out models that worked to minimize physical and emotional pain.  It fought for government funding to bring hospice care to people who needed it.

The organization expanded its mission by merging with a similar one in South Carolina, where the needs were the same.

“So, fast forward, here we are, we’re still in the trenches, advocating for the needs of providers, clinicians and consumers who are engaged in the care of those living with a serious illness,” says Marisette Hasan, The Carolinas Center’s president and CEO.

But today, The Carolinas Center (TCC) has catapulted to the Cloud, bringing Carolinians – prospectively in the future any adult within the U.S.– a first-of-its-kind innovation to ensure their wishes for their end-of-life care are known and administered.

“We’re just scratching the surface,” Hasan says.  “There’s so much opportunity to raise awareness and to educate our communities on the resources that are available to support patients and caregivers to ensure they can get the right care when they need it the most.”

The Carolinas Center doesn’t provide hospice or palliative care services but is instrumental in assisting organizations that promote care and planning for people in the latter stages of life.  It offers training and technical assistance and regulatory and legislative advocacy to more than 50 hospice and palliative care provider members and other organizational community stakeholders, across the Carolinas.

A challenge for these members is the stubbornly low percentage of people who create Advance Directives (the legally-binding document that expresses the nature and type of care they want at the end of their life), and, who actually receive that care.

“We saw this was a problem, especially for aligning people’s wishes when they can’t speak for themselves,” says David Sevier, developer of a Duke Endowment-funded project to change this situation. “Our research shows 35 to 40 percent of all adults have created an Advance Directive that ends someplace inaccessible, when needed.”  

Carol Meyer, The Carolina Center’s former CEO, along with Sevier and his spouse, a TCC board member, oncology nurse and former cancer center administrator, envisioned a way that technology might address these problems.

The momentum started three years ago with a $1.1 million Duke Endowment Grant to create a cloud-based, online platform to plan and upload Advance Directives at an individual’s request.

“We believe this represents the first time that these documents will be transferred directly from the individual to their electronic health record (EHR),” says Sevier. “Until a directive is uploaded to the health system, it’s outside the (privacy restrictions of the) HIPAA wall.  Then, once you indicate you want to upload it and make it available to your provider, it gets transferred to a health system’s EHR.”

The platform, called Mind My Health, is available to users in the Carolinas through its website: www.mindmyhealth.org. Developers envision the system to be much more widespread in the future.

“Our goal is for people’s care to be aligned to their wishes much more clearly than in the past,” Sevier says.

“It’s a platform for people 18 and older, not just for those who are seriously ill, but healthy folks who need to be shepherding their own health and figuring out what their values are and what they want done,” says Hasan.  “That could be a 20-year-old who’s going to college, or it could be a 40-year-old person diagnosed with a life-limiting illness that could really change the dynamics of their family.”

Once a person fills out an Advance Directive, meets the necessary legal requirements (North Carolina requires two unrelated witnesses, plus a notary) and uploads the hard copy document through Mind My Health, the platform enables them to also email the document to their loved ones or advocate.

Their end-of-life wishes are therefore readily accessible to those who need to know this information at the moment when it’s most needed, rather than being inaccessible, behind lock and key.

“A major concern is if somebody shows up at the E.R., perhaps unconscious from a traffic accident, and somebody asks the question ‘Do they have an Advance Directive?’” Sevier says. “It’s often not accessible, because nobody knows where to look for it.”

This game-changing development in advance care planning emanated from North and South Carolina but will hopefully proliferate further through Internet access via mindmyhealth.org.  Still, its current capability does not yet fully offer the technology’s potential, nor does it reconcile deeply entrenched cultural barriers. 

These are the surfaces which Hasan says The Carolinas Center is starting to scratch.

Technologically, TCC is partnering first with Cone Health, a Greensboro, N.C.-based health system, to interface Advance Directives which Cone patients may upload via Mind My Health. When a Cone clinician accesses the patient’s EHR, a banner note will reveal the patient’s Advance Directive.  One by one, The Carolinas Center plans to integrate this capability within as many health systems as possible.

