Monday, October 19, 2015

From Clinical Care to System Improvement

A reward I derive from working half time is the flexibility to take on labors of love, one of which is being a member of the ethics committee at the Commonwealth Care Alliance.

Commonwealth Care Alliance (CCA) is a not-for-profit, consumer governed care system for Medicare and Medicaid beneficiaries with complex medical problems. It embodies the values that have guided my whole career, so when I was invited to join the CCA ethics committee I jumped at the chance.

Here's a story (slightly edited) from the every-other-week email circulated by Bob Master, CEO of the organization:
RA is a 61-year-old man with poorly controlled diabetes and severely compromised circulation in his legs who is living alone with a very limited ability to care for his complex medical issues. RA has also been battling a long-standing heroin addiction without success until he was prescribed Suboxone, which for many like RA, is a newer, more effective and safer treatment approach than Methadone. With Suboxone treatment, RA has experienced a full recovery from his addiction with dramatic improvement in his ability to live independently. 
 During his recovery, RA fell and sustained an ankle fracture that required surgery. Because of his diabetes, very compromised leg circulation, and requirements to avoid “weight bearing” on his surgically repaired foot, post hospital skilled nursing facility care was deemed essential. 
 However, existing regulations today prohibit individuals requiring Suboxone to be admitted to Skilled Nursing Facilities. RA’s primary care physician, and CCA Medical Director, Stefan Topolski, explains it this way: “To find that something so simple, so easy and so safe to prescribe as Suboxone – somehow becomes an impediment to needed skilled nursing facility care even when physicians providing care in that facility are certified to prescribe it, makes no sense.”
 Nurse practitioner Cary Hardwick explained that RA had been very well maintained on Suboxone. “It dramatically changed his life and his ability to live independently.” RA agreed, saying “It kept me from doing a lot of bad choices.” 
So without other options but suboptimal care in a compromised home situation, a home care plan with a high likelihood of failure was instituted. Sadly, despite best efforts, significant infection occurred at the surgical site. Ultimately, RA needed to have an amputation below his knee.
[A short video featuring RA, Cathy Hardwick, and Stefan Topolski, can be seen here.]

This is a powerful and painful clinical story. The reason I'm publishing it in a blog on organizational ethics is what Bob Master said next:
RA’s story did not need to happen, and likely would not have happened if policies were in place that promoted rather than restricted the use of effective ongoing addiction medications such as Suboxone in skilled nursing facilities. Clearly, this policy and probably many others need to change. It should come as no surprise that we are the first entity to uncover this problem and the first entity engaged in promoting such needed changes.
Accordingly, I’m proud to report that our skilled nursing facility team is now actively working with the Massachusetts Department of Public Health to change this counterproductive regulation so that individuals like RA in need of SNF care can be admitted to SNFs while being prescribed these important medications. It is admittedly a small step but I am proud to say a very important one. 

It's all too easy for us clinicians to throw up our hands in despair when we encounter a problem like the one that arose in RA's care. And it's easy for the wider public to fall into cynicism about "dumb bureaucracy." The story from CCA illustrates the kind of quality improvement from the ground up that our health system needs. I know the Massachusetts Department of Public Health. It's not a nest of "uncaring bean-counting bureaucrats." But we're all capable of making mistakes. The key skill our system needs is the kind of activism the story illustrates - moving from impediments to giving the right kind of clinical care to improvement of the system.

Hats off to the Commonwealth Care Alliance, and to RA, who wanted his experience to be used to help others!

[For a 2011 post about the Commonwealth Care Alliance, see here.]

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