The Affordable Care Act brought about the expansion of Erie Family Health Center, the only health clinic in Evanston and Skokie. Long after its opening in Evanston, Erie Family Health Center was under capacity and wanted to reach more people. In contrast, the Evanston and Skokie Health Departments conducted community surveys in 2013 and found that one of the most prevalent health issues identified by the community was access to healthcare.
Something needed to change in the way that people accessed the healthcare system and the way they were connected to information and care. Inequalities in the healthcare system limit the types of care and information for people of different backgrounds. Many people do not know how to access quality health information or where to go for their health-related needs.
A Community Collaboration Promoting Health
Students at Northwestern University are partnering with public institutions, community organizations and university departments to create student-run health resource centers at the Evanston and Skokie libraries. Called the Health Information Resource Centers Utilizing Libraries in Evanston and Skokie (HIRCULES) Health Hub, the initiative will work to promote health literacy, preventative care, awareness of community resources and understanding of the existing healthcare system. The program is powerful and unique; it empowers people to take ownership through guidance, linkage and education.
The HIRCULES Health Hub will provide the Evanston and Skokie community with a trusted central resource where they can be connected to educational materials to improve health literacy. The HIRCULES Health Hub desks will be staffed by Northwestern students trained as medical librarians at Evanston and Skokie Public Libraries. Students will gather resources and search for materials for library patrons. HIRCULES will also include a website with relevant health resources and databases that contain searchable information including frequently asked questions, health services available in Evanston and Skokie and a calendar of health-related community events.
Identifying Challenges, Creating Solutions
The HIRCULES Health Hub will feature monthly themes with digestible and accessible information. Developing these monthly themes has taught staff a great deal about the community and led to new solutions. For example, last summer staff created a Back to School theme and wanted to inform parents where they could obtain school supplies if they could not afford to buy them from a store. The organization that had previously provided this service had recently closed, and with two months until the start of the new school year, no one else was planning to provide supplies to any Evanston school districts. HIRCULES staff reached out to community organizations, Parent Teacher Associations and school district boards to find a point person who ran a program to fill the need for school supplies for low-income students. Because of HIRCULES, real needs of the community were identified and addressed.
Improving Knowledge and Health
Normalizing routine, preventative care is another important aspect of the project. HIRCULES staff will promote preventative care through education of how to utilize Federally Qualified Health Centers and medical homes. Most people are not aware of the implications of the Affordable Care Act, which promotes preventative care. This reduces costs and improves health outcomes over time. Emphasis on preventative care education is imperative in empowering people to utilize pre-acute and ambulatory points of access to health systems. The partnership between HIRCULES and Erie Family Health Center helps establish a healthy lifestyle through regular, preventative primary care checkups and referrals for more complex health services.
Information Hub for the Community
The final objective of HIRCULES is to guide people to health-related resources, simplifying their search for health and wellness and improving services in the existing, complex healthcare system. All available, health-related resources in the community are being compiled into a virtual database accessible online and through visiting the HIRCULES Health Hub. For example, if an expecting mother wants to know where she can access prenatal and postnatal care, HIRCULES staff can direct them to Family Focus. If a parent needs assistance enrolling his or her family in health insurance, they will be connected with a local health insurance navigator and resources from Get Covered Illinois.
These major health issues will take time to address and overcome. Programs like HIRCULES are a vital contribution to making positive changes and improving the health of Evanston and Skokie citizens.
Brittany Zelch & Emery Weinstein
Brittany and Emery are undergraduate students attending Northwestern University Weinberg College of Arts and Sciences who study global health. They helped found and remain involved in the HIRCULES Health Hub.
Hospital Eliminates Paid Bathroom Breaks; Installs Computers In Restrooms For Mandatory Nurse Charting.
"After great thought and input from ourselves, we concluded the ten year plan just didn't have wiggle room in the budget for paid restroom breaks," said Dan Stenwick, Chief Financial Officer at Barner.
"Over the last few years, we've had to make some difficult sacrifices on behalf of our team members to maintain our rapidly rising salaries here in administration. After already eliminating 401-K matches and changing to a $10,000 per year high deductible healthcare plan, we felt getting rid of paid bathroom breaks was the most logical next step."
