Thursday, August 23, 2012
Everyone has something that just bothers them and causes their teeth to chatter and chills to go up their back: something that elicits the same sort of visceral reaction as fingernails on a chalkboard (although I know I date myself with that metaphor in this day of white boards and markers). For me, that pet peeve is when someone, especially someone in a caring profession, says, “There is nothing I can do.”
That simple statement signifies giving up, abandonment and an attitude that fails to recognize the infinite options and the infinite good that is possible when people who care keep trying. Some may see this as being unusual as I am the same person who wrote in a previous blog “Don’t just do something, stand there!” But when you stand with someone and you support a person through tough times, you are doing something and you are doing something extremely important.
A book I just read entitled “Nine Lives” written by Dan Baum also makes an aspect of “doing something” come to life. In this oral history of nine people’s lives in New Orleans before during and immediately after the Hurricane Katrina disaster, one of those people, Wil, relates the story of his father’s illness and time in the hospital. His father, Da, a larger than life figure who was Wil’s model for being a pillar of strength and dignity, was in the hospital with cancer and had massive bleeding from his rectum. Wil seeks out the doctors caring for his father and is told, “Your father is dying right now.” “We could put a shunt…but that wouldn’t change anything. We got men in here that can survive…We got to look after them first.” Wil goes back into the room and his father says, “They told you I was going to die.” His father, Da then goes on, “You go home to that new pretty wife of yours and get some sleep. I’m going to call you in the morning. We’re going to get them to give me that surgery.” Early in the morning while it was still dark, the phone rings and Wil lets it ring thinking that is the hospital saying that his father has died. He finally answers and hears, “I told you I was going to call you in the morning,” Da’s voice said. “You thought it was them people calling to say I was gone, didn’t you?” “They’re about to take me down to surgery.” Da was someone who knew how to be strong and fight for himself as an individual. Caring professionals can and should help people be strong and fight even if there is supposedly “nothing” that we can do.
Doctors, nurses and other health professionals are often faced with examples of problems that do not have any apparent solution. In those cases there is still something that can be done. Just giving someone their own voice, helping them find their strength, giving them options (and there are always options even if all of the options are not very good) and helping them marshal the resources they need to cope with their situation no matter the medical prognosis of that situation is “doing something”.
This type of problem is commonly seen with people who suffer from chronic pain. A recent article from the latest issue of the American Journal of Medicine illustrates this through a description of the lived experience of pain. Using the poetry of Emily Dickinson, which may seem unusual in a scientific peer reviewed medical journal, the author emphasizes the experience of living with pain. He states: “Chronic pain sufferers typically report experiences of isolation and alienation from their physicians and providers, from their caregivers, and even from their own bodies.” The author closes the article by stating “the healer can assist the pain sufferer in the reconstitution of his or her world, one in which pain is still present but does not entirely blank out the colors of the pain sufferers existence.” So it is for health professionals and those in caring roles in which “doing something” often means helping the person cope with a medical issue or other issues which have no concrete solution but have solutions to the alienation and isolation that accompanies them.
I hear the phrase, “There is nothing we can do” and hear an attitude of negativity and capitulation. The complacency and cavalier attitude that can easily overcome us is reflected in that simple statement. Those in need are all unique people and we are helping them when they do not know where else to turn. That is our job and our mission. We have to think of each individual and always find a way to do something to help them in their own journey no matter how difficult and “hopeless” it is. There is always hope when there is caring.
Monday, August 20, 2012
This week, Inc. Magazine announced their fastest growing companies for 2012 and Accolade was at the top of the list for health care companies. While this is a great accomplishment I cannot help but see it as just the beginning; the beginning of a great company and of a new profession. Speaking personally, the effort of starting this company has been the culmination of my entire career. For years before our start, I spoke out about the need to help people not manage disease in managed care and spoke about the need to have people when sick be recognized for their unique situations and attributes and have their care customized on that basis. While it knowledge of evidence based practice is critical, it must be used as a core element and not as a limiting factor of care.
At this point in the growth of Accolade we have proved that you can take that customized approach that includes not only scientific medicine but the unique dynamics of each and every family, and actually spend less money overall than if you just used a standardized, one size fits all approach. We have learned a lot along the way and realize that we are just beginning to move Accolade and the profession of Health Assistant being recognized as a needed resource in our health care world of complexity.
