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Recruiting and Training a Health Professions Workforce to Meet the Needs of Tomorrow's Health Care System

Raffoul, Melanie; Bartlett-Esquilant, Gillian; Phillips, Robert L
The quality of any health care system depends on the caliber, enthusiasm, and diversity of the workforce. Yet, workforce research often focuses on the number and type of health professionals needed and anticipated shortages compared with anticipated needs. These projections do not address whether the workforce will have the requisite social, intellectual, cultural, and emotional capital needed to deliver care in an increasingly complex health care system.Building a workforce that can deliver care in such a system begins by recruiting individuals with the requisite knowledge, skills, and attributes. To address this and other workforce needs, the authors argue that health professions education programs must make purposeful changes to their admissions criteria, such as focusing on emotional intelligence and diversity and recruiting students from the communities where they will return to work; partner with communities; ensure that accreditation systems support these goals of fostering diversity; recruit students who can bridge the gap between public health and health care; and invest in health professions education research.In this article, they contemplate how health professions education programs can recruit and educate talented health professionals to create a high performing workforce that is capable of serving in the complex health care system of tomorrow. They provide examples of successful programs to highlight the potential effects of their recommendations.
PMID: 30681446
ISSN: 1938-808x
CID: 3610762

Financial Viability of Emergency Department Observation Unit Billing Models

Baugh, Christopher W; Suri, Pawan; Caspers, Christopher G; Granovsky, Michael A; Neal, Keith; Ross, Michael A
BACKGROUND:Outpatients receive observation services to determine the need for inpatient admission. These services are usually provided without the use of condition-specific protocols and in an unstructured manner, scattered throughout a hospital in areas typically designated for inpatient care. Emergency department observation units (EDOUs) use protocolized care to offer an efficient alternative with shorter lengths of stay, lower costs and higher patient satisfaction. EDOU growth is limited by existing policy barriers that prevent a "two-service" model of separate professional billing for both emergency and observation services. The majority of EDOUs use the "one-service" model, where a single composite professional fee is billed for both emergency and observation services. The financial implications of these models are not well understood. METHODS:We created a Monte Carlo simulation by building a model that reflects current clinical practice in the United States and uses inputs gathered from the most recently available peer-reviewed literature, national survey and payer data. Using this simulation, we modeled annual staffing costs and payments for professional services under two common models of care in an EDOU. We also modeled cash flows over a continuous range of daily EDOU patient encounters to illustrate the dynamic relationship between costs and revenue over various staffing levels. RESULTS:We estimate the mean (±SD) annual net cash flow to be a net loss of $315,382 ±$89,635 in the one-service model and a net profit of $37,569 ±$359,583 in the two-service model. The two-service model is financially sustainable at daily billable encounters above 20 while in the one-service model, costs exceed revenue regardless of encounter count. Physician cost per hour and daily patient encounters had the most significant impact on model estimates. CONCLUSIONS:In the one-service model, EDOU staffing costs exceed payments at all levels of patient encounters, making a hospital subsidy necessary to create a financially sustainable practice. Professional groups seeking to staff and bill for both emergency and observation services are seldom able to do so due to EDOU size limitations and the regulatory hurdles that require setting up a separate professional group for each service. Policymakers and healthcare leaders should encourage universal adoption of EDOUs by removing restrictions and allowing the two-service model to be the standard billing option. These findings may inform planning and policy regarding observation services.
PMID: 29768698
ISSN: 1553-2712
CID: 3121442

A tick-acquired red meat allergy: A case series

Khoury, Joe Kevin; Khoury, Neil Christian; Schaefer, Deborah; Chitnis, Anup; Hassen, Getaw Worku
Allergic reaction is a common clinical picture in the Emergency Department (ED). Most allergic reactions are from food or drugs. A detailed history is an integral aspect of determining the causative agent of an allergy. Galactose-alpha-1,3-galactose (alpha-gal) allergy is a tick-acquired red meat allergy that causes delayed-onset allergic reaction or anaphylaxis due to molecular mimicry. Alpha-gal allergy may not be widely known as a cause of allergic reactions. Lack of universal awareness of this phenomenon in the ED and Urgent Care setting could lead to misdiagnosis, or delayed diagnosis. Subsequently, lack of proper instruction to avoid red meat could put patients at risk for future attacks with morbidity or mortality. We report three cases of allergic reaction presumed from red meat consumption secondary to alpha-gal allergy.
PMID: 29074067
ISSN: 1532-8171
CID: 2907672

Care of Traumatic Conditions in an Observation Unit

Caspers, Christopher G
Patients presenting to the emergency department with certain traumatic conditions can be managed in observation units. The evidence base supporting the use of observation units to manage injured patients is smaller than the evidence base supporting the management of medical conditions in observation units. The conditions that are eligible for management in an observation unit are not limited to those described in this article, and investigators should continue to identify types of conditions that may benefit from this type of health care delivery.
PMID: 28711130
ISSN: 1558-0539
CID: 2639892

Increased Public Accountability for Hospital Nonprofit Status: Potential Impacts on Residency Positions