Starting today, all nurses will be GPS tracked at every moment in the hospital and sophisticated computer algorithms will be able to flag nurses - in real time - who fail to perform any charting while taking refuge in the restroom.
"It's important for our nurses to know that this new policy is not optional and failure to chart while you fart is grounds for immediate dismissal. To help set the stage for our new era in efficiency, we have renamed all our staff restrooms to chartrooms," said Dan.
To enforce the new policy, Barner Hospital hired six new Charting Enforcers to hand out pink slips under the bathroom stalls - 24 hours a day- when nurses are caught not charting with their pants down.
Surprisingly, the policy was receiving mixed reviews by nursing staff. Some of the old-time nurses were outraged while most of the new graduates just figured it was for the good of the team, because they just didn't know any better.
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| Mandatory bathroom charting in the new normal for some nurses! |
"This new policy is crap. I give it a year or two before they figure out how ridiculous it is, like everything else new they try around here," said the experienced nurse. "While going #2 this morning, I accidentally charted I gave 2 Dilaudids instead of 1. Talk about a near miss error!"
Barner quality officials say they have anticipated a rise in multitasking errors and have implemented forms to track #1 and #2 type errors in the chartroom with the hopes of fine-tuning a training program to minimize chartroom errors in the future.
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UpToDate® Forced To Admit Google Used as Their Main Source of Information.
In a prepared statement to reporters, Wolters Kluwer Health, which owns UpToDate, confirmed that Google is hands down the most popular resource used by their 6,000 physician authors to regurgitate medical information into neatly repackaged articles for the $500 per year professional service.
"I don't even know why this is news. Everyone knows doctors have been using Google for years to get their trusted medical information like the rest of us, said CEO Nancy McKinstry.
"As little as 20 years ago, our physicians would have had to go to a library and ask a librarian to find peer reviewed articles, but nobody has time for that anymore. The use of Google is just a natural extension of the internet revolution."
UpToDate says they actually encourage their authors to use lay people resources to fine tine their articles for the current patient-satisfaction-centered model of care. "We know patients are using Google to find their trusted information. It just makes sense for our authors to use Google too so our users don't find themselves in the uncomfortable situation of questioning the accuracy of Google with their patients," said Nancy.
In fact, just last week UpToDate stopped hosting all images on their servers and instead link directly to Google images to help physicians see hundreds, sometimes thousands of examples for any given condition.
"Our goal is to have Google and UpToDate coexist in a perfect symbiotic relationship where doctors feel good about using our service instead of Google and patients feel comfortable their physicians aren't dumber than Google," said Nancy.
"In my article on performing lap appys, I linked to a 2007 YouTube video with over 2 million views I found by typing lap appy videos into the Google search engine. And I even included recommendations on post-operative care from an online forum by a guy who calls himself Knot-A-Surgeon."
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| It turns out Google and UpToDate are pretty much the same thing. |
Fenwick, a Kentucky Hospitalist who's state license totally coincidentally requires 60 CME to be renewed next week.
Recent research confirms the lack of patient mortality difference between physicians preferentially using Google over UpToDate as their research choice. However, one subset of patients did suggest physicians with prolific Wikipedia experience may actually have a slight survival benefit.
"The data is intriguing and we may have to gently nudge our authors to lean more heavily on Wikipedia than we have in the past," said Nancy, who also notes a 78% increase in patients printing Wikipedia articles to show their doctors.
The close relationship between Google and UpToDate has some financial speculators suggesting Google my purchase UpToDate and change its name to GoogleCME®.
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Nurse Admitted to Hospital After Literally Working Her Ass Off.
"I tell my husband and kids all the time that I'm exhausted after working my ass off at work , but I never thought it would actually happen," said Jan.
The strange event occurred while Jan was giving Ativan to an old and naked demented guy trying to ask her out on a date while two young Facebookers demanded more Dilaudid for their abdominal pain of no possible cause, one patient's out-of-town physician daughter was on hold waiting to reverse an end-of-life DNR and two smokers descended on the nurses station, in their street clothes, asking when the doctor would be there to discharge them.
"I was just standing there, overwhelmed with nonsense, when I felt a sudden weight lifted off my pelvis. I turned around and there was my ass laying on the floor in a pool of c diff.," said Jan.