Culturally, it’s aiming to use other grant dollars to boost advance care planning education and activity in diverse populations where discussing and sharing such information is more challenging. This will involve teaching clinicians and community leaders to initiate the conversation, and to also launch a multi-tiered education and outreach plan to encourage the use of Advance Directives.

“Folks who haven’t had opportunity to talk through what matters to them usually don’t have the kind of ending that they want,” Hasan says. “It’s often filled with regret, where people sit in ICU waiting rooms without the quality of time with the dying person they would have wanted because there wasn’t a discussion earlier.” 

The Carolinas Center has engaged its expansive network within its two-state domain to promote Mind My Health.  The technology is new, but what drives the movement is as old as The Carolinas Center itself.

“We’re all about being a connector for people,” Hasan says. “When the synergy and the connection is right, the mission aligns, and we can make a difference in people’s lives.”

Aligning Practice with Policy: Sharp HealthCare

BY JON STONE

The notion of ‘change’ and ‘healthcare’ might seem contradictory to people who believe that change is long overdue in the administration of healthcare.

But outcroppings of institutional change are developing at all levels of the U.S. healthcare system.

Consider a hospital being seen not as a revenue maker, but as an entity designed to minimize admissions and billings for the greater good of its patients and the community.

That’s the philosophy and practice of Sharp HealthCare, a nonprofit, San Diego-based integrated delivery system, which includes hospitals, medical groups, a health plan, and other practice areas like community-based palliative care.

The highest healthcare costs for Medicare beneficiaries in the U.S. involve people who are in their last year of life.  These costs are most directly tied to services which they receive in a hospital.  But generally, when a patient’s overall health is managed within an integrated system, intervening early before a trip to the hospital reduces costs for both the patient and the health system.

Sharp is achieving such success through its Sharp Transitions program, which provides care for qualifying patients who have advanced illnesses.  Through this program, the patient’s existing care team is expanded to include a palliative nurse, social worker and chaplain, who focus on pain management and the psycho-social effects of their advanced illness.  Often, this enables them to be cared for in their homes. 

“If you can engage your patients upstream, they do better, the costs go down, they live longer, and they experience the entire end of life years in their home,” says Dr. Daniel Hoefer, associate medical director for Sharp Hospice Care.

Sharp says that its Sharp Transition program has contributed to a drop of up to 65% in patient emergency room visits, and that if these patients are admitted to the hospital, they’re 1/3 less likely to be readmitted.  Sharp’s data also shows that only 8% to 11% of Sharp Transition patients die in the hospital compared to more than 50% of advanced illness patients who are not in the program. This combines to yield an average cost savings to the system per patient of $24,000, and a high family satisfaction rating.

Many palliative care programs that provide these services struggle to sustain themselves because Medicare doesn’t pay for the full care team. The challenge is particularly profound for these programs with a high percentage of patients insured by Medicare’s traditional fee-for-service (FFS) model.

“You don’t get the coverage you need for social workers, chaplains, nurses.  It is a cost-ineffective service from that perspective, if you try to run it in fee-for-service,” says Hoefer.  “Virtually all these programs have to have subsidies or donations or some other service to make them run well.“

Medicare Advantage (MA) offers a different payment and incentive structure than traditional fee-for-service. MA plans compensate providers on a per-member, per-month basis, and attach incentives to boosting the health outcomes and satisfaction of the people they serve.  Nearly 50 percent of Sharp’s patients are covered under MA and if the palliative care program keeps them healthier and out of the hospital, the system enjoys the resulting cost savings and better patient outcomes.

But regardless of whether its Medicare patients are enrolled in MA or FFS, it’s still up to Sharp to fund its palliative care team at the point where Medicare stops.  Hoefer believes full government support for these services makes complete sense.

 “There’s a huge cultural change that needs to occur in the United States, starting from the top, recognizing that the best care is keeping patients so healthy that they need no care,” he says.

