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May 13, 2020
The Health of Aging Populations State Health Policy Leadership Delivery System Reform COVID-19
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Before COVID-19, Rhode Island’s health care institutions and providers determinedly competed with one another, fighting over turf and patients. We tried a number of times to better align resources, but politics and egos often got in the way. Financial incentives challenged common sense and best practices. Inefficiencies became the norm. Patient outcomes and health care cost trends were worse as a result.
This is hardly unique to our community. These trends play themselves out nationally, too. The lack of cooperation in the health sector has contributed to rising obesity rates, falling life expectancy, and health care spending rising to comprise approximately 18% of the US gross domestic product. The system has been failing in slow motion.
The correlation between rising health care costs and falling health outcomes points to a worrisome conclusion that providers aren’t prioritizing their patients. But during the pandemic, our priorities have been realigned to meet the needs of patients. Health providers across the continuum of care are adjusting their services and collaborating in inspiring ways, especially for those most vulnerable to the pandemic: elderly populations.
Hospitals are doing what they uniquely do best: emergency response and critical care management. They have pushed off urgent elective surgeries and ancillary services to surgery centers and to stand-alone clinics. These surgery centers and specialty clinics are experts at performing certain procedures and have equipment specifically designed for the task.
Primary care clinics are coordinating with hospitals and serving as the first line of defense in managing the pandemic, identifying people with COVID and triaging as appropriate. Telemedicine regulations have been loosened and we are more focused on providing the right kind of care in the right setting rather than making sure we have done all the paperwork first.
My PACE (Program of All-Inclusive Care for the Elderly) organization, which is an integrated provider-sponsored health plan that offers nursing home-level care—has adapted its services to meet the needs of its patients during the epidemic. Fortunately, we are mostly funded through capitated payments from Medicare and Medicaid, which allows us to readily modify our services. Additionally, the interdisciplinary team at PACE—which includes doctors, nurses, social workers, certified nursing assistants (CNAs), physical therapists, occupational therapists, transportation, life enrichment, dieticians, day center directors, and more—already has all the necessary components to serve participants via telemedicine or home care.
Traditionally, our frail elderly participants would come to our centers to receive primary care and attend our day centers. Given the concern for infection, one center remains open for those participants who absolutely need to come in, but otherwise, our health professionals see participants in their homes. We make daily calls and provide activities to help reduce participant boredom, loneliness, and anxiety. We provide meals, medicines, and behavioral health support. Our participants have only had two non-COVID-related hospitalizations as a result.
We have also deepened our collaboration with other health care entities. We offered to serve frail elderly family members of essential hospital workers. Recently, the Hope Alzheimer’s Center program, which also offers adult day care, referred three people to us. We are grateful for Hope’s trust in our ability to temporarily care for their clients. Neither program worried about turf; we worried about the safety and well-being of our older clients.
I believe that as health care providers, we are at our best during a crisis. When we harmonize our efforts to be a true system of care, we create a safety net that more people can rely on. Each provider offers services that are cords in that net; urgent care, an ambulance ride, a home-delivered meal.
At the same time, our local, state, and federal governments should be doing everything they can to incentivize care that prioritizes health outcomes over profits. In the face of reported price gouging for personal protective equipment (PPE) and nursing home space, the Attorney General of Rhode Island has responded swiftly and decisively. That same vigilance can help shape the way our system runs on a daily basis. Going forward, government agencies should consider their own regulatory practices with an eye towards making it easier for providers to do what is right for patients.
Prior to the virus, a supposed competitor agency could not simply “give” a client to PACE. Prior to the virus, a PACE program could not stay open 24 hours. Prior to the virus, home care visits had to be approved and orders written. These changes were made out of necessity, and not all of them will prove valuable after the virus, but we should consider which of them would.
As the health system has responded to COVID-19, there has clearly been more innovation and collaboration in service of the patient. We at PACE are and have always been privileged to care for someone during their worst days or their final hours. This crisis has helped us remember that. Things are not the same. It would be great if they could stay that way.
Joan Kwiatkowski is CEO of the PACE Organization of Rhode Island.
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