Rapid response team members transported the hard working nurse to the ER where Emergency physicians worked for hours to try and find an admitting physician.
"The ER doctor told me he was working his ass off to find a surgeon to admit me and I just looked at him and shook my head. I told him 'You don't get to say that to me today.'"
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| Surgeons working their asses off to fix Jan's ass. |
"We've got some pretty hard workers here at the hospital but Jan is one of our best. We'll have to take this incident back to our 12 committees to start a root cause analysis," said Wendy Stenson, Vice President of Meetings.
"But regardless of what we find, we just don't have the money to increase staffing ratios. Maybe we'll think about implementing mandatory prophylactic ass taping for all our staff."
Since Jan's remarkable event went viral, she has received hundreds of job offers, but Jan is thinking about taking advantage of the workers' compensation lifestyle for awhile instead.
"I think I've earned it."
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ACA, Medicaid and Unintended Consequences for People with Disabilities
People with disabilities who are eligible for healthcare through Medicaid may experience painful gaps in coverage during transitions. There are groups of people with disabilities that are particularly vulnerable: those who need long-term care services, those who apply but are not yet found eligible for SSI in 209b states with expanded Medicaid and youth transitioning to the adult system.
Long-term care services and supports, such as personal assistance services or durable medical equipment, are critically important to some people with disabilities. Medicaid packages for people with blindness and disabilities, or AABD or SSI Related Medicaid, offer comprehensive coverage, including long-term care supports and services. For those who need them, these services are a lifeline to independence, living in the community and employment. Either not affordable or available through the private insurance market, Medicaid has been the sole access point for people with disabilities who need long-term care services. The Adult ACA Medicaid group, or expansion group, is a Medicaid program that may or may not provide an individual with long-term care services in any given state.
209(b) Expansion States Facing Challenges with Transitions
One key difference across states is the option to automatically provide SSI Related Medicaid to recipients of the federally-administered state supplementary payments though the Supplemental Security Income (SSI) program. Ten states use at least one eligibility criterion that is more restrictive than the SSI program for Medicaid eligibility and are referred to as 209(b) states. This means that an individual in these states who applies and is found eligible for SSI must make a separate application for Medicaid coverage.
The following states are currently 209(b) states: Connecticut, Hawaii, Illinois, Minnesota, Missouri, New Hampshire, North Dakota, Ohio, Oklahoma and Virginia. All but Missouri, Oklahoma and Virginia have expanded Medicaid eligibility through the ACA.
Limited Access to Long-Term Care and Providers in the ACA Adult Group
Because many SSI applications take longer to process than Medicaid applications, people with disabilities can frequently be found eligible for ACA Adult Medicaid while waiting for SSI eligibility to be approved. While this group of individuals who have been approved as ACA Adult Medicaid eligible has access to healthcare, they may not have access to long-term care services.
Once SSI eligibility is approved, however, the beneficiary is no longer eligible for the category of Medicaid (ACA Adult) they are currently receiving. When they are put into the correct category for coverage (SSI Related Medicaid), they are sometimes dropped from one health plan and put into another without their knowledge. The end result is a current Medicaid beneficiary who is denied or faces delayed access to long-term care services he or she should be receiving under SSI Related Medicaid, as well as potentially losing access to providers and being forced to reapply altogether.
In addition to the lack of access to needed long-term care services, people may also experience challenges related to accessing medical service providers. In some states, the integration of the ACA and managed care has vastly changed provider infrastructure, with managed care plans for SSI Related Medicaid offering different provider networks and services than ACA Adult Medicaid managed care plans.
Many individuals, especially those new to SSI Related Medicaid, will not be aware that they are in a different category until another action is taken, such applying for a Medicaid waiver service, attempting to contact their managed care plan or going to see their providers. Both of these issues can result from the timing of an individual’s Medicaid application and approval.
Youth with Disabilities Facing Challenges with Transitions
Youth with disabilities can also potentially face significant unintended consequences around access to appropriate healthcare coverage. Children with disabilities are found eligible for SSI due to a reduction in both Activities of Daily Living and Instrumental Activities of Daily Living. This means a youth can be eligible for SSI under a broader context of criteria, like an inability to socialize or play with others.