Two evidence-based proposals under consideration by the U.S. Department of Health and Human Services (HHS) – introduced by C-TAC and the American Academy of Hospice and Palliative Medicine — are paving a path for Medicare payment reform by allowing Medicare to fully fund palliative care programs. This would allow Sharp to sustain and scale its community-based primary care program by being compensated from both MA and FFS.

The result would provide current and prospective patients with broader access to these programs and the confidence to know they’ll be available to maintain and offer their services. The support to health systems –large and small—would promote better health outcomes and the corresponding saving of money.

 “We’re eager for solutions for people who live with advanced illness that coincide with their values and preferences,” says Hoefer. “Inclusive and innovative care models that show promise for future, wide-scale implementation, taking into consideration quality, cost, and accessibility.”

Spinning the (news) cycle: A PR practitioner's take on Peloton’s PR problem

11 months into the Covid-19 pandemic and holed up in our home, in February 2021, the outside world delivered to our door sustaining relief.

Two men lugged a big box to our basement, unpacked and assembled the Peloton bike we ordered more than three months prior.  The impatience we endured prior to its delivery, delayed to due to burgeoning backorders, burned through, and away, with the very first spin.

100 (+) rides later, and to this day, I credit the bike and Peloton’s programming with launching the endorphins that have kept me mentally above water amidst the drowning despair of the pandemic. And so, last week I smiled when I joined my wife for some light entertainment midway through episode two of ‘And Just Like That’ (Sex in the City’s re-boot) in time to see Mr. Big similarly sweating toward the crescendo-ed conclusion of his Peloton ride.

“Companies pay big bucks for product placements like that,” I remarked to Linda.

A few moments later, Mr. Big went into cardiac arrest, living long enough for his TV wife Carrie to arrive home and watch him die.

Stunned, we winced, then concluded, “Ooh. That’s not good for Peloton.”

Peloton, the company, has sustained a fair share of public relations problems the past year, from the  recall of its treadmills last spring following a child’s death and its subsequent response,  to its CEO’s instructor-studded holiday party this past week. HBO’s unexpected scripting of Mr. Big’s post-Peloton death continues to impose a financial assault on its stock price.

Publicly traded, consumer-focused organizations often respond to such events through a statement or comment to provide stakeholders with perspective they need to assess the situation. As a big fan of my Peloton bike, as well as a PR practitioner, I waited for word – the company’s word – on how fictional Mr. Big’s Peloton-induced heart attack was just that: fiction.

Dr. Suzanne Steinbaum, a cardiologist on Peloton’s health and wellness advisory council, delivered the company’s comment within the fictional framework where the PR crisis unfolded. “Mr. Big lived what many would call an extravagant lifestyle, including cocktails, cigars and big steaks and was at serious risk as he had a previous cardiac event in Season 6,” she said.  “Riding his Peloton bike may have even helped delay his cardiac event.”

‘And Just Like That’ is a made-up series. Mr. Big is a make-believe character.  His heart attack never happened.  Peloton’s decision to deliver its initial comment within the HBO-created scene setting is questionable to me amidst the real-life consequences the company sustained in real time.  And in choosing to do so, why not extol the benefits of owning and riding a Peloton bike, rather than diverting focus to the unhealthy, writer-created behavior of the character who died?  

Folks who know me know of my aversion to the practice of “spin” in explaining publicly why something went wrong or fell short.  Spin as a strategy rarely results in an ultimate win (with the exception, perhaps of politicos). For sure, an organization’s public comments should advance its best interests, but many recognize that honesty, forthrightness and even the expression of regret are compatible with that goal. Disingenuousness, half-truths, and deceit spun into a response tend to prolong problems, and foster distrust.

To provide clarity to its audiences, in its initial response, Peloton had the opportunity to forcefully disavow the fake event with simple facts, that might have included:  

·         ‘And Just Like That’ is a fictional show. Scenarios that occur in the series are fiction.

·         Peloton bikes are safe, innovative and best-in-class.

·         Peloton enables nearly 6 million people around the world to meet their fitness goals and improve the health of their heart and lungs.

