Telemedicine, Virtual Health Coaches, and Other Wonders: The Future of Health in Kent County, Part 1

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UM Shore Regional Health Center – Chestertown

Small rural hospitals are an endangered species everywhere in the U.S. In Kent County, an intense, citizen-led campaign to save the Chestertown hospital has made progress, but—contrary to recent press reports—the hospital’s fate is still uncertain. Shore Regional Health, part of the University of Maryland Medical  System that provides healthcare to 5 mid-shore counties and which owns and operates the Chestertown facility, has said it would like to maintain in-patient services in Chestertown after 2022, as part of a broader plan to upgrade healthcare on the Eastern Shore.  But doing so will be contingent on legislative or regulatory changes to establish a new reimbursement model for vulnerable rural populations. Whether such legislation is passed is likely to depend on recommendations in the upcoming report of the Maryland Rural Health Study, due this September.  Watch this space for an in-depth report when the recommendations are released.

But the future of the hospital—as a full in-patient facility or as a standalone medical facility with more limited services—is only one of the factors that are likely to shape healthcare in the county in coming years. Moreover, a just-released nationwide assessment of the quality of health—county by county within each state—finds that Kent County has lots of room for improvement. It ranks only 18th (out of 24 Maryland counties) in health outcomes, far behind Talbot (5th) and Queen Annes (7th), and only barely ahead of Caroline and Dorchester.

Healthcare is changing rapidly, driven by both economic pressures (healthcare expenditures make up nearly 20% of the U.S. economy, far above all other industrial countries) and by new technology.  Shore Health’s strategic plan for the Eastern Shore deals with both aspects, but focuses on improving access to care, while also implementing services that can help keep people out of hospitals. Here we profile some technologies and other innovations likely to impact our healthcare in one form or another in coming years, drawing on both local and national examples.

Transport. A big unmet need in Kent County, as in most rural areas, is transport to get people to care.  That could take the form of local transport—to see a doctor, then pick up medicines at a drugstore—or could mean emergency transport by van or helicopter to a distant hospital. One model for local transport could be a kind of “Uber for healthcare” service that would allow people without cars or who can’t safely drive to arrange pickup and transport when they need it with just a phone call or an app. Potentially, a similar service—private but subsidized, or run by a healthcare system or insurer—could also provide transport services to regional hospitals. Will any of these happen? Such services are being started or are under discussion in a few places already, but whether they happen here may depend on local initiatives and some state financing.

Telemedicine and Telehealth. Under the best of circumstances, however, it’s a hassle to drive across the bridge to consult a surgeon or a specialist not found on the Eastern Shore. Suppose instead you could talk to them over a video link from a local facility or, eventually, even from home? As it happens, Shore Regional Health is already gearing up for telemedicine services on the Eastern Shore, in part under a grant from the Maryland Health Care Commission. In April the first patient, a 22-month old boy brought to the emergency room at the Easton Hospital, was linked in minutes to a specialist at the University of Maryland Medical Center in downtown Baltimore—resulting in a diagnosis, immediate treatment, and referrals for followup. “Bridging the gap between the eastern and western shores is a wonderful opportunity that this technology has given us,” says Marc T. Zubrow, MD, vice president of telemedicine for the University of Maryland Medical System. “We will continue to enhance and expand the telemedicine capabilities [to] allow patients to receive the expert care they need without having to leave their local communities and support systems.”

Telehealth refers to broader, non-emergency services at a distance, linking patients at home to doctors or nurses via voice or video or data links. A patient with high blood pressure at risk for stroke, for example, might periodically measure his or her blood pressure at home with a device that transmits the data to be screened automatically by an algorithm and checked periodically by a nurse. Many wearable or in-home sensors capable of monitoring chronic health conditions are now available. Telehealth calls or data streams can also record physical exercise, help patients to improve their nutrition, help a mother decide whether her baby’s fever is high enough to need a doctor’s care, or address other health concerns. The savings in costs and peace of mind could be substantial, and sometimes life-saving.

In-home Care. Some health conditions call for personal contact by a nurse, physical therapist, or health coach. Increasingly, taking care to the patient at home is not only less expensive than institution-based care, but sometimes far more effective—as well as overcoming the necessity to travel and the tendency to put off seeking care.  Surgical aftercare through home visits is now common, in-home infusions or dialysis or massage therapy constitute a growing trend.  Regular visits by a nurse or a health coach, especially for seniors with chronic conditions or for those struggling with opioid and other addictions, are being tested or considered in many places, and there is some evidence that such visits are more effective in helping people adopt healthy behaviors than care in an institutional setting—as well as less expensive. Assistance with non-medical tasks of daily living that are important to maintaining health are now often provided by volunteers, but increasingly such wellness services are being viewed as a part of basic healthcare. In one instance in California, simply inspecting homes of seniors and installing grab bars or stair railings or replacing loose rugs cut the number of falls (and the resulting hospital stays) in half.

