The Perfect StormCynthia A Fleece, RN, MBA, ACM, CHCQM-CM Merriam-Webster Dictionary defines Perfect Storm (noun) as a critical or disastrous situation created by a powerful concurrence of factors. The perfect storm – healthcare staffing shortages (nursing, physicians and other ancillary support staff), antiquated care delivery models often created in response to payer business models, processes not developed to handle the volume surges experienced during the COVID-19 pandemic; the perfect storm.
Dr Ronald Hirsch and Stefani Daniels RN made mention of this perfect storm in Chapter 1 of their book, “The Hospital Guide to Contemporary Utilization Review – Third Edition” where they state, “It will take years to measure the financial impact on America’s hospitals that accompanied the COVID-19 pandemic.” Never has a truer statement been made.
Hospitals are struggling to regain the financial losses experienced during the closing of services during COVID, struggling today to find staff to accommodate patient’s seeking services, existing hospital teams that are exhausted from the back-to-back COVID waves and now face delays due to the lack of post-acute services for their patients, and challenges in navigating the overwhelming health disparities related to patients with underlying SDoH (Social Determinants of Health) conditions. You are probably thinking this is not a new finding and I would have to agree; however how many of the care delivery models took these conditions into consideration? How many Care Coordination departments developed hard wired relationships with community partners in addressing the discharge needs of this patient population pre-pandemic? During the pandemic when hospitals were experiencing surges, the Department of Health and Human Services (HHS) advised utilizing SOFA (Sequential Organ Failure Assessment) scoring during triage to identify patients with a higher risk of mortality.1 This quick assessment tool targets patients with neurological and chronic health conditions commonly found in patients with underlying SDoH thereby creating barriers to access care during pandemic surges.
Ellen Fink-Samnick stated in her 2019 book, “The Social Determinants of Health: Case Management’s Next Frontier,” “Clients predisposed to the SDoH (Social Determinants of Health) have been identified as the costliest and most challenging individuals for the healthcare industry to care for, with figures soaring independent of the source. As a result, healthcare organizations across the board have sustained the brunt of fiscal impact.” And she goes on to say that the SDoH, “affect clients across the healthcare industry and in every practice setting. They involve physical and behavioral health conditions, invoke stress, foster helplessness, and make clients feel more susceptible to illness and premature death.”
What about the long-term symptoms for COVID-19 patients? Currently hospitals continue to struggle with staffing shortages, financial loss, and patients continue to experience delays in treatment because there aren’t enough healthcare professionals. Christopher Cheney writing for HealthLeaders, September 10, 2021, identifies a group of patients experiencing behavioral health issues as a result of having acquired COVID. He writes, “Coronavirus ‘long haulers’ who are afflicted by long term anxiety can develop specific anxiety disorders such as panic disorder and posttraumatic stress disorder. One of the most mysterious characteristics of COVID-19 is that a significant number of patients who are long haulers experience symptoms for weeks or months after recovering from the acute phase of the illness. Long haulers have a range of physical symptoms, including cough, shortness of breath, constitutional symptoms such as numbness and tingling, cardiac issues, hair loss and deconditioning.” There has never been a more urgent and complex situation facing hospital personnel today.
Enough of rehashing the spoils of pandemic years. There are several good things that are being developed or recognized as a result of the aforementioned situation in healthcare. Hospitals are looking to employ technology in addressing the staffing shortages both in nursing and in physicians. Healthcare leaders are recognizing the value of high performing utilization teams consisting of nurses and physician advisors addressing clinical decisions, regulatory requirements and compliance and payer reimbursement. Physician advisors are utilizing computer-based venues to address managing challenging populations like observation, where they can concurrently interact with the utilization nurses and collaborate on status and discharge recommendations. This is tool also allows for real time communication to utilization teams that are working remotely.
Healthcare leaders are looking to new care delivery models that employ the use of technology and community partnerships in addressing patient needs. The use of telemedicine is a real option in helping deal with physician shortages. Specialists utilizing telemedicine can deliver care to a greater number of patients as well as manage chronic health conditions. Devonta Davis wrote an e-article for the Tampa Bay Business Journal dated March 8th, 2022, “Local health system, Feeding Tampa Bay Partner to Open Health Education Center.” The article documents the partnership between the Community Health System and Feeding Tampa Bay Food warehouse. The featured community health system opened its first health education center in Feeding Tampa Bay food warehouse in Hillsborough County, Florida. This healthcare facility will provide self-monitoring telehealth stations and a private area for personal health consultations. This facility also serves food-insecure families around the county through the efforts of Feeding Tampa Bay. As we move forward partnerships with community agencies addressing SDoH is a top priority for healthcare facilities and a solution for addressing the healthcare needs of this patient population.
This is only the first step. Access to behavioral health services is a growing concern and hospital and community leaders are starting to embrace telehealth or pop-up clinics to address the needs of this patient population. Physician Advisors and Case Management leaders understand that addressing the psychological as well as the physical needs utilizing community resources can help prevent the patient from returning to the hospital. Telehealth also supports the health of the healthcare team as they can work remotely to serve their patient needs. Artificial Intelligence (AI) technology is stepping into the healthcare arena to present AI solutions to servicing patient needs as we reinvent meeting these needs with fewer staff at the bedside. Healthcare leaders are painfully aware of the staffing crisis throughout the hospital and are looking for more technology-based solutions knowing the lack of staff presence at the bedside jeopardizes patient safety. Healthcare is embracing the use of technology within their walls to address safety concerns. I would not be surprised to see Amazon’s Alexa on the bedside table of hospital beds in the future. Just think of it, “Alexa please call my nurse at ----------- and ask if it is time for my medication.” This seems farfetched but I believe there are teams currently investigating this very option.
Case Management and Utilization Review departments’ have had to reinvent their processes as more teams work remotely. The shortages within Care Coordination can be addressed through developing training and intern opportunities aimed at attracting the next generation of Care Coordination teams. Exploring new remote options for discharge planners and utilization review is only the beginning. This is our time to shine, our time to rebuild and reinvent; there is no suggestion, idea, or recommendation that is off limits; because when you start at ground zero the only way is up.
Cynthia Fleece is the Director of Utilization and Denials for the BayCare Health System in Clearwater, Florida.
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