Tag Archives: public health

Should the Paramedics take on the role of Rural Home Health Nurse?

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What do you think?
Earlier this week I attended a 3-hr of public hearing in Sacramento where a variety of speakers were debating a pilot program proposal for an increased role of PARAMEDICS in managing chronic care diseases when attending to home care needs of patients (in rural on inner city areas they say).

While I fully support the notion that something must be done with the dreadful state of CA public health, access to medical care and adherence to home care / discharge plans, with all due respect and deference to paramedics, to manage a chronic condition in a home setting takes fine tuning and years of studies and practice. Just because nobody is bleeding does NOT mean it is not critical, problematic or very complexed issue to deal with.
There is a reason new grad RNs are NOT hired for home health because you MUST have experience in dealing with the disease management before you will be even considered to be sent out there making decisions on location!

It is usually the patients who are not bleeding or vomiting or collapsing that are the biggest problem in a home health setting, those who sit quietly, those who if you don’t know what and how to ask OR if you don’t know what signs to look for – usually, they are the ones who don’t even tell you! They don’t wanna be a ‘bother’ – I’ve heard that SO MANY times from grandmas and grandpas
(Again, I am talking about chronic disease management in home care, not discharge home from tonsillectomy, for example)

To manage chronic care diseases, you must know and understand the disease process, the disease signs & symptoms, to know how it was managed in a hospital, what can be the side effects of any of the above, what to look for, how probable complications look like even before they become major problems…. And finally, you must understand how to fine-tune the care!
Again, paramedic are GREAT and FANTASTIC at what they do, which is the FIRST phase of giving emergency care, I worked with them for many years on 2 continents (and in Czech I worked in the department!), so my hats off to you, but to manage the last part so-to-speak of care such as COPD or CHF or HTN or DM – that takes years of training, learning and practice!

Also, I am NOT saying we, the nurses, are fine-tuning or managing the treatments, that’s why we have specialists such as fantastic pulmonologists, but we the nurses are fine-tuning the plans of care upon discharge, the follow ups and the adherence to those. At least that’s what the nurses should do – but we don’t have them!
WHY?
Because the State cut the budget in 2011 and DHS and DSS just don’t have the funding! Those positions got cut. …Now we see how much it actually cost us because just because you cut a position or access to care here does NOT mean those patients will not seek the treatment or medical attention elsewhere. Now, all those trips to ERs – they get very expensive for the State! And now with added millions of new patients via Obamacare – don’t get me even started!

While I fully support the need for a change and innovation in our roles and in health care system delivery overall, in fact I have been calling for it for some time now, I do not believe paramedics as chronic care managers or home health caregivers are the long-term solutions to our much bigger problem.
They are trained as ‘ready to go’ as first responders, and I believe they are the BEST in the WORLD, but not as chronic care or home health care giver, and 16-18 hours of added education will not change that.
… At the same time, I absolutely understand what they are trying to do or accomplish and WHY!
I get it, I understand.
But I don’t believe this is the right solution.

Is ‘population diversity & behaviors’ to blame for lower U.S. life expectancy…?

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Government Spending

Government Spending (Photo credit: Tax Credits)

Last week I posted article asking a pertinent question “If U.S. Spending is so Outrageous, Are We Getting the BEST?”

https://marketahouskova.wordpress.com/2013/04/22/if-u-s-health-care-spending-is-so-outrageous-are-we-getting-the-best-2/

The answer is “kind of”.

We do have the best technological and medical advancements in the world, and our acute care and treatments can deliver miracles.  We don’t have to wait 4-6 month for a surgery, we mostly get timely care, good care, and we do have great outcomes. However, as wonderful as that is, it does not impact the overall measurements of ‘life expectancy’ as it falls under the category of ‘acute care’ and we do really well here.

It is injuries or conditions lasting more than 6 months that are considered ‘chronic’ and require ongoing management, ongoing medication, follow-up doctors visits, repeated test, etc… and that’s where the U.S. is seriously lacking. So yes, while we are very good at acute care, we lack in chronic care management – and that does impact the overall ‘life expectancy’ and quality of life.

