In the spirit of President Elect Obama’s/HHS Secretary Designee Tom Daschle’s efforts to mobilize a grassroots “get out the health” series of house parties, I am re-posting my first Disruptive Women post:

My Top 10 Priorities for the Next HHS Secretary (NOTE: this was written prior to the selection of Tom Daschle–not surprisingly, I was holding out hope for a woman–no offense to Mr. Daschle):

The next Secretary of the US Department of Health and Human Services (DHHS) will have a plate that is not only full, but is overflowing. While all the political rhetoric is focused around access—health insurance for all—there are a number of other critical areas that need immediate attention as well.

Clearly there are many more than 10 priority areas. However, if I just so happened to find myself sitting across from the next Secretary of HHS, I would remind her (just indulge me on that) that she is the Secretary of Health AND Human Services—that for her to make a dent on the health side of things, she must take into account whether people have: the support systems they need, heat, a home, transportation, enough to eat.

Here is my list of the top 10 priorities, in no particular order:

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We have all seen the disturbing headlines of economic failures, bailouts, corporate bankruptcies, and massive layoffs. Economies around the world are slowing down. We also see the continued and raging debates over health care costs, delivery and quality as healthcare organizations and providers fight to reduce or control costs while delivering quality health care and attracting a qualified workforce. Whatever the reasons, there is a growing shortage of clinical, health, and allied health workers. Factors cited as contributing to the shortage include an aging workforce; high retirement eligibility; difficulty in recruiting and retaining workers; lack of educational, training, and retraining opportunities; high vacancy rates; high turnover rates; lack of opportunities for career advancement; low pay; and/or increased work load demand.

Recently, increased attention (and resources) has been placed on deploying new clinical technologies, devices, and treatments. Initiatives and advances include automated solutions for electronic health and medical records, bio-surveillance and disease reporting, public health monitoring, electronic prescribing, clinical decision support, personal health records, home health monitoring, and remote consultations. As the demand for and ability of these technologies to improve patient safety and quality grows their adoption will (hopefully) be more widespread. Yet, these technical advances also contribute to the workforce shortage because of the growing need for educated and trained personnel to develop, maintain and use these applications, products, and systems. (more…)

So-called “medical homes” are finally receiving national attention from the Centers for Medicare and Medicaid and foundations after their purported inception over 30 years ago by pediatricians (home care nurses have been coordinating health care for people with chronic illnesses for more than a century). But we’re about to make the same mistake that we’ve made in developing other approaches to improving health care nationwide—we’re medicalizing it, instead of focusing on health.

Medical homes are proposed to be primary care practices where people can get help with coordinating their care, particularly for chronic illnesses. The U.S. health care system emphasizes specialty practice rather than primary care. It’s one of the reasons why we pay more than any other nation for health care but have outcomes that lag behind those of even moderately developed nations. If I have diabetes and heart failure, I go to one specialist for treatment of my diabetes, the cardiologist for my heart failure, the gynecologist to get my annual GYN exam, a podiatrist, a retinopathist or ophthamologist, a dentist who may prescribe medications before and after procedures, a shrink to help me cope with this mess, and possibly others to screen my various body parts for myriad diseases. Each is prescribing medications that may interact in adverse ways. In fact, I may end up with a costly hospitalization because of these adverse effects. No one knows all of me or focuses on my overall health—unless I have a primary care provider who can oversee all of these specialties, follow all of my treatments and medications, and coordinate my care. (more…)

With more than 35 years experience within the Nursing profession, I’ve seen it all. Today, I’d like to share some of my thoughts on health care and life in general.

- Everyday you rise and ponder… Is this the day when caring for humans will override caring for houses, money, cars and the 30 seconds of fame that appear to be an American phenomenon? What do you think? I believe it can happen.

- It’s important for each of us to consider what’s at stake with this and every election. It isn’t about age or race. It’s about moving from dreams that we have held onto for a lifetime to creating the path to make the dreams come true.

- The old saying beauty is in the eye of the beholder is never truer than when you’ve worked twenty-two hours straight and someone tells you that you look great!

Last Monday, Stephanie Mensh wrote about her experience with medical homes. Dr. Pamela Mitchell, President of the American Academy of Nursing, has provided Disruptive Women with another perspective.