The Amazon Dot, a smaller version of the Amazon Echo, can help with daily tasks, make phone calls, answer questions, even remind a person to take medication at a certain time.

A Virtual Health Coach. Millions of people now have an Amazon Echo and its voice-driven intelligent assistant, Alexa, that they use to order new supplies, turn on lights, or play music—just by talking to it.  Now Alexa (and similar voice-based systems from Google and Apple) are starting to be used in healthcare. Alexa can answer questions about your conditions or symptoms or an upcoming doctor’s appointment, remind you to take medicines or order refills, or provide updates on vital signs or pain levels to a remote nurse—all without touching a computer. If you fall, Alexa can call the ambulance. For patients with limited eye sight or who are bed-ridden, Alexa can become a constant companion and a vital link to assistance.

Expert Assistance. Increasingly, large organizations are using artificial intelligence tools to mine large datasets and “learn” how to do things more effectively. So as voice-driven systems interact with millions of patients, asking them about their symptoms—and that data is coupled to the clinical signals provided by in-home sensors for blood pressure, blood sugar, fever, etc.—it’s not very far fetched to imagine that IBM’s Watson or other AI systems may be able to diagnose many health conditions as well as even the most expert doctors—and enable earlier diagnosis and treatment—all without leaving home.

If such things seem hard to imagine, remember that Kent County will soon have the essential infrastructure—near universal access to fast internet connectivity.  Keeping in-patient services at the hospital would be important (and might take some lobbying with lawmakers in Annapolis).  But in the long run, improved access to care through the new tools and services described above, especially for vulnerable populations, may be even more important for the future of health than what kind of local health facility we have.

The Amazon Echo with “Alexa,” your new personal – and maybe even healthcare – assistant.

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Mid-Shore Health Future: Maryland Rural Health Workgroup Director Ben Steffen

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In many ways, Ben Steffen seems like the perfect person to head up a work study group on the future of Maryland’s rural hospitals. While he certainly has the professional experience to carry out those duties, including his current role in running the Maryland Health Care Commission, his most unique qualification is the fact that he grew up in the isolated farmland of Northeastern Iowa. It was in that kind of health care environment that Ben experienced first hand the special requirements of rural health care and the complexity of deliveries those services.

Now he is faced with the extremely challenging task of managing a state task force to decide what Maryland needs to do for the rural hospitals in towns like Chestertown and Cambridge to meet those special needs. Over the course of only one year, he will need to share with his 36 member committee the extraordinary data collected on these health care centers as well as guide them through a decision-making process to develop long-term recommendations for the Mid-Shore.

In his Spy interview, Ben talks about the Maryland Health Care Commission’s interest in rural hospital issues, the process of the workgroup, and his thoughts about rural hospital solutions, including “critical care” models and transportation challenges.

The first meeting of the workgroup will be held at Chesapeake College August 30th from 1pm to 5pm.

This video is approximately fifteen minutes in length 

 

Mid-Shore Health Future: Dr. Jerry O’Connor on Shore Hospitals

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Dr. Jerry O’Connor, a surgeon who has practiced for 32 years at the University of Maryland Shore Medical Center at Chestertown, has some very serious concerns about the future of the Chestertown hospital. After three decades of watching the medical center be downsized and merged into the UM Health system, he has decided to speak out about those concerns as Shore Health begins a final review process for its long term strategic master plan.

One of Dr. O’Connor’s issues is related to the process that Shore Health has used in this planning effort, which he feels has ignored or marginalized the concerns of many medical professionals in Chestertown. But his main concern is the possible loss of in-patient care in Kent County. He believes this is a result of Shore Health, and other Maryland health care providers, relying on GBR (global budget revenue) and population health metrics which focuses on numbers rather than people.

In his Spy interview, Dr. O’Connor remains guardedly optimistic that Shore Regional Health leadership has not closed the door on a workable solution for Chestertown. In particular, he is eager for decision-makers to look more carefully at making Chestertown a “Critical Access Hospital” allowing for a more flexible reimbursement structure. While that might take some time, he feels Shore Health can in the meantime do far more outreach and consultation with doctors in Kent County before a final plan of action has been decided.

This video is approximately fifteen minutes in length

 

 

Mid-Shore Health Future: The Serious Medicine of Laughter with Ken Sadler

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Clown work is no laughing matter if you ask Ken Sadler. The Louisiana native, retired insurance executive and longtime Oxford resident has significant credibility in expressing his opinion since he has served as the Shore Health’s CLO (chief laughter officer) for almost a decade.

Each week, Sadler, a.k.a. Dr. Goodwrench makes his rounds in the inpatient wards of the hospital to administer humor to those that are willing to take this powerful medicine. Those that do have a good chance of experiencing lower blood pressure, less pain, and a happier outlook as a result.

In this Spy profile, we talk to Ken about how he started his “practice,” the science of laughter, and the national Caring Clowns organization that certifies hospital clowns throughout the country.

