real change through advocacy: a cure for moral injury
TRANSCRIPT
Real Change Through Advocacy:
A Cure for Moral Injury
The WorkshopACEP BalancED Conference
Aisha Liferidge MD, MPH02.19.2019
Workshop Objective:• To teach and discuss targeted advocacy strategies – at the
institutional, state, and federal levels - to be used to ameliorate the effects of moral injury.
THE PLAN:• Introduction and Background (13 MIN)• PART I (institutional): Coordinated Care/Integrated Services (25 min)• PART II (state): Social Determinants of Health (25 min)• PART III (federal): Mental Health Care Reform (25 min)• WRAP UP (2 min)
OUR PATIENT:
76 y.o. Afr. Am. male veteran presents to ED by ambo, status post self-inflicted GSW to the L anterior chest wall
PM/SurgHx: HTN, CAD, DM, s/p CABG 6 months ago
Meds: metoprolol, metformin, ASA, colace Allergies: NKDA
SHx: remote tobacco hx; widowed, 3 grown children, lives alone
Vital signs/PE: 138/74 80 14 99% on RA A&Ox4
PART I:
COORDINATED CAREAND
INTEGRATED SERVICES
ACA’s Plan for Coordination• Hospital Readmission
Reduction• Hospital Value-based
Purchasing • Pay for performance• Bundled payments• Accountable Care
Organizations • Patient-Centered Medical
Home bonus payments
“Health care should be safe, effective, patient-centered, timely, efficient, and equitable. “
- Institute of Medicine (IOM); Crossing the Quality Chasm
Patient Centered Medical Home
Capacity Accountability
ED-based Care Coordination CriteriaEnsures incorporation of information from prior health care visits.
Provides educational services on continuing care needs after discharge.
Develops post-ED treatment plan and next steps for appropriate aftercare.
Transfers current ED visit information to continuing care providers.
-Katz et al. Ann of EM. Vol 60, No 1, July 2012.
4 Ways to Coordinate Care Through the ED
1. Resource Allocation
2. Primary Care and Specialist Communication
3. Facilitating the Execution of Discharge Plan
4. Frequent Utilizer Care Planning
PART I:CREATE INSTITUTION-BASED CARE
COORDINATION / INTEGRATED SERVICES PLAN FOR OUR PATIENT
(15 MIN)TIPS:• Consider public health and policy-based interventions which
acknowledge social determinants of health.• Consider use of data, value of registries, multidisciplinary teams,
community outreach, interventions addressing care transitions.• Consider ED-based care coordination criteria and techniques.
PART II: SOCIAL DETERMINANTS OF
HEALTH (SDOH)
Source: Schroeder S N Engl J Med 2007; 357:1221-1228.
40% 45%30%
MEDICAID AND THE SDOH’S• Joint state-federal insurance program, state-based with
federal funding assistance• ~ 30% of ED visits from Medicaid payer source• For those with limited income, physical ability, and
resources; Medicaid mission naturally relates to SDOH’s• Medicaid ACO’s incentivized to address SDOH’s• Seeks and rewards state innovation
• Waivers (i.e. 1115, 1332)• Immigrant coverage• Emergency Medicaid
PART II: DESIGN PLAN TO ADDRESS SDOH
THROUGH STATE-BASEDMEDICAID ACO’S
(15 MIN)TIPS:• Consider state-based efforts• Consider encouraging or requiring SDOH interventions• Consider developing risk adjustment strategies• Consider recruiting and incentivizing SDOH-saavy ACO’s• Consider encouraging or requiring community partnerships• Consider providing continuum of care for pediatric populations
PART III: MENTAL HEALTH CARE
REFORM
ED Psychiatric Boarding
Legal Action: Due Process
Mental Health Parity
Mental Health Parity
Congressional Health Committees
•SENATE•Appropriations•Health, Education, Labor, & Pension
•Finance•Budget
•HOUSE•Appropriations•Energy & Commerce
•Ways & Means•Budget
PART III: CREATE FEDERAL-BASED STRATEGY
TO ADDRESS ED PSYCHIATRIC BOARDING
(15 MIN)TIPS:• Consider due process concerns• Consider mental health parity• Consider improved Medicaid coverage of inpatient services • Consider Psychiatrist reimbursement • Consider use of specific congressional health committees
TAKE HOME POINTS:• Health status is determined by multiple socioeconomic
factors (i.e. SDOH) and is minimally influenced by clinical care alone.
• Moral injury results from repetitive insults which hinder ability to provide patients with care and resources needed to achieve health; it undermines physicians' professional purpose and skillset – often leading to symptoms of burnout.
TAKE HOME POINTS:• Development of institution-based coordinated care/integrated services
initiatives and innovative state-based Medicaid strategies are effective means of health policy advocacy.
• Effective mental health reform can be achieved by addressing several policy issues such as due process, parity, insurance coverage, and provider reimbursement.
• Moral injury and burnout symptoms can be healed through effective advocacy efforts.
“ PHYSICIAN, HEAL THYSELF ” (Luke 4:23)
… THROUGH ADVOCACY
Thank You!
Real Change Through Advocacy:
A Cure for Moral InjuryACEP BalancED Conference
Aisha Liferidge MD, MPH02.19.2019