Journal Club: Medical Legal Partnerships at VA Medical Centers Improved Housing and Psychosocial Outcomes for Vets

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This month’s journal club, we discuss the article Medical Legal Partnerships At VA Medical Centers Improved Housing and Psychosocial Outcomes for Vets  by Jack Tsai, Margaret Middleton, Jennifer Villegas, Cindy Johnson, Randye Retkin, Alison Seidman, Scott Sherman, and Robert A Rosenheck. David Rosenthal and Audrey Provenzano are joined by the lead authors of the study Jack Tsai and Margaret Middleton. If you would like to learn more about medical legal partnerships, please review the website of the National Center for Medical Legal Partnerships.

If you enjoy the show, please give us 5 stars wherever you listen. Tweet us your thoughts @RoSpodcast and leave us a message on our facebook page at www.facebook.com/reviewofsystems. Or, you can email me at audrey@rospod.org. We’d love to hear from you, and thanks for listening.

Reprise: Design Thinking with Bon Ku

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This week we are featuring a reprise show with Bon Ku, the Assistant Dean for Health and Design and an Associate Professor at the Sidney Kimmel Medical College at Thomas Jefferson University, to talk about design thinking and medicine. Bon is a practicing emergency medicine physician and the founder and director of JeffDESIGN, a first-of-its-kind program in a medical school that teaches future physicians to apply human-centered design to healthcare challenges. Bon has spoken widely on the intersection of health and design thinking (TEDx, South by Southwest, Mayo Clinic Transform, Stanford Medicine X, Association of Collegiate Schools of Architecture) and serves on the Design and Health Leadership Group at the American Institute of Architects. Bon talks with us about what design thinking is, how he got into it, why he thinks physicians would benefit from learning to think in this way, and how to apply it to common primary care challenges, like walk-ins. He also directs listeners to the following resources to learn more about design thinking in medicine: the Stanford Dschool, and ideou.

If you like the show, please rate and review us on itunes or stitcher, which makes the show easier for others to find; and share us on social media. We tweet at @rospodcast and are on facebook at www.facebook.com/reviewofsystems.  Please drop us a line at contact@rospod.org. We’d love to hear from you.

Understanding how to address social determinants of health with Laura Gottlieb

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These days, we hear about social determinants of health constantly – more of us are screening for social needs in our clinics and payers are searching for effective ways to address them as an avenue to improve outcomes and ideally reduce costs. Dr. Laura Gottlieb, a family physician and researcher at UCSF joins us today to talk about her research, which focuses on evaluating interventions to identify and address social factors in health care.

You can find many of Dr. Gottlieb’s publications here, as well as the Health Affairs blog post by Drs. Toyin Ajayi and Iyah Romm mentioned in the podcast. You can also use this link to the SIREN website to find more resources on the intersection of social and medical care.

A little more about our guest: Dr. Gottlieb is Associate Professor of Family and Community Medicine at the University of California, San Francisco and director of the Social Interventions Research and Evaluation Network (SIREN). Dr. Gottlieb’s current research focuses on evaluating interventions that identify and address social factors as part of health care delivery. These interventions include volunteer-powered social services Help Desks, payment reforms that support social programs, and other efforts that support responding to patients’ social needs in medical practice, like re-designing electronic medical records to incorporate social determinants data. Dr. Gottlieb also is an Associate Director of the Robert Wood Johnson Foundation Evidence for Action National Program and was a co-founder of HealthBegins, a non-profit organization providing education, consulting, networking, and technology services to health care providers interested in joining the effort to move medicine upstream. Prior to her current appointment, Dr. Gottlieb was a Robert Wood Johnson Health and Society Scholar at UCSF/UCB. She completed her MD at Harvard Medical School and both her MPH and residency training at the University of Washington.

If you enjoyed the show, please give us 5 stars wherever you listen. Tweet us your thoughts @RoSpodcast and leave us a message on our facebook page at www.facebook.com/reviewofsystems. Or, you can email me at audrey@rospod.org. We’d love to hear from you, and thanks for listening.

This interview has been lightly edited for length and clarity. Photo courtesy of Dr. Gottlieb.