Adult disability determinations, by contrast, are made based on a disabling condition that impacts employment—not only current employment, any employment in the country that may be available to someone with such impairments. These are vastly different criteria.
As a result, many children are found eligible and begin receiving childhood SSI and SSI Related Medicaid. However, when they turn 18, they are required to meet the adult disability guidelines in order to remain eligible. Many children fail to meet those adult requirements and their benefits are terminated. Of those that are found ineligible when they turn 18, a number are later found to be eligible in further review or appeal processes. Because Medicaid waiver programs are available only to individuals who are current Medicaid recipients, a child may have waited years to be eligible for Medicaid waivers, be found eligible, only later to be denied eligibility for adult disability—which results in losing benefits under SSI Related Medicaid and SSI eligibility. If, upon later application, the individual is once again found eligible for both adult SSI and SSI Related Medicaid, he or she must now go to the back of the waiting list for the same waiver services previously lost under a youth determination. This can result in years without necessary, critical services and care.
Experiences in the States
Health & Disability Advocates conducted a short, informal survey of seven 209(b) states that have expanded Medicaid to learn more about how states identify people who are in the “wrong” eligibility category and the processes states have in place to prevent this from happening. With six of the seven states responding to the survey, HDA found that:
• Three of six respondents offer Medicaid provider packages that are different depending on whether you are in SSI Related Medicaid or ACA Related Medicaid.
• Three of the six responding states offer some variety of waivers to individuals even if they are placed in ACA Related Medicaid.
• None of the responding states have a formal process for coordinating information about individuals who transition eligibility from one service package to another.
• Four of six states are unaware of whether individuals have been improperly placed in the wrong Medicaid eligibility package; the remaining 33% have implemented trainings, but know that individuals continue to get placed into the wrong eligibility group.
• Five states (all but North Dakota) were not aware of specific alerts that notify the Medicaid beneficiary that their eligibility for one program has ended and another started.
Upon further contact, roughly half of the states were in the early stages of identifying the issue of individuals being inappropriately placed and noted a need to develop a process for re-engaging the beneficiary to get them connected to appropriate providers for maximized health.
Recommendations Going Forward
While states are currently uncertain about the scope and breadth of these issues, it is important to identify individuals who have fallen through the cracks and may experience a significant disruption in services and eligibility. At a minimum, requiring states to create an automated notification system for changes to eligibility would provide beneficiaries greater clarity and time to plan. In North Dakota, for example, individuals receive a notice as they leave eligibility under one Medicaid group and become eligible for another. Notice of and clear information about the ramifications of the change is critical.
Another recommendation for states is to look at integration of its systems and data tracking of disability populations. Data exchanges between the state and federal systems, along with the differing eligibility criteria among various programs, should make tracking persons with disabilities a high priority for states. Minnesota, for example, is developing a new integrated system with the capacity to match data sets to a broader context of information, such as employment status. This will greatly enhance the ability of the state to make sure that people with serious health needs receive the proper services and have access to the supports they need for the greatest possible independence.
Joe Entwisle, MS, CLCP
Sr. Policy Analyst
Health & Disability Advocates
The Future of Enrollment in Illinois: Where We’ve Been and Where We’re Going
When Get Covered America came to Illinois before the first open enrollment period for the Affordable Care Act in 2013, there was a lot of work to be done. At that time 78% of the uninsured had not heard of the health insurance marketplace and were unaware of the new health coverage options or opportunities for financial help available to them for the first time. The initial awareness gap was daunting, but hundreds of thousands of Illinoisans stood to benefit from the marketplace and needed to know how the Affordable Care Act could help them.
Many Milestones Through Collaboration
Fortunately, there were a number of stakeholders like Health & Disability Advocates (HDA), the Campaign for Better Health Care (CBHC), Alivio Medical Center and the AIDS Foundation of Chicago, among others, eager and ready for the challenge ahead. This commitment helped achieve many of the goals laid out in the beginning. After two successful open enrollment periods, nearly 350,000 Illinoisans have enrolled in health insurance through the marketplace, and hundreds of thousands more have received coverage through expanded Medicaid and CHIP. Working together towards the same mission, Get Covered America and its partner organizations increased awareness and provided enrollment resources for consumers across the state.
