When the COVID-19 pandemic swept communities across the country last spring and led to mass illness, hospitalizations and deaths, leaders from many patient care organizations began mobilizing both for optimal patient care and for what managed to reduce hospitalizations at a time when many hospitals were filled to capacity. How to properly care for patients with COVID-19 who do not need to be hospitalized but require intensive care?

In California, leaders of the Kaiser Permanente Southern California Integrated Health System, which includes hospitals, medical groups and a health care plan, quickly developed a clinical home monitoring program to reduce the burden on the health care system while keeping patient safety at the forefront. The program was commissioned by Kaiser Permanente’s Southern California regional executive leadership as well as Southern California Permanente Medical Group leaders. A working group was formed that included clinical and operational leaders from pulmonology, infectious diseases, hospital medicine, emergency medicine, continuity of care and population health management. Through a partnership with the organization’s health care innovation department, a set of care pathways was developed in which patients who are given equipment, including a pulse oximeter and thermometer, are given access to an app on a smartphone or computer in which they enter their daily vital signs and symptoms. The program is enhanced with patient education and real-time support in English or Spanish. All of this is supported by a centralized clinical pool of nurses and physicians working 24/7.

To date, more than 16,000 patients have participated in the program, of whom approximately 95 percent have recovered and completed the program and 10 percent have been hospitalized for timely treatment. A higher percentage of patients who died or were hospitalized were found to have comorbidities. Of the patients included in the program, 47 percent were admitted from an inpatient unit, 25 percent from an emergency department and 28 percent from an emergency or outpatient unit. The large number of demographically diverse patients was handled in a short period of time, and the program served as a safe alternative for treating patients outside the organization’s inpatient facilities. For this groundbreaking work, Healthcare Innovation editors honored the Kaiser Permanente Southern California and Southern Permanente Medical Group team as the third place winner in the Healthcare Innovation 2021 Innovator Awards program.

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In Memphis, Tennessee, black women are about three times more likely to die of breast cancer than white women. The Memphis Breast Cancer Consortium (MBCC), formed in 2016, was the first phase of a comprehensive community-wide effort to address disparities.

While several activities had already been implemented to raise awareness of breast cancer disparities and service delivery, MBCC members began by creating the first-ever community-wide report. (Common Table Health Alliance (CTHA) is the administrative center for the Memphis Breast Cancer Consortium. CTHA has been focused on health equity and health disparities for more than 21 years.)

MBCC is now working to understand and improve the way care is delivered. “By developing patient-centered care, MBCC plans to systematically address the root causes of disparities,” Carla Baker, the group’s chief operating officer, said in a statement.

MBCC currently represents 38 member organizations, including survivor groups, consumer advocacy groups, health systems, universities, health plans, the Shelby County Health Department and the Tennessee Department of Health.

The group created the Care Pathway initiative, sponsored by Amgen, to establish baselines for quality of care with the overall goal of improving quality of care. Rabble Health, a digital patient engagement company, evaluated 81 breast patients on their ability to receive optimal care and services. After a baseline assessment, solutions to improve health literacy and patient empowerment were highlighted, including the myRabble digital patient engagement platform.

“The data from the Margaret West Comprehensive Cancer Center, part of the West Cancer Center, was remarkable,” said Aubrey Kelly, CEO of Rabble Health, adding, “As a full-service facility, many breast cancer patients treated at West were able to have same-day mammograms and biopsies if needed. With cancer, every day matters, and patients should be given the tools and resources to communicate, understand their options, communicate treatment goals and manage their diagnosis . The effectiveness of the care delivery system can lead to optimized care and potentially improved outcomes.”

Preliminary findings include a call to action for breast centers to address disparities in care by measuring adherence and improving quality and health literacy.

“To make a significant impact on health disparities, our health centers must take an objective look at their data, policies and practices,” said Gregory Vidal, M.D., a breast oncologist at West. We are pleased to see independent data supporting the exceptional level of care we provide to all patients at our West Cancer Center. We hope that this approach can be replicated in other facilities to help eliminate disparities in care in our beloved city.”

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The COVID-19 pandemic put a lot of pressure on the entire health care ecosystem, and one of the biggest early challenges for patient care organization leaders was navigating the new landscape of transitioning a large number of in-person visits to telemedicine. While the pandemic has certainly impacted many health care institutions, hospitals have been disproportionately burdened; the American Hospital Association estimates that hospitals have suffered a financial loss of $202.6 billion, or an average of $50.7 billion per month, from March 1 to June 30, 2020. Part of that group in great financial difficulty were children’s hospitals, of which there are more than 250 In a May 2020 letter to then U.S. Department of Health and Human Services (HHS) Secretary Alex Azar, executives from more than 75 children’s hospitals were explained that their revenues had dropped by more than 40 percent and were suffering losses of about $2 billion a month. One of the largest pediatric health systems in the United States, located in North Texas, sees about 75,000 patients each year as part of one of the largest pediatric health systems in the United States.

However, like most organizations across the country, the typical patient experience at Children’s Health began to change rapidly as COVID-19 became more prevalent in the Dallas metro area. Suddenly, patients became hesitant to attend their in-person appointments, make new appointments, or receive medical care in general for fear of contracting the virus. About 15 percent of pediatric patients nationwide are classified as children with special health care needs, and about 3 million U.S. families have more than one child with such needs, as indicated by the Special Needs Financial Planning Organization. At Children’s Health, in particular, the organization’s behavioral health team, which offers its patients a variety of behavioral health services, treatments and therapies, recognized that their core work would become even more important in these unprecedented times, prompting team members to change their existing strategies and operations to ensure comfort and safety for both patients and their families.

When the behavioral health team assessed the patient population at the beginning of the pandemic, three key groups came to the fore: general patients with various medical conditions; patients recovering from substance abuse; and people with developmental disabilities. With this key audience information, the behavioral health team set out to create strong alternatives to traditional face-to-face care, and the efforts of the integrated behavioral health team and the health system’s virtual health program led to it being named a third person.

School-based mental health moves into the home As part of a common cohort of patients with a variety of conditions, Children’s Health’s school-based remote behavioral health program virtually connects students in 178 North Texas schools with licensed mental health professionals. addressing common behavioral health issues, including depression, anxiety, self-esteem and coping skills. Usually in this program, the school will identify a student with a potential behavioral health need and then, if deemed necessary, refer the student to Children’s Health. If such a referral occurs, a licensed health care provider will conduct family outreach, conduct a behavioral health assessment, provide supportive telephone case management and, when clinically appropriate, offer telehealth behavioral health therapy sessions at the student’s school. at the school and with a physician at another location.

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