Nwando Olayiwola – primary care, tech, and leadership

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How can we use tech to make healthcare better and more accessible? Dr. Nwando Olayiwola, a family physician, faculty member at UCSF, and Chief Clinical Transformation Officer for RubiconMD, a leading provider of electronic consultations between primary care and specialty care providers, has spent many years thinking about that question. She joins us this week to tell us about her career in primary care, tech, and leadership. We also discuss her powerful essay, Racism in Medicine: Shifting the Power, and her research looking at various aspects of tech and care delivery.

Thank you to the Harvard Center for primary care for helping to facilitate this interview. I did make a few recording snafus on this interview – so my apologies for the sub-optimal audio quality in a few sections.

A little more about our guest: Dr. Nwando Olayiwola is a family physician and the inaugural Chief Clinical Transformation Officer for RubiconMD, a leading provider of electronic consultations between primary care and specialty care providers. She is also currently an Associate Clinical Professor in the Department of Family and Community Medicine at University of California, San Francisco. She served as the Director of the UCSF Center for Excellence in Primary Care until February 2017. In that role, she supported the Center in achieving strategic objectives around primary care transformation and systems redesign regionally, nationally and internationally. Prior to her work at UCSF, Dr. Olayiwola served as the Chief Medical Officer of the largest Federally Qualified Health Center system in Connecticut, Community Health Center, Inc. (CHCI), where she developed expertise in medical administration, translational and implementation research, professional development, systems based and quality improvement and practice transformation of twelve primary care practices into Patient-Centered Medical Homes. Her work led to CHCI being one of the first organizations in the United States to receive both the NCQA Level 3 PCMH and Joint Commission PCMH Recognitions. She has been a leader in harnessing technology to increase access to care for underserved and disenfranchised populations and is an expert in the areas of health systems reform, practice transformation, health information technology and primary care redesign. She is on the advisory board of Primary Care Progress and the Robert Graham Center for Family Medicine and Primary Care Policy.

If you enjoyed the show, please give us 5 stars wherever you listen. Tweet us your thoughts @RoSpodcast and leave us a message on our facebook page at www.facebook.com/reviewofsystems. Or, you can email me at audreyATrospod.org. We’d love to hear from you, and thanks for listening.

This interview has been edited for length and clarity.

Reprise – How does architectural design influence c-section rates? With Mass Design & Ariadne Labs

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This episode starts with a question: “what if the architectural design of an obstetric unit influenced the c-section rate in that unit?”

That question occurred to obstetrician/gynecologist Neel Shah when he attended a presentation by Michael Murphy, the co-founder and executive director of Mass Design, an architectural design and research firm that focuses particularly on healthcare architecture. Neel thinks about c-section rates all the time and is a leading researcher in the field of maternal health. C-section rates vary widely throughout the US – from 7 to 70%, and where a woman delivers better predicts whether she will get a c-section than her own personal risk factors. So, Michael Murphy’s contention that “Architecture is never neutral. It either heals or hurts” stayed with Neel and inspired him to pursue a research initiative between Mass Design and his research group, Ariadne Labs.

Neel Shah and two of his collaborators, Amie Shao and Deb Rosenberg, researchers and architects with Mass Design, join us to talk about their collaboration and the report they produced.

Amie Shao is a director with MASS Design Group, where she oversees research focusing on health infrastructure planning and evaluation. In addition to guiding impact research for MASS built projects, she coordinated the production of National Health Infrastructure Standards for the Liberian Ministry of Health and has been involved in the design and evaluation of healthcare facilities in Haiti, Africa, and the United States. Deb Rosenberg joined MASS in 2015, with a unique background in healthcare and architecture. Throughout her career in nursing and architecture is a common ambition to promote health and well-being, and she believes that the spaces where people live, work and heal have the capacity to greatly support or restrict our human potential. Neel Shah, MD, MPP, is Assistant Professor of Obstetrics, Gynecology and Reproductive Biology at Harvard Medical School, and director of the Delivery Decisions Initiative at Ariadne Labs. His team is currently collaborating with hospitals across the United States, and using methods from design, systems engineering, and management to reduce the epidemic of avoidable c-sections.

If you enjoyed the show, please give us 5 stars wherever you listen. Tweet us your thoughts @RoSpodcast and check out our facebook page at www.facebook.com/reviewofsystems. Or, you can email us at audreyATrospod.org. We’d love to hear from you, and thanks for listening.