Several days had passed when the company took steps to attempt to further defend its reputation and that of its premier product by widely distributing a quickly turned commercial.

Created in the vein of the fictional storyline that first caused the controversy, it showcases Mr. Big, along with a Peloton instructor and some Peloton bikes. Belatedly and fleetingly, it ends with a statement Peloton could have delivered from the onset: “Regular cycling stimulates and improves your heart, lungs and circulation, reducing your risk of cardiovascular diseases. Cycling strengthens your heart muscles, lowers resting pulse and reduces blood fat levels,” a narrator asserts.

Creating distance from the issue Peloton unwittingly inherited, the narrator nonetheless gives it a final nod. “He’s alive”, he says in conclusion, a reference to the real actor whose Peloton-precipitated death was never real to begin with.

Building a Bridge Toward Better Health Care

Galina Dronova, University of Minnesota Medical Laboratory Sciences Class of 2014

Ten years ago, Galina Dronova, newly graduated from the University of Minnesota with a bachelor’s degree in Microbiology, experienced the first of two encounters that would inform and indelibly alter her career.

The first occurred as she sat in a clinic lab for a blood draw, and came to the same conclusion she had many times before, in this environment: that she would find her true professional passion somewhere within a laboratory’s walls.

“Every time I went to get my blood drawn, I would see a laboratory and ask, how can I work there?  I was just interested in the clinical field,” she says.

This calling inspired Galina to enroll in the University’s Medical Laboratory Sciences (MLS) program and to graduate with a second bachelor’s degree, this in MLS.

“The program really stirred me,” she says. “It provided a direct application.  You are a certified member of health care.”

Park Nicollet hired Galina to work in its laboratory as a medical laboratory scientist, preparing and analyzing lab specimens, so care teams could diagnose and treat illnesses. She ascended to become team lead. And then, the health system instituted a change that for a second time would steer her professional path in a direction she never anticipated. It recruited her to a temporary role, as it integrated a new lab information system (LIS) called Epic Beaker into its electronic health record platform. Her job was to teach and train others in the lab, how to enter lab data into the system and troubleshoot technology problems.

Following the Epic Beaker implementation, a full-time role developed to assist Health Partners’ Principal  Trainer as a Learning Specialist, and Galina took it.

At about that time and across town, a major development was underway within the region’s health care ecosystem.  Fairview Health Services (now MHealth Fairview) and HealthEast had initiated a merger. The simple premise was that the combined entity would expand access to health care throughout the Twin Cities and provide value to patients.

But like many integrations, executing this vision meant managing through myriad complexities. It would involve merging Fairview’s seven hospitals and multiple primary care clinics, and HealthEast’s four hospitals and its clinics, into one system. 

This included the massive task of combining the IT platforms that support the two entities’ medical laboratories, into one.  And that involved finding a Principal Trainer to teach laboratorians across the system how to use Epic Beaker as MHealth Fairview’s new LIS and integrate it with the Epic Beaker platform that HealthEast already uses. 

Galina accepted MHealth Fairview’s offer to step up to the role.

“I was so conflicted because I love this line of work, but I also loved working directly in the lab,” she says.

The “work” that Galina’s role involves, is to ensure that every MHealth Fairview laboratory professional is fluent on the new LIS leading up to and following the integrated system’s planned go-live date in July, and that they know the system well enough to troubleshoot problems.

To do this, she needed to design a training plan and set in motion a workforce involving credentialled trainers, who train “power users”, who train the “end users”, the laboratorians throughout the MHealth Fairview-HealthEast system, who will be entering the laboratory data into the electronic record.

There are 1,300 laboratory practitioners within the MHealth Fairview system, alone.

“One of the most exciting things about this go-live is that currently we’re one system but we don’t operate on the same lab information system,” Galina says. “It’s going to be a lot easier to track the movement of that specimen from location A to location B because now you’ve built that bridge between the two lab information systems.”

In effect, the contributions of Galina and her team will make it easier for care teams to access a patient’s lab results regardless of where, within MHealth-Fairview/HealthEast the patient received care, where the patient’s lab sample was taken, and where that specimen was analyzed.  The patient will receive results and a corresponding care diagnosis and care plan quicker, as a result.