Which brings me to the fact that even after spending over $8,000 per capita in overall healthcare expenditure in 2010 (the highest in the world) , the U.S. has a lower life expectancy compared to other OECD nations. Why is that? Is “healthcare”  to blame? Is “public health” to blame? Or is it due to our “population diversity and behaviors“?  I have heard many  blaming it on the “diversity & behaviors” part, but in that case a question remains –  isn’t it the health and life expectancy of the whole population, no matter what diversity groups it includes, that makes for ‘life expectancy’ studies, surveys and measurements?

I agree with you that our diverse population is an integral part of our society, however, it is 21st Century and everybody knows that if you want to live longer and have a good quality of life, when you are not feeling well or have certain episodes – you should go see a doctor. And this is where the crux of “it is population diversity & behaviors fault” argument weakens, as 50 million of low-income working Americans (yes, majority about 80% are working and 82% are legal citizens) DO NOT have options or access to a non-acute or preventive care, so they go without seeing a doctor, without taking medications, and without ongoing management of preventable conditions – NOT because of their population diversity or behaviors – but because under the current system they have no viable option for obtaining health plans!

This clearly and directly impacts the overall life expectancy and thus the overall quality of healthcare we as ‘all Americans’ get.
If 1 in 5 Americans don’t have access to health care – it seriously impacts all of us in terms of loss of economic potential, loss of productivity, and in the end, in an increase in overall health care spending.

I ask again, does $8,000 per capita (twice as much as others developed nations) deliver the best health care to our society? Does it…?

Now, since we established that “population diversity & behaviors” are not to blame for lower U.S. life expectancy, is it a fault of healthcare, or public health? The answer is “yes” as the status of U.S. health care and it’s overall total health care spending and expenditures is a direct result and implication of U.S. health policies implementations. States are responsible for health care but federal government plays its role in Medicare, Medicaid, CHIP & other programs.

Medicaid, for example, by covering health care needs of pregnant women and prenatal care is not only delivering health care, but also implementing a U.S. public health policy. Smoking cessation programs – public health issue, or health care issue? Both, as continued smoking leads to lung cancer, COPD, emphysema etc… and that is very costly in terms of health care spending. Public health programs are offering smoking cessation in order to prevent future health care spending, a clear integration of health care and public health policies.

Without proper public health policies we will not be able to deliver proper health care to our diverse population. Clear and simple.

P.S.

Yes, while certain “diverse” behaviors cause increase in health care spending (i.e. smoking, bad diet etc..), if we look at it closer – these behaviors span all socio-economic levels, not only diverse population often mentioned. So we are back at the beginning, why the U.S. has lower life expectancy that other OECD nations? The one clear answer is that it is not due to “population diversity and behaviors”.

.

If U.S. health care spending is so outrageous, are we getting the BEST?

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In today’s heated political and economic debates, healthcare reform and healthcare spending remain a hot topic of conversation – and rightfully so!

Why is it that while the U.S. spent over $8,000 per capita on health care in 2010 (almost 50% more than Norway and Switzerland in 2nd and 3rd place), per OECD ratings, we deliver only average level of care based on U.S. lower life expectancy, lower than Switzerland or Norway. Life expectancy graph puts the U.S. roughly in the middle of the developed countries in life expectancy at birth (the longest gevity is in Japan). How Does the United States Compare page 1.

The problem with that is that other developed countries who show even higher life expectancy than the U.S. are able to bring their population to such age for a fraction (or at least for 50% less) of total health care cost than here in the U.S. It shows that the huge per capital spending does NOT necessarily assure or ensure longer gevity delivered through better care or more advanced technological treatments.

So WHY does health care cost so much in the U.S.?

The answer comes under the cloak of science, as the most significant contributor to U.S. health care cost growth is technology innovation & medical advancement. Clear and simple. We have the best diagnostics, imaging, new-surgery-techniques, technological possibilities and acute care treatments & capabilities in the world – bar none. The fact that we are also a wealthy country contributes to our income growth meaning that the wealthier the country – the more of healthcare consumer spending and insurance-induced demand there is.