We have learned that in order to come this far you need:
· Investors and a Board of Directors who understand that it takes time and money to build a company that truly improve people’s lives and create value that can be reflected in revenues. We have such a Board and more. We have a Board that understands that the building of an Accolade is really about improving the world and not only building a company.
· A leader who can put all the pieces in place and create a culture that supports a truly unique and new way of doing business and who questions all old assumptions in the building of a new approach, a new profession and a new company.
· A group of people, all of whom understand the fundamental principles we work under, to design all the different elements, from the training to the IT systems, to the operational systems, to the support materials to even the designs of the office spaces that all support the culture and the values of helping people.
· Very strong IT systems, operational systems and support personnel to make this work. Health Assistants cannot work in a vacuum and are only affective if they have the proper tools and the proper information in place when they need it.
· Most importantly you need a group of individuals to actually do the work of caring, of supporting, of understanding and of helping those in need. Our Health Assistants, whatever their initial backgrounds and degrees all have come together to build something that is great and that has a profound impact on those we help and on those we will help in the future.
In addition, other major lessons learned and some of the reasons it has taken five years to come this far building an approach that makes so much sense and is so successful in both helping and lowering health care costs are:
- Changing a paradigm is extremely difficult. When you build something new, that does not fit nicely into preconceived notions, it is hard for others to understand.
- Creating simplicity for individuals and employers is extremely complex
- You need forward thinking, creative people leading the employers who work with you. We are fortunate to have that in Comcast, Medtronic and now Lowe's
What we have done thus far is not for the faint hearted. It is hard and it requires a blend of extremely different talents and knowledge.
The movement towards building the profession of Health Assistant also addresses in a positive and productive way the complexity that is inherent in a health care system that must take human behavior into account and that must have the knowledge of all aspects of care which includes the clinical/scientific, the financial, the emotional, the social and the religious elements. When one is sick, it is a family affair that affects every part of every person who is in that family unit. The profession of Health Assistant recognizes those pieces and helps the patient and the family through all of it. The professional Health Assistant also helps someone regardless of whether they are critically ill or merely in need of reliable advice about staying healthy and everything in between. Meeting people where they are and not just trying to cherry pick those people who are spending large sums of money or who happen to be using the health care system at a point of time creates the right relationships to make a real difference across a large population.
I can only hope that as Accolade continues to grow that we will see more and more people recognize how affordable care depends on a customized patient by patient approach and that approach can be simplified for all concerned by having Health Assistants for every person in this country and possibly the world. If that seems overly ambitious think again. We at Accolade know that we can help people as individuals make their own decisions and create a better health care system at the same time.
Wednesday, August 8, 2012
Recently, in the New England Journal of Medicine (NEJM), there were two articles that gave different points of view on how to reform health care in order to decrease costs in the wake of the continuing discussion about the Affordable Care Act (ACA). The two articles both had identical short introductions by the editors of the journal that read, in part, “There is wide agreement that we must find ways to bend the health care cost curve. Taking different approaches, the two articles that follow present a range of options, including reducing both the prices and quantity of services for public and private payers, reducing administrative costs, implementing new market based incentives and reforming the tax subsidy for employer sponsored heat insurance.”
I was struck as I read both articles and reviewed the ideas that both contained that they shared a common focus. Both articles looked at patients and their families as consumers and focused on the financial incentives and the financial barriers to receiving quality health care and both framed the discussion strictly in terms of cost, legislation, and administration. Both addressed patients as consumers, rather than as people who are frightened, depressed, and concerned about their own frailty and the effects of their disease on others around them. In both defense and deference to the authors, (and they hardly need my defense), they are all people who care deeply about patients in a holistic way and were specifically commenting on aspects of health policy and not on patient care.
However, I do believe that when addressing health policy, you have to think about individual people in need or the policies developed can easily have unintended negative consequences for those who are faced with using the health care system in all of its glory, cost and confusion. Tom Lee understands that as evidenced in an article in that same journal published one month earlier. His article entitled “Care Redesign– A Path Forward for Providers” did not focus on the national issues of decreasing cost and instead focused on how people obtain care. Early in the paper he states, “…healthcare is intended to help people, not just provide a commodity as inexpensively as possible”. Now this was something I could relate to!
Much of Lee’s article gives a primer on asking patients what is important to them, which is unfortunately quite a radical principle. We at Accolade founded our company upon this simple philosophy of listening to the patient and addressing their concerns first. Lee’s stated goal in care redesign is, “to improve the value of care as defined according to the patients’ perspectives”. In order to do this he states “we must understand the outcomes that matter to patients and families and what it costs to achieve them”.