Raffoul, Melanie C; Phillips, Robert L
BACKGROUND:The Institute of Medicine recently called for greater graduate medical education (GME) accountability for meeting the workforce needs of the nation. The Affordable Care Act expanded community health needs assessment (CHNA) requirements for nonprofit and tax-exempt hospitals to include community assessment, intervention, and evaluation every 3 years but did not specify details about workforce. Texas receives relatively little federal GME funding but has used Medicaid waivers to support GME expansion. The objective of this article was to examine Texas CHNAs and regional health partnership (RHP) plans to determine to what extent they identify community workforce need or include targeted GME changes or expansion since the enactment of the Affordable Care Act and the revised Internal Revenue Service requirements for CHNAs. METHODS:Texas hospitals (n = 61) received federal GME dollars during the study period. Most of these hospitals completed a CHNA; nearly all hospitals receiving federal GME dollars but not mandated to complete a CHNA participated in similar state-based RHP plans. The 20 RHPs included assessments and intervention proposals under a 1115 Medicaid waiver. Every CHNA and RHP was reviewed for any mention of GME-related needs or interventions. The latest available CHNAs and RHPs were reviewed in 2015. All CHNA and RHP plans were dated 2011 to 2015. RESULTS:Of the 38 hospital CHNAs, 26 identified a workforce need in primary care, 34 in mental health, and 17 in subspecialty care. A total of 36 CHNAs included implementation plans, of which 3 planned to address the primary care workforce need through an increase in GME funding, 1 planned to do so for psychiatry training, and 1 for subspecialty training. Of the 20 RHPs, 18 identified workforce needs in primary care, 20 in mental health, and 15 in subspecialty training. Five RHPs proposed to increase GME funding for primary care, 3 for psychiatry, and 1 for subspecialty care. CONCLUSIONS:Hospital CHNAs and other regional health assessments could be potentially strategic mechanisms to assess community needs as well as GME accountability in light of community needs and to guide GME expansion more strategically. Internal Revenue Service guidance regarding CHNAs could include workforce needs assessment and intervention requirements. Preference for future Medicaid or Medicare GME funding expansion could potentially favor states that use CHNAs or RHPs to identify workforce needs and track outcomes of related interventions.
PMID: 28720635
ISSN: 1558-7118
CID: 3071492

Office Visits for Women Aged 45-64 Years According to Physician Specialties

Raffoul, Melanie C; Petterson, Stephen M; Rayburn, William F; Wingrove, Peter; Bazemore, Andrew W
BACKGROUND:The increase in access to healthcare through the Affordable Care Act highlights the need to track where women seek their office-based care. The objectives of this study were to examine the types of physicians sought by women beyond their customary reproductive years and before being elderly. METHODS:This retrospective cohort study involved an analysis of national data from the Medical Expenditure Panel Survey (MEPS) between 2002 and 2012. Women between 45 and 64 years old (n = 44,830) were interviewed, and reviews of corresponding office visits (n = 330,114) were undertaken. RESULTS:In 2002, women aged 45-64 years (62%) went to a family or internal medicine physician only and this reached 72% in 2012. The percentage of women who went to an obstetrician-gynecologist (ob-gyn) only decreased from 20% in 2002 to 12% in 2012. Most went to a family physician or general internist for a general checkup or for diagnosis or treatment. By contrast, visits to ob-gyn physicians were predominantly for general checkups. Those who went to an ob-gyn office were more likely to have a higher family income, live in the Northeast, and describe their overall health as being excellent. CONCLUSIONS:Women aged 45-64 years were substantially more likely to obtain care exclusively at offices of family physicians or general internists than of ob-gyn physicians. Overlap in care provided at more than one physician's office requires continued surveillance in minimizing redundant cost and optimizing resource utilization.
PMID: 27585369
ISSN: 1931-843x
CID: 3098842

COST SAVINGS AND PALLIATIVE CARE REFERRALS FROM THE EMERGENCY DEPARTMENT

Fermia, Robert; Wilkins, Christine; Rodriguez, Danielle; Read, Kevin B; Gavin, Nicholas; Caspers, Christopher; Jamin, Catherine
Early palliative care consultation ha the potential to provide comfort to patients and families, and decrease costs and length of stay.
PMID: 30571866
ISSN: 2374-4030
CID: 3663862

Observation Services Linked With an Urgent Care Center in the Absence of an Emergency Department: An Innovative Mechanism to Initiate Efficient Health Care Delivery in the Aftermath of a Natural Disaster

Caspers, Christopher; Smith, Silas W; Seth, Rishi; Femia, Robert; Goldfrank, Lewis R
OBJECTIVE: The emergency department (ED) of NYU Langone Medical Center was destroyed by Hurricane Sandy, contributing to a public health disaster in New York City. We evaluated hospital-based acute care provided through the establishment of an urgent care center with an associated ED-run observation service (EDOS) that operated in the absence of an ED during this disaster. METHODS: We conducted a retrospective cohort study of all patients placed in an EDOS following a visit to an urgent care center during the 18 months of ED closure. We reviewed diagnoses, clinical protocols, selection criteria, and performance metrics. RESULTS: Of 55,723 urgent care center visits, 15,498 patients were hospitalized, and 3167 of all hospitalized patients (20.4%) were placed in the EDOS. A total of 2660 EDOS patients (84%) were discharged from the EDOS. The 8 most frequently utilized clinical protocols accounted for 76% of the EDOS volume. CONCLUSIONS: A diverse group of patients presenting to an urgent care center following the destruction of an ED by natural disaster can be cared for in an EDOS, regardless of association with a physical ED. An urgent care center with an associated EDOS can be implemented to provide patient care in a disaster situation. This may be useful when existing ED or hospital resources are compromised. (Disaster Med Public Health Preparedness. 2016;page 1 of 6).
PMID: 27087398
ISSN: 1938-744x
CID: 2079872

Graduates of Teaching Health Centers Are More Likely to Enter Practice in the Primary Care Safety Net

Bazemore, Andrew; Wingrove, Peter; Petterson, Stephen; Peterson, Lars; Raffoul, Melanie; Phillips, Robert L Jr
PMID: 26554280
ISSN: 1532-0650
CID: 1934202

Cultural Competence Education for Health Care Professionals

Raffoul, Melanie; Lin, Kenneth W
ISI:000353249800003
ISSN: 1532-0650
CID: 2373972