It stands to reason that while new medical technology may be expensive, when used in time and appropriately, it does extend patients lives, improves their quality of life which in turn makes them live longer and makes them more productive. So technology – it’s a go! But the need for increased healthcare efficiency with curbed spending will bring a major strain on the U.S. health system in the coming years.

While the U.S. has the best diagnostic and acute health services in the world, we are lacking in preventive care and in management of chronic diseases and conditions affecting a large segment of U.S. (aging) population. Additionally, the wealthiest country in the world and we have around 50 million un-insured people from working families! Yes, you heard right, a vast majority are from working families – as in low-income workers unable to afford private or employer-based health plans premiums. Kaiser Family Foundation Primer (2010) states that 50% of ALL health care spending is used to treat 5% of the population and they are the people with 3+ chronic diseases needing ongoing medical & nursing care, list of medications, follow-up doctor’s visits and other services. http://www.kff.org/insurance/upload/7670-03.pdf

Needless to say that the un-insured have overall much worse health conditions as, due to financial constrains, they do not go see doctors with first symptoms, do not get medications to correct or manage conditions, do not go for tests or follow ups to see how such condition(s) can be treated or fixed or improved. So such condition(s) grow in silence and when finally there is a life-threatening event – they will go to emergency rooms where they will get the care including all those technology innovation & medical advancement tests, images, diagnostic procedures and latest treatments, but they will also get a bill for all that technology innovation & medical advancement. And anybody who went through ER and spent a couple of days in a hospital knows the amount I am taking about here! And without insurance plan to help cover the large amount, they are left with a stark total! http://www.kff.org/uninsured/upload/7451-06.pdf

Let’s not forget, these un-insured are not insured not because they don’t want to or feel like getting a health insurance, but because their low-income jobs leave them unable to pay for private or employer-sponsored health plans and not eligible for Medicaid and too young for Medicare (over 65 y.o.)  Yes, it is true, hospitals can write something off, but on average, it still leaves the low-income un-insured with a bill of about 1/3 of the hospital cost. And good luck with that!

 

Issues to ponder about U.S. emergency response in a small pox sentinel event [1/2]

Posted on by • Posted in Emergency preparedness, emergency response and disaster relief, Program Administration, sentinel event • Tagged , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , • 7 Comments

http://rt.com/news/uk-smallpox-terror-threat-379/

(this post is as a response to the above mentioned article)

My area of expertise is NOT discussing the threat level colors with national security experts and advisors arguing about a possible impending terror plot using biological weapons. I leave that complicated and complex discussion and decision-making to those experts, and God be with them and us…

My area of expertise is program administration, infrastructure coordination and immediate implementation of emergency response policies such as putting the correct SOPs to work, dealing with and trying to protect the first responders, dealing with city & hospital command centers, dealing with local,  state and federal agencies, organizing teams and rolling out regional plans… and of course managing & administering it all in the most productive, cost effective, safe and human capital most efficient way.

Reading about the split view between the US and UK on the response to small pox threat, while out of my area of expertise, nonetheless all I see in this are the problematic areas of such sentinel event response starting with the politics of preventing public panic, not knowing the degree of events we would be dealing with as the latency of small pox is up to 3 weeks and they are highly infectious – and that’s just for starters!
In today’s globalized and inter-connected world we would be probably looking at pandemic situation where 2 million doses of US vaccines – even when and if administered at the most opportune time to the right people – would barely scratch the surface of such disaster.    …Would antivirals save lives? In time?
So yes, from the administrator point of view, a band-aid solution… and didn’t we learn, band-aid solutions cause more damage and are followed by increased public anger and outrage plus are usually way more costly in the end?