Stepping Back to Move Forward
Because of the great work that has happened on the ground in Illinois, Get Covered America will be stepping back with full confidence in capable partners like HDA, CBHC and many others—such as Family Guidance Centers and Ada S. McKinley—to continue this important work to make health care enrollment a permanent part of communities. It’s clear that the coalition of partners who have come together on this issue have made great strides over the past two years. As the insurance landscape changes and the number of uninsured Illinoisans continues to decrease, Get Covered America wants to make sure that resources are allocated in the smartest and most effective way.
While Get Covered America won’t have an active outreach presence on-the-ground in Illinois moving forward, the organization will continue to support partners in the state with cutting edge data, best practices, tools and resources. Get Covered America will refine and continue to offer digital tools like the Get Covered Connector while also introducing new programs, like training and support for local partners and health insurance literacy resources for the newly insured.
The Enrollment Challenge Ahead
Just released by Get Covered America, the State of Enrollment Report takes a critical look at the lessons learned and what still needs to be done to get Illinois covered. Using on-the-ground knowledge and data analysis, the report identified several key initiatives integral to maximizing the number of Illinoisans who enroll in coverage. This is a great resource for partners on the ground and the foundation for a sustainable coalition for years to come.
The Get Covered America team is thrilled at what has been accomplished in Illinois so far, but there’s still important work to be done. While more Illinoisans have health coverage than ever before, there are still too many who remain uninsured and need the facts about how the Affordable Care Act can help them and their families. On-the-ground partners like CBHC, Family Guidance Centers and Alivio Medical Center will continue this work and make health care enrollment an institutional reality for years to come. And Get Covered America looks forward to supporting their efforts.
David Elin
National Fundraising Director
Enroll America
Joint Commission Implements Mandatory Universal Patient Helmet Regulations.
Patient death or serious injury associated with a fall while being cared for in a health care setting has been a recognized since 2002 as one of 27 original never events as defined by the National Quality Forum (NQF). The complete list was revised in 2011 to include 29 never events, but falls by confused old naked men have continued to result in serious injuries despite endless attempts to counteract natural traumatic hospital acquired deaths.
"We've heard from hospitals loud and clear. They've tried everything from 4 point leather restraints and putting on fall-risk arm bands to Ativan drips with soothing country music and we have concluded that patients are just gonna fall. So we figure it makes sense for us to force all patients to wear a helmet," said Mark R. Chassin, M.D. FACP, M.P.P, M.P.H, president and chief executive officer of The Joint Commission (TJC).
"In a few years, universal helmet use will be as normal as universal hand washing is today."
Hospitalists were thrilled to learn about mandatory helmet regulations in the hospital. "I get at least two calls a night from the night nurse letting me know they found a patient laying unresponsive on the floor in a pool of blood at 2 a.m. with a large pulsating scalp bleeder and do I want to do anything about it," said Hospitalist James Fleming.
"But now with mandatory helmet regulations, I think we'll be more comfortable not ordering the stat CT head. It's just going to take some time getting used to."
While hospitalists were thrilled with their new found nocturnal freedom, not all specialities were equally excited. Stan Bedlow, a prominent local Neurosurgeon was concerned the new policy would interfere with his ability to operate effectively and efficiently.
"We asked The Joint Commission to waive their tough new standards for neurosurgical patients, but they said no. "I'm not really sure how I'm going to access the brain through a helmet, but we believe The Joint Commission is the gold standard in safety, so we'll probably just consult the hospitalist to manage it.
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| Hospitals prepare for mandatory patient helmet use. |
Even the Obstetricians were left scratching their heads on the new mandatory helmet policy. "We've been told by our hospital quality officials that all expectant mothers and their newborns will be required to have a helmet secured prior to the baby exiting the birth canal or C-section. We figured this was a perfect job for the third year medical student so we've decided to base their whole clerkship grade on how well they perform retraction-helmet duty," said Academic Obstetrician Dr. Michelle Johnson.
The Joint Commission expressed confidence their strict new safety measures would be accepted kindly by physicians who understand the importance of universal safety precautions in the hospital. "We anticipate physician experience with our helmet regulations will help them fully embrace our anticipated full body Charmin wrap requirement planned for next year's accreditation process," said Dr. Chassin.
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