Guest post by Pamela H. Mitchell, RN, PhD, FAHA, FAAN

There is much talk these days in health professional, health payer, and even legislative circles about the “medical home.” This is a term coined in 1967 by the American Academy of Pediatrics. The medical home was originally meant as a single place for a child’s medical record and was particularly salient for children with special care needs. It later expanded to denote the one place that families with children with special care needs might obtain coordinated, continuous, family-centered and culturally effective care.¹ The concept of a medical home has additional roots in recognized needs for care coordination for people with chronic illness in managed care, case management, disease management and comprehensive discharge planning for complex or chronic illnesses. Most recently, a coalition of the American Association of Family Practice, American College of Physicians, American Academy of Pediatrics, and American Osteopathic Association developed and disseminated “Joint Principles of the Patient-Centered Medical Home.” This document defines the Patient-Centered Medical Home (PC-MH) as “an approach to providing comprehensive primary care for children, youth and adults. The PC-MH is a health care setting that facilitates partnerships between individual patients, and their personal physicians and, when appropriate, the patient’s family.”¹ At its best, this new movement promises quality, coordinated care for people, rather than their diseases. Further, it recognizes that care coordination and management is a complex skill that deserves payment in our current payment system. However, because of the consistent emphasis on physicians as the home “owner” and leading partner, it connotes care centered in a particular practice profession rather than care for the person or family who comes “home.”

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As working professionals with decades of experience in health care, we face several workplace challenges, including co-workers from different (often younger) generations and retirement plans crumbling in this era of economic downturn. As mothers we face the dynamics of child birth and the hair pulling dilemmas of child raising. But it is as baby boomers who are part of the sandwich generation, that I think we are experiencing hurdles more difficult than contemplated. For me, front and center has been the need to confront care planning and end of life decisions for family members living hundreds of miles away. (more…)

Since becoming CEO of the American Academy of Nursing, I have been inspired by the nurses and other health care providers that have seen health care challenges in their communities and created cost-effective solutions that improve health outcomes.

For example, under the direction of Margaret Grey, DrPH, RN, FAAN, nurses associated with the Yale School of Nursing have provided coping skills training to youths and their families suffering from type 1 diabetes and at risk for type 2 diabetes for more than 12 years.

Or take for example, the Eleventh Street Family Health Services, which serves families who live in public housing developments in the Philadelphia area. Fifty-seven percent of patients are covered by Medicaid and 33 percent are uninsured.

Or in Kentucky, Kay Roberts, EdD, MSN, FAAN offers weekly hypertension management clinics and classes for self management of chronic illness. Since opening its doors in 2003, the clinic has prevented unnecessary hospitalization in approximately 25 percent of its clients with chronic illness and reduced the cost of primary care by more than 50 percent for each client.

Americans are known for their creative and innovative spirit, and as policymakers reform our health care system, they should closely examine what is being done by various health care providers across this country. When they see models that work policymakers should examine why they are successful and encourage the implementation of these models in communities facing similar problems.

True health care reform has already been set in motion by nurses and other health care providers on the ground and in the field working tirelessly to help Americans stay healthy. It is now time to scale up and spread these initiatives.

The US health care system includes a vast and diverse array of dedicated organizations, institutions and individuals striving to bring quality health care to our citizens. The system includes the front line and hands on workers like those in clinics, offices, hospitals, hospices, laboratories and nursing homes facing the complexities of delivering care in a complex and dynamic environment. The system includes the researchers and scientists seeking answers to some of the most complicated questions of disease and treatment. The system includes teachers and mentors working in schools, colleges and universities helping train the next generation of professionals entering the health care workforce. Our new President and the Congress should assure that we continue to have a dynamic and diverse pipeline of qualified and trained personnel to continue to work in the health and health care system. Workforce development and ongoing education and training is one of the key aspects to the future sustainability of our system and the health of citizens.

A “new” profession of pharmacy is about to be born in the US. There are those who will pace nervously awaiting its arrival. Like expectant fathers they’ll anticipate – but also fear – the consequences of the blessed event. It will change their lives forever. Though at this point there won’t be any turning back, perhaps they’ll wonder if it was such a good idea after all to allow pharmacists to be direct providers of health care, with independent prescribing authorities.

Mr. President, you can help midwife this innovation in health care by keeping those expectant fathers – and especially those in the federal government – out of the way.

What will this baby look like?

The “new” profession of pharmacy in the US will be the younger sibling of the one born at the start of healing traditions created in ancient worlds.

In ancient times the profession was a separate, distinct, third branch of medicine. Patients selected a pharmacist, a physician or a surgeon to treat their condition. I predict that patients in the US will be able to make a similar choice.

It won’t be long now, perhaps even within your term in office. The “new” profession of pharmacy in the US will likewise become independent healers of the sick and enablers of health and wellness, and yes, with totally independent prescribing authorities.

Why do I say that? Everywhere, I see signs of this impending birth.

Pharmacists are trained, skilled and ready:

• All graduates today have Pharm.D. degrees, supplying the country with the best trained pharmacists the world has ever known.
• Their information on medications is superior to all other clinicians.
• They are the best trained clinicians in the interpersonal skills required to manage patients and the problems they encounter with their diseases and lives.

Pharmacists are equipped for the job:

• Their computerized information systems help manage increasing numbers of prescribed medicines and increasingly complex combinations prescribed by separate clinicians.
• Their medication use and disease management infrastructures are among the best in the world.