This interview has been lightly edited for length and clarity.

Caring for high need, high cost patients with Jeffrey Brenner

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Jeffrey Brenner is best known for his ground-breaking work with high-need patients in Camden, New Jersey, where he founded the Camden Coalition and changed how we all think about caring for this subset of our patients. He joins us this week and talks with us about how a shooting and subsequent relationship with the Camden police led him to a physician breakfast club and then the coalition; what it was like to catapult to fame after being featured in Atul Gawande’s hotspotter article in The New Yorker; his decision to join United Health Care to continue his work caring for the most vulnerable patients; and what he thinks the future of primary care should look like.

I’d like to thank the Harvard Center for Primary Care for helping to facilitate this interview; and just a warning in case you are listening around young ears, there is some adult language in this episode.

If you enjoyed the show, please give us 5 stars wherever you listen. Tweet us your thoughts @RoSpodcast and leave us a message on our facebook page at www.facebook.com/reviewofsystems. Or, you can email me at audrey@rospod.org. We’d love to hear from you, and thanks for listening.

 This interview has been lightly edited for length and clarity. This podcast episode contains adult language. Photo courtesy Jeffrey Brenner.

Journal Club: Lightning Round! Primary care vs Specialty care, Doorknob moments & Cost effectiveness of buprenorphine initiation in the ED

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This week Thomas Kim, David Rosenthal, and Audrey Provenzano talk about three recently published manuscripts for a lightning round edition of Journal Club. Thomas shares a paper by Bynum et al, Outcomes in Older Adults with Multimorbidity Associated with Predominant Provider of Care Specialty, examining outcomes among patients primarily cared for by specialists vs primary care providers. David shares a paper describing a novel technology for agenda setting and evaluation of social determinants of health by Wittink et al, entitled Patient priorities and the doorknob phenomenon in primary care: Can technology improve disclosure of patient stressors? (H/T Primary Care Progress for tweeting it!). Lastly, Audrey shares a paper entitled Cost effectiveness of emergency department initiated treatment for opioid dependence by Susan Busch et al, which is a cost-effectiveness analysis of an RCT of ED-initiated buprenorphine performed at Yale, previously featured on the podcast in an interview with Gail D’Onofrio

If you enjoy the show, please give us 5 stars wherever you listen. Tweet us your thoughts @RoSpodcast and leave us a message on our facebook page at www.facebook.com/reviewofsystems. Or, you can email me at audrey@rospod.org. We’d love to hear from you, and thanks for listening.

Integrating Primary Care & Behavioral Health at Lynn CHC: Kiame Mahaniah & Mark Alexakos

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Primary care models integrating behavioral health services are being adopted across the country. This week, we talked with two leaders at the Lynn Community Health Center (LCHC), Dr. Mark Alexakos and Dr. Kiame Mahaniah, about their experience with integration.

LCHC is unique among community health centers in that it started out as a mental health counseling center, and now has the largest community health center-based behavioral health program in Massachusetts. In this conversation, we talk about what it means to integrate behavioral health services with primary care clinical services – how it can reduce the fragmentation of services to better meet the needs of patients and the demand for mental health care (2:40), why it may better position clinics participating in accountable care (7:40), what successes they’ve seen (8:45), and the resources it has required (12:28). Along the way, our guests make it clear that the staff at LCHC love working in integrated teams. You can learn more about various other models of integrated behavioral health here.

Mark Alexakos MD, MPP, is the chief behavioral health officer of LCHC. He has a joint degree in medicine and public policy and developed an early interest in the interface between policy, research, and service delivery as they relate to access barriers, health disparities, and community health. Before working at LCHC, he spent seven years developing intensive, school-based mental health services that combined health promotion and prevention with quick access to behavioral health treatment in five Boston Public Schools.

Kiame Mahaniah, MD, is the chief executive officer of LCHC, though at the time of this interview, he served as the chief medical officer. His passion resolves around social and restorative justice, in the context of healthcare.   His twin clinical interests are teaching—he holds an appointment at the Tufts University School of Medicine—and integrating opioid addiction treatment into the primary care/behavioral health matrix.