This allows Galina to continue to feel connected to the laboratory and the people it serves, despite leading a function that moved her away from direct specimen testing.

“I’m technically a part of the health information technology learning development department, but most of my day is actually spent with lab operation, working with laboratory leaders to understand what their needs are,” she says. “If I can teach with the joy and teach the curiosity to empower the user to provide the most efficient workflow or find the information, then I’ve done my job.”

She is equipped to thrive in this role, she says, because of the teaching she received within the University of Minnesota’s MLS program.

“At the University of Minnesota, they don’t just train laboratorians, they train leaders. They teach you high level synthesis problem solving skills, teamwork and the importance of collaboration.  They give you the passion and drive to make this degree whatever you want it to be,” Galina says. “That’s not something that’s written in a textbook, that’s semesters of the culturing of a person.  Where I am today is 100 percent a derivative of what the MLS program has done for me.”

Galina preparing for MHealth-Fairview LIS launch

University of Minnesota Occupational Therapy graduate Helps COVID-19 Patient Recovery

There’s so much Michelle Hutchens doesn’t know about the time gaps that passed between that mid-November day she tested positive for COVID-19, and the vague memory of her son forcing through her door to rush her to the E.R., and the blur of hospital personnel as she emerged from a coma more than a month later.

But the hours and days she later spent recovering in her son’s home played out in painstaking and sometimes painful detail.

The effects of COVID-19 left Michelle winded and strained, unable to ascend from her basement bedroom and to tend to her most basic needs. Every minute was a reminder of the things she couldn’t do, and a cause for worry that she’d never be able to do them again.

“I’m not a patient person, so it was very hard,” she says. 

Less than a week after her discharge, a person Michelle had never met rang the doorbell, introduced herself, and began a process that would restore her self-sufficiency, and calm the anxiety that so commonly accompanies recovery from COVID-19.

Kelly Holden

Kelly Holden, a home health occupational therapist with AccentCare Fairview, brought to Michelle the expertise, inventiveness and compassion cultivated by more than a decade helping people live their best lives possible, and, before that, an immersion in the University of Minnesota’s Occupational Therapy (OT) program.

“The first hurdle with Michelle was the mental aspect of realizing that she was not able to do the things that she was doing before and adjusting to that,” Kelly says. “When she got home, she could barely get up and down the stairs because she was too fatigued. She had bad body aches and back pain, and after lying in a bed in I.C.U. she was very deconditioned.   I had to validate her condition that this was a normal part of the healing process.”

Kelly circumvented the lingering unknowns and uncertainties of COVID-19’s overall effect on a person’s mind and body, with techniques she first learned in the University of Minnesota’s OT program, and has put to use with every patient since.

“She asked what I need help with,” Michelle says. “She’s a great listener.”

“Task analysis is a big thing we learned in school. You have to look at the person, their beliefs, their goals and their physical environment,” Kelly says. “So, our goals were teaching her energy conservation strategies such as sitting for a shower or pacing, taking her time, mixing activity with rest, and trying to wean her off of supplemental oxygen.”

And, Michelle added, regaining enough strength to be able to return to work.

Steadily, the encouragement, therapies, and strategies to help Michelle learn to help herself, enabled her to reclaim her independence, perform tasks that are important to her, and forgo the need for additional oxygen.  Two months after Kelly first entered the home of Michelle’s son, Michelle is ready to move out -- to her own home, and to reclaim the job her employer held open for her.

“I’m elated,” Kelly says.  “That was her goal. To be strong enough to be able to go back to work.”

“They didn’t know if I would walk or talk again,” Michelle says. “I’m excited to work. I’m excited to move. I’m very grateful.”

Michelle Hutchens

Kelly Holden

Kelly and Michelle

“I thrive on structure, but I also love the flexibility that it gives me to choose when and where I do my work”

Andrea's Story

Like millions of others, Andrea Gredvig committed to a university education in 2019, fully unaware of how 2020 would change it.