Pharmacists are needed to assure access and quality care:

• Clinicians have abdicated medication management under reimbursement stress.
• Pharmacy hours and locations make them the most accessible professionally-managed health care settings in the nation.

Pharmacists are preferred professionals:

• Consumers trust pharmacists and want the convenience, quality and care they deliver.
• Payers are looking for effective alternatives to traditional care.

Pharmacists can be held accountable:

• Their information systems are already in place and enable them to be held accountable for pharmaceutical care to a much greater degree than in traditional medical and nursing clinical care.

As you see, Mr. President, when this sibling arrives, it will not be an infant or even a toddler. Nor will it be a weak sister to medicine or surgery.

Perhaps your own clinicians, after they have diagnosed some condition, will refer you to a pharmacist who will take over any pharmaceutical care you need, identify the right doses and combinations of medicines you need, counsel you on how to take them, encourage you to embrace healthy practices (and even give you stress management tips!), monitor your progress and adjust the regimen accordingly.

Will this be good for patients, clinicians, payers and even you, Mr. President?

I have some ideas about how to make it so, and since it’s starting to happen as states expand practice authorities, we need to be sure to “get it right.”

“Getting it right” means that you should not meddle in this. Pharmacy is a profession that is evolving into what patients and health care reform need. Let it happen. Don’t stand in the way and stop this progress.

Pharmacists like my own terrific pharmacist team – Andrew and Greg – are ready. The right question is this: are the rest of us?

That will be the subject of my next blog.

As a leader from the Hispanic community with supportive parents and counselors and with a stellar academic background, I was fortunate to have the opportunity to participate in the Federal Health Careers Opportunity Program (PHS Title VII) – not only to be a program coordinator for a local CBO (East LA Health Task Force, 1980), but as a pre-med student from Stanford University who had not completed the pre-med curriculum upon graduation, I was appointed to an HCOP post-bac program (Creighton University, 1981) and was accepted into UCLA Medical School in 1982 where I served as a counselor for minority premed students for the State of California HCOP program. I know several Latino physicians and public health professionals who benefited from this program and wouldn’t be where they are if it hadn’t been for this program. HCOP has been the major recruitment program for disadvantaged students to enter medicine and public health careers - until the Federal government decided to decimate it in 2006. Now with the current physician and public health workforce shortage along with the tremendous growth in the diversity of the U.S. population, this program should be brought back to its 2005 funding level. In addition, I believe there should be a regional approach to workforce planning and implementation, so that programs in regions with large Hispanic populations target their efforts to bring Hispanic students into the region’s medical and public health schools. The next President needs to understand the importance of having a diverse health care workforce – the literature has shown that Hispanic and African American physicians and dentists generally care for more minority, Medicaid and uninsured patients - the most vulnerable patients in our society, and those who, without health care, tend to be the sickest with the greatest health care costs to the nation.

Amidst the frenzy of critiques of the US health care systems (yes, there are several), what is still working are the workers, the health care providers - from community health aides and orderlies to chief nursing officers and medical staff leaders - who continue to slog through the detritus of the systems’ dysfunctions, get up every day and try to figure out how to care for patients, their families, and their communities despite the incessant shifting obstacles to meeting that goal. The vast majority of health care providers made their occupational choices with one thing in common: they thought it would be a way to help people suffering from disease and its consequences. Most keep trying to do this.

Reluctantly, I am going to use a war metaphor to amplify. The national discussion on wars often emphasizes the “troops on the ground” and their perceptions of their situation. I try to imagine all those soldiers being asked to divert themselves from their primary responsibilities to collect “performance metrics” so we can find out where they are failing to do their job or making errors. I picture us posting these shortcomings so we can prove that we are transparent. I try to imagine literally hundreds of external experts creating elaborate documents and initiatives designed to ignore the larger enterprise of war and instead creating bureaucratic monsters eating time, resources and even lives in an effort to tinker with the system. I try to imagine soldiers incessantly being blamed in the media for the obvious human errors that wars create. I try to imagine benchmarking this war against other wars so we can see which war is more wonderful. Enough!

I like to think that my analogy is germane because the two groups share a common goal: keeping Americans safe.

In the next cycle of change, I would hope we might get back to the overriding mission in health care: to take care of people faced with challenging health experiences. Quality care and cost containment are polar forces to be balanced. Using the tools of cost containment to assess quality care is at best naïve. Try measuring compassion or the tears of a child watching her mother die of cancer. “Not everything that can be counted counts and not everything that counts can be counted.” (A. Einstein) A bit more emphasis on the mission might change the dialog.

I would recommend the President, his cabinet members, and all the members of Congress try an anonymous three-day hospitalization. They could go through the admissions process stating they have no health care coverage, for starters. The “boots on the ground” might inform the discourse, unveil the impact of provider shortages, demonstrate the nuanced nature of giving good individualized health care, reveal the cost of cost control measures, and introduce them to some providers who are trying to give quality care despite all the disturbances swirling around them.