This interview was edited lightly for length and clarity.

photo credit: Lynn Community Health Center

Lori Tishler of Commonwealth Care Alliance – Caring for the Most Vulnerable Patients

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Have you ever felt lonely and overwhelmed in a clinic room with a patient whose needs are far beyond your skills and ability to meet? I have, many times, and so has our guest this week, Dr. Lori Tishler. Dr. Tishler is the Vice President of Medical Affairs at Commonwealth Care Alliance, a not-for-profit organization that cares for more than 20,000 of the most vulnerable patients in Massachusetts, duals, or individuals who have both Medicare and Medicaid.

We talk about how CCA’s member-centered approach (as opposed to a physician-centered approach) has helped her feel more effective in caring for these vulnerable patients. We talk about the range of services that CCA offers, the role of their care partners, and the freedom that their financial model permits – for example, they provide 90% of care to patients in their homes.

You can find the Atlantic Magazine article we referenced featuring CCA here, and find a few Health Affairs blogs featuring CCA here, and a blog post focusing on building the business case for a community paramedicine program here.

A bit more about our guest: Lori Tishler is the Vice President of Medical Affairs at Commonwealth Care Alliance, a not-for-profit organization that cares for more than 20,000 of the most vulnerable patients in Massachusetts, people who have both Medicare and Medicaid.  She oversees CCA’s physicians and is involved with clinical aspects of quality, utilization, and pharmacy.  In addition, she is an Assistant Professor at Harvard Medical School and an active member of the General Medicine Faculty at Brigham and Women’s Hospital, As a caring and connected physician leader, mentor, and educator, Dr. Tishler’s passion has been providing care for the medically and socially vulnerable and making a difference in health systems for all.   Tishler has found that the most rewarding way to help change and grow our health care systems is to mentor learners who are interested in clinical care, leadership, and innovation.

Her leadership roles have extended outside of the clinic and outside of primary care.  She served on the Partners Healthcare Board of Directors, the Board of Directors for the Office for Women’s Careers, and the Board of the Schwartz Rounds while at the Brigham.  At Commonwealth Care Alliance, she teaches and presents nationally about our care model and innovations.

In addition to her leadership work, she continues to provide clinical care  Tishler feels that working as a clinician informs her choices and decisions as a leader.  Outside of work, Dr. Tishler loves to spend time with her husband and teenaged daughter, to travel, read, and knit.  She is honored to have been interviewed on Review of Systems.

If you enjoyed the show, please give us 5 stars wherever you listen. Tweet us your thoughts @rospodcast and check out our facebook page at www.facebook.com/reviewofsystems. Or, you can email us at audreyATrospod.org. We’d love to hear from you, and thanks for listening.

Understanding High Utilization of Unscheduled Care in Pregnant Women of Low Socioeconomic Status – Mehta et al

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This week, we are discussing an article from the Journal Women’s Health Issues, entitled: Understanding High Utilization of Unscheduled Care in Pregnant Women of Low Socioeconomic Status, by Pooja Mehta, Tamala Carter, Cjloe Vinoya, Shreya Kangovi, and Sindhu Srinivas. Pooja Mehta, the lead author of the study, joins us for our conversation. 

You can find the interview with Dr. David Buck referenced in our conversation here.

Dr. Mehta is Director of Maternal & Women’s Health Policy for the Consortium for Health Care Transformation, and Assistant Professor of Health Policy and Systems Management and Obstetrics and Gynecology at the Louisiana State University Health Sciences Center, advising the Louisiana Department of Health and Medicaid Program.

Dr. Mehta’s interests are in the use of health care delivery innovation and community-engaged accountable care models to reduce reproductive health disparities, pregnancy-associated mortality, and low-value care, and to support patients with complex health and social needs. Her research has been supported by the Health Resources and Services Administration, the American College of Obstetricians and Gynecologists, and the Leonard Davis Institute of Health Economics.

If you like the show, please rate and review us on itunes, google play, stitcher or your favorite podcasting app, which makes the show easier for others to find; and share us on social media. We tweet at @RoSpodcastand are on facebook at www.facebook.com/reviewofsystems.  Please drop us a line at audrey@rospod.org. We’d love to hear from you.

Listen at the end of the episode for a promo code to receive 15% off registration fees for an upcoming conference from the Harvard Center for Primary Care: Primary Care in 2020 – Future Challenges, Tips for Today.

This interview has been lightly edited for length and clarity.