The University of Minnesota accepted her into its three-year Occupational Therapy Doctorate program, to begin in the fall of 2019, out of its Rochester, MN campus.  This opened the door to Andrea’s dream to become a licensed OT, enabling her to help older people adjust their home environments so they can live there, independently. 

The program’s longstanding hybrid education structure, which combines in-class education, onsite client fieldwork and on-line access to lectures and other classes, appealed to Andrea, allowing her to visit her parents in the Twin Cities while still accessing her coursework.

“I thrive on structure, but I also love the flexibility that it gives me to choose when and where I do my work,” she says. “I can still see my parents and have home cooked meals while also being able to do all of my work and not miss anything.”

Schools around the world wouldn’t know how the Covid-19 pandemic would disrupt their ability to teach, once they were forced to cancel onsite instruction early in 2020.  And students couldn’t know the degree to which the disruption would affect their access to learning.

But the University of Minnesota’s OT program had two things in its favor, as it instituted a Covid-controlled format:

First, its historic expertise and academic success with all aspects of hybrid teaching enabled it to seamlessly switch to on-line only.

And secondly, as experts in creating adaptive therapies, the OT program’s educators put to use their skills to circumvent the challenges of hands-off, socially distant learning.

“We were lucky to have OT professors because that’s what OTs do, we help adapt and modify the activities to fit whatever the needs are,” Andrea says. “Once we switched to fully online, it didn’t feel that different to me.  For example, my professor, with his son who was at home, showed us how we would palpate different muscles on a client, and tips on how to find them.”

Andrea awaits the day when in-person OT interaction can resume. But she also believes her present form of on-line learning lends itself to exploring whether – and how – it might translate into the use of telehealth as a way to help the clients she’ll eventually serve.

Andrea Gredvig

Alumni in Action: Susan Becker, University of Minnesota OT class of '69, still applies skills, 50 years after graduating

“Occupational therapy is hard to explain to people,” says Susan Becker, University of Minnesota OT graduate from the class of 1969. “I remember a joke I heard about this: ‘Physical therapy will get you ready to run a marathon and occupational therapy will make sure you have your pants on.’”

It turns out the endurance of Becker’s own OT expertise spanned more than a marathon, when she found herself applying her skills earlier this year, 50 years after she graduated from the “U”, to help someone who’s very close to her.

That person was herself.

Following complicated back surgery, Becker says she developed an infection that required more surgery, and she sustained cracked vertebrae during her transport to and from a nursing facility.  The ordeal left her temporarily unable to walk, and in a rehabilitation facility. “The occupational therapists had equipment and I showed them how to do it,” she says.  “I was surprised how many of the muscle names and nerves I remembered and the terminology.  I must have learned it really well because it came to me 50 years later.”  

When she left rehab and returned to her Chicago area home last April, she conditioned her arms to accommodate a walker, and her mobility has improved in the time since.

Becker’s ongoing passion for OT and its role in helping improve peoples’ lives began during her research for a report on the topic in 9th grade.  This solidified her determination to study the field. “I thought that sounds really cool,” she said of the profession. 

When she later enrolled in the University of Minnesota, her early studies focused on Classical Greek, before she entered the OT program.  Now, like then, OT students approach the program with a wide variety of academic backgrounds.

And now, like then, OT graduates also apply their expertise within numerous different settings.  Susan Becker chose the intersection of psychology and occupational therapy, working within several Chicago-area hospitals to help psychiatric patients with their daily living skills.  Her career also involved teaching and consulting nursing homes.

Year after year, Becker chose to donate to the University of Minnesota’s Occupational Therapy Program, to “support children, whether it’s for books or some special thing they need to do.”  She has also committed to support an education that continues, to this day, to remain relevant to her own life, and has no plans to stop.

“They’re in my will. I think I’ve been very blessed to have had the education I got and to do the things I’ve wanted to do in terms of working with populations.  Its important to support the people who’ve supported you.”

Susan Becker, University of Minnesota OT class of 1969