The political and societal fall out of such health security threat sentinel event would reach heights we have never seen before with Twitter, Instagram, Facebook, instant messaging, YouTube, Pintrest etc… It would be up to the administrators and the politicians to calm and reassure the population that all the necessary steps are being taken… Are they? Would they?
Again, we are talking about small pox with 3 weeks prodromal stage, highly infectious spread and don’t forget – scary looking, as I can already see the horrible images floating on Instagram, YouTube and being posted on FB and the enormous public panic &  fear that would create as a result, because in today’s inter-connected and globalized world we all are much closer to one another, both literally and figuratively speaking.
(Highly developed, skilled and organized social crises media management during emergency response is and will be an indispensable and absolutely vital part of any emergency planning, preparedness and response).

So both countries better return to the point of origin and start thinking of the proper procedures, administration and coordination of such wide-spread effort with proper planning, training, established (and properly working and functioning!) channels of communications, assigned priorities, tasks, set ways of decision-making during such sentinel events – with proper management and foresight into what may come.
Without well prepared and well though-out massive plans of response, the division of views between the US and the UK on this issue will sadly be completely irrelevant.

Would you dare to make a political decision in emergency response to small pox, in such disaster scenario…? [2/2]

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The U.S.may perhaps have vaccination and antivirals for the whole population, even though the storage and management of vaccination for millions of people must be quite an undertaking, nevertheless the utmost responsibility and primary role of the government is to protect its citizens and keep the people safe from enemies foreign, domestic, or in this case enemies of highly infectious nature and spread (yes, an infectious event most likely brought on by one or the other enemy mentioned above)

So to answer the above question if I dared to make a political decision for such program…? Yes! …but I am not a career politician…they make decisions differently – and for very obvious reasons.

Should that be a part of my job and a part of my professional expertise and my professional recommendation, should that be my decision-making responsibility – then yes, of course, I would make a decision and I would accept the responsibility.
In fact, that was exactly why I was “there” occupying that office and that position, to lead as leaders are sorely needed! So if in spite of knowing all about the small pox sentinel  event scenario had I accepted this (fictitious) appointment or a position then yes, it would be my decision, my recommendation and my responsibility for such scenario and for the people – whatever the decision may be, either do something or do nothing.

That’s my final answer, Alex (doesn’t that sounds familiar … ??)

While the crises analysis and projection of impact studies can be (and hopefully are) low on probability, and we all do hope so, it is still the responsibility of the government and its appropriate agencies to discuss, debate and plan for varied scenarios and call different “plays” all in order to prepare for such – even if – unthinkable event.

As I stated in my previous post, I am not an expert on the likelihood of small pox epidemic event or on the effectiveness or amount of US vaccines or antivirals, so I will not be delving into those issues.
However, what I am an expert on is emergency response, efficient administration, effective organization of people and key infrastructure – including the level of preparedness and skilfulness to deal with basic human behavior in crisis + panicked public (and they would be PANICKED, trust me!) and dealing with the complexities of emergency response management of such massive scale (I am still using the scenario of a sentinel event here).

Let’s be honest, when this hits, we will not have few days (or a week) of luxury to watch and wait “for the water to go down to save people from their rooftops”- aka Katrina emergency response. So while perhaps almost an unlikely event – great, we won! However, should any level of this event occur and we would not respond in the right, correct and specific way – we would be in deep Katrina waters, I mean in deep troubles.

Few years back I was a part of a sentinel event disaster and emergency response exercise in a regional hospital that had a central command center set up. We are talking seasoned medical and nursing professionals who make life-or-death decisions and see things every day the rest of the population doesn’t even know they exist, and yet the underlying panic, the hesitancy to give orders, the miss-communication, and the lack of feed-back to properly assess the ongoing developments – it was eye-opening for everybody. GOOD! That’s exactly why we have these exercises and preparation sessions – to learn!

So overall, it was a successful day even though the staff did not look like “success” at the end of the day. Again, these were highly motivated, educated, experienced professionals and senior staff members in an acute care setting, you would think they know what to do in an emergency as they deal with almost every possible scenario on daily basis…
But as I was told by one old and revered ER physician in the hallway: “You know young lady, there is an emergency, and then there is an Emergency”.