What if the Role of Healthcare Was to Maximize Health?

Identifying Barriers to Post-Acute Care Referral and Characterizing Negative Patient Preferences Among Hospitalized Older Adults Using Natural Language Processing

Our objective was to detect common barriers to post-acute care (B2PAC) among hospitalized older adults using natural language processing (NLP) of clinical notes from patients discharged home when a clinical decision support system recommended post-acute care. We annotated B2PAC sentences from discharge planning notes and developed an NLP classifier to identify the highest-value B2PAC class (negative patient preferences). Thirteen machine learning models were compared with Amazon's AutoGluon deep learning model. The study included 594 acute care notes from 100 patient encounters (1156 sentences contained 11 B2PAC) in a large academic health system. The most frequent and modifiable B2PAC class was negative patient preferences (18.3%). The best supervised model was Extreme Gradient Boosting (F1: 0.859), but the deep learning model performed better (F1: 0.916). Alerting clinicians of negative patient preferences early in the hospitalization can prompt interventions such as patient education to ensure patients receive the right level of care and avoid negative outcomes.

New Horizons-Addressing Healthcare Disparities in Endocrine Disease: Bias, Science, and Patient Care

Unacceptable healthcare disparities in endocrine disease have persisted for decades, and 2021 presents a difficult evolving environment. The COVID-19 pandemic has highlighted the gross structural inequities that drive health disparities, and antiracism demonstrations remind us that the struggle for human rights continues. Increased public awareness and discussion of disparities present an urgent opportunity to advance health equity. However, it is more complicated to change the behavior of individuals and reform systems because societies are polarized into different factions that increasingly believe, accept, and live different realities. To reduce health disparities, clinicians must (1) truly commit to advancing health equity and intentionally act to reduce health disparities; (2) create a culture of equity by looking inwards for personal bias and outwards for the systemic biases built into their everyday work processes; (3) implement practical individual, organizational, and community interventions that address the root causes of the disparities; and (4) consider their roles in addressing social determinants of health and influencing healthcare payment policy to advance health equity. To care for diverse populations in 2021, clinicians must have self-insight and true understanding of heterogeneous patients, knowledge of evidence-based interventions, ability to adapt messaging and approaches, and facility with systems change and advocacy. Advancing health equity requires both science and art; evidence-based roadmaps and stories that guide the journey to better outcomes, judgment that informs how to change the behavior of patients, providers, communities, organizations, and policymakers, and passion and a moral mission to serve humanity.

Population Health Innovations and Payment to Address Social Needs Among Patients and Communities With Diabetes

Policy Points Population health efforts to improve diabetes care and outcomes should identify social needs, support social needs referrals and coordination, and partner health care organizations with community social service agencies and resources. Current payment mechanisms for health care services do not adequately support critical up-front investments in infrastructure to address medical and social needs, nor provide sufficient incentives to make addressing social needs a priority. Alternative payment models and value-based payment should provide up-front funding for personnel and infrastructure to address social needs and should incentivize care that addresses social needs and outcomes sensitive to social risk.

CONTEXT

Increasingly, health care organizations are implementing interventions to improve outcomes for patients with complex health and social needs, including diabetes, through cross-sector partnerships with nonmedical organizations. However, fee-for-service and many value-based payment systems constrain options to implement models of care that address social and medical needs in an integrated fashion. We present experiences of eight grantee organizations from the Bridging the Gap: Reducing Disparities in Diabetes Care initiative to improve diabetes outcomes by transforming primary care and addressing social needs within evolving payment models.

METHODS

Analysis of eight grantees through site visits, technical assistance calls, grant applications, and publicly available data from US census data (2017) and from Health Resources and Services Administration Uniform Data System Resources data (2018). Organizations represent a range of payment models, health care settings, market factors, geographies, populations, and community resources.

FINDINGS

Grantees are implementing strategies to address medical and social needs through augmented staffing models to support high-risk patients with diabetes (e.g., community health workers, behavioral health specialists), information technology innovations (e.g., software for social needs referrals), and system-wide protocols to identify high-risk populations with gaps in care. Sites identify and address social needs (e.g., food insecurity, housing), invest in human capital to support social needs referrals and coordination (e.g., embedding social service employees in clinics), and work with organizations to connect to community resources. Sites encounter challenges accessing flexible up-front funding to support infrastructure for interventions. Value-based payment mechanisms usually reward clinical performance metrics rather than measures of population health or social needs interventions.

CONCLUSIONS

Federal, state, and private payers should support critical infrastructure to address social needs and incentivize care that addresses social needs and outcomes sensitive to social risk. Population health strategies that address medical and social needs for populations living with diabetes will need to be tailored to a range of health care organizations, geographies, populations, community partners, and market factors. Payment models should support and incentivize these strategies for sustainability.

Cherry Blossoms, COVID-19, and the Opportunity for a Healthy Life

To date, short-term funding and policy fixes for the coronavirus disease 2019 (COVID-19) pandemic have focused on saving the current health care system; policies have not maximized the population's health, prioritized the safety net, nor addressed the fundamental problems that have hindered our nation's response for our most vulnerable neighbors. We need to plan more lasting equity-specific reforms now. I explain 3 lessons that should inform reforms to the health care delivery and payment systems to reduce health disparities and maximize the public's health: (1) Proven roadmaps and processes for reducing health care disparities already exist, as do themes of successful interventions. Implement them; (2) Payment reform needs to create a business case for health care organizations to address social determinants of health and implement care interventions to reduce health disparities; (3) We as a nation need to have hard conversations about whether we truly value the opportunity for everyone to have a healthy life.

Practical Lessons for Teaching About Race and Racism: Successfully Leading Free, Frank, and Fearless Discussions

Successfully teaching about race and racism requires a careful balance of emotional safety and honest truth-telling. Creating such environments where all learners can thrive and grow together is a challenge, but a consistently doable one. This article describes 12 lessons learned within 4 main themes: ground rules; language and communication; concepts of social constructs, intersectionality, and bidirectional biases; and structural racism, solutions, and advocacy. The authors' recommendations for how to successfully teach health professions students about race and racism come from their collective experience of over 60 years of instruction, research, and practice. Proficiency in discussing race and addressing racism will become increasingly relevant as health care institutions strive to address the social needs of patients (e.g., food insecurity, housing instability) that contribute to poor health and are largely driven by structural inequities. Having interprofessional team-based care, with teams better able to understand and counteract their own biases, will be critical to addressing the social and structural determinants of health for marginalized patients. Recognizing that implicit biases about race impact both patients and health professions students from underrepresented racial/ethnic backgrounds is a critical step toward building robust curricula about race and health equity that will improve the learning environment for trainees and reduce health disparities.