This video is six minutes in length. For those interested in becoming a partner in Dr. Goodwrench practice, please contact Ken at 410-310-9218 or email him at kensadler73@gmail.com

Mid-Shore Health Future: Setting the Price with HSCRC’s Donna Kinzer

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As the Mid-Shore’s UM-Shore Regional Health starts to finalize reorganization plans this fall, including the future role of health care in Chestertown, Cambridge, and Easton, the Spy thought it would be interesting to understand more clearly the economic forces at play that required organizational reconstruction in the first place.

And on that question, we could find no better place to turn to than Maryland’s Health Services Cost Review Commission, or affectionately known as HSCRC. While the name might sound bureaucratic and even rather benign, the truth is that the HSCRC is at the heart of a revolutionary change taking place on the Eastern Shore and every other region in the state.

Why? It is because this tiny state agency, located next to a Burlington Coat Factory and a Panda Express near Baltimore, single-handedly decides the rates and global budgets for hospital services located at a hospital – for both inpatient and outpatient services. In other words, it doesn’t matter who pays your medical expenses, private health insurance, Medicare, or Medicaid, those charges only exist with the full approval of the HSCRC. It’s a big deal.

In fact, Maryland is the only state in the country that can control significant aspects of its health economy. And while it has been able to set health care costs since 1977, it was only in January of 2014 that the HSCRC instituted a new “All Payer” model that permanently terminated its pay for services model.

The end of pay for services has been replaced by a revenue model that encourages and economically rewards health systems that appropriate care options beyond inpatient care. At the same time, that same model pushes regional hospitals to increase community health programs that dramatically reduce the need for inpatient care with those with chronic illnesses.

Sitting on top of this revolution is Donna Kinzer, HSCRC’s executive director. A health policy consultant and analyst for several decades prior to joining HSCRC, her passion for redefining health care comes from a personal family tragedy. While caring for her terminally ill husband when she was 39 years old, Donna witnessed first hand how the old “hospital door to hospital door” model was grossly inadequate for both the patient and as a sustainable business model.

This video is approximately fourteen minutes in length

Mid-Shore Health Future: UM Shore Regional Health CEO Addresses Rumors About Chestertown Hospital Changes

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“With regard  to Chestertown, the Shore Health Center of Chestertown will continue to be a viable organization for the foreseeable future. We have an obligation to the community to provide excellent health care,” Ken Kozel, President and CEO of UM Shore Regional Health, said at Monday’s town council meeting.

While no hospital closure is in sight, other changes will take place with the kind of medical services to be provided at Chestertown’s hospital.

“No decisions have been made with this process. We are evaluating what our future needs will look like in the realm of national change,” noted Kozel.

Kozel was invited by Mayor Chris Cerino to address rumors circulating about the future of the Chestertown Hospital. Rumors have run the gamut of a full hospital closure to a stand-alone Emergency Department only without inpatient care.

He said that UM Shore Regional Health is currently evaluating how Mid-Shore communities would best be served by the health organization and placed the evaluation process in the context of nationwide changes in how health services are provided.

Kozel also described the unique position Maryland holds in the national healthcare landscape—the Medicare waiver, which allows Maryland to continue setting hospital reimbursement rates. In turn, that changes how hospitals do business. Medicare reimbursement is no longer directly related to hospital admissions—erasing the incentive of admitting more patients for inpatient care—to focusing on keeping people healthy before they get sick and focusing more on the outpatient area.

The UM Shore Regional Heath CEO said that a research committee comprised of 22 residents and physicians from Mid-Shore counties will profile specific community needs to determine where specialty services should be located for the benefit of all.

Questioned by the council about projected changes, Kozel said, “Let me clear about one thing, Shore Health can not be all things to all people. The days of us providing every level of service in all locations are far gone.”

He added that UM Shore Regional Health will include community involvement during several steps of the process.

This is a two part video of Mr. Kozel’s update of UM Shore Regional Health’s process to evaluate how medical services would be delivered throughout the mid-shore counties.

 

The Mid-Shore’s Health Future: Maryland Rural Health Association’s Michelle Clark

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With over ten years of experience working with, and for, the rural counties of Maryland on health accessibility issues, Michelle Clark has had a front row seat as executive director of the state’s Rural Health Association while watching the extraordinary changes that have occurred during that time.  Over the course of a decade, Clark has seen both improvements as well as almost insurmountable obstacles in providing access to communities far away from the dominant urban counties that capture the lion’s share of health resources, including doctors, at the state level.

In her Spy interview, Michelle talks about the current state of rural health care, the extraordinarily unique role Maryland is playing in the nation as the only all-payer state, and what rural communities are doing to adjust to an entirely new health services paradigm, which she notes is like living in, “an experiment.”

This video is approximately eight minutes in length

Editor’s Note: Over the next few months the Spy will be interviewing a number of local stakeholder and rural health experts on the special challenges the Mid-Shore faces in terms of accessibility to medical services, facilities, and other special needs as the region awaits the University of Maryland Shore Regional Health’s reorganization draft report later this year.