Most physicians and health care organizations believe that they know what people want and it appears obvious – they want to get better and they want to spend as little money as possible doing so. However that misses the point that as you delve into detailed discussions with people you often find out that what they want as an outcome actually deviates in the details from the physicians’ assumptions. For example, in Tom Lee’s article he described a study of stroke patients. He states, “From interviews with patients, we learned that many of them are interested less in readmission rates than in the number of days spent at home during the first 90 days after a stroke.” The Stroke team that did these interviews, also came to understand that “we know how to measure readmission rates but not yet how to measure what matters more to our patients” and also came to understand “we don’t reliably capture information regarding other outcomes, such as continence and mobility, that are important to patients who have had a stroke”.
More than five years ago, when we were just starting to design Accolade, we understood that to be successful in helping people and lowering costs, we had to understand what people across the health care spectrum wanted as outcomes, including those who were healthy and those trying to stay healthy, those who were acutely ill, those with chronic illness and those with catastrophic, life threatening illness. We talked to them and to this day our model of caring continues to depend on talking to individuals continuously to find out what they want and what outcome is important to them. One of our lessons is that as illness progresses and enters new stages of recovery or chronicity people’s desired outcomes change as well. Asking people at one point in time is important but even more important is having a relationship with them that allows for that constant discussion as people’s priorities change.
Lee states in the article that “An emerging insight is that our overall organization has to function more like our most beloved clinicians – showing patients that we care by asking them how they are doing and by responding accordingly, even when were not fact to face with them.” It is important we follow Lee and Osler’s wisdom, understanding every “sort of person” who has a disease and always “asking them how they are doing and responding accordingly”.
Sunday, August 5, 2012
Health care is a team sport which, when done well, appears as elegant and seamless as watching the Dream Team at the Olympics. It is a sport that combines the talents of many skilled professionals while also including the caring amateurs who are closest to the patient. I have a chance every day to watch and take part in this team sport as part of the Accolade Olympics. The nice part of this is these Olympics are normal days rather than once every four year events surrounded by pageantry.
Recently, I expanded my chance to observe our teams at work. It was almost by chance that I accomplished this and it involved something as mundane as changing my office. But to understand this change, first you have to define what an office is as my office is a riddle. The riddle goes, “When is an office small but large, central but peripheral, alone but surrounded by people, and on different floors in a building and even in different buildings?” The answer is when the office is actually a standing desk on wheels that can be parked anywhere in the office. I have used a standing desk for a long time, mainly for health and comfort reasons, however I recently switched to a standing desk on wheels that I can take and park anywhere. Now that Accolade is in more than one location, I even have similar “offices” in both of our locations. I have found that this allows me to spend time working in different parts of the company from one day to the next and even from one hour to the next if I like. So now I get to spend time with more of some of the neatest people in the world, the people who work as Health Assistants for the clients of Accolade and who are part of the daily Accolade Olympics.
On a recent day while I was working at one site, I had a wonderful microcosm of an ordinary extraordinary day for an Accolade team. I got to see Don in action, talking at length to someone with a mental health issue that had never been addressed, watching him as he paced and talked and gained the trust of that person on the phone who needed help desperately in order to create an entry into a needed visit to a therapist. He was masterful with the only challenge being not walking into me as I also pace while on the phone working in my “office”.
I got to listen in as Michael spoke to a doctor’s office, advocating for a client to have the office furnish a pre-certification form to the Health Plan so that a needed service could move forward and be reimbursed. While one may think this would be simple in this instance it was not with the office showing very little desire to cooperate. Michael, by being firm, professional, forceful and friendly all at the same time, made it happen. It was as beautiful to watch as a 9 from the judges during the diving competition.
I saw Dana and Marya, teaming up beautifully to help someone with a medical problem that had medical issues that needed a Clinical Health Assistant like Marya and the trust, calming and expertise in logistical and health plan related issues from a professional Health Assistant like Dana. Both Dana and Marya made real connections with this client and you could sense the trust and calming effect both had on that person as you listened to the tag team formed by that dynamic duo. The two person woman’s volleyball competition did not see coordination and teamwork as strong as that.
I saw Jamie working way past her scheduled time to leave wanting to make sure that her client’s needs were totally addressed with a sense of ownership of those needs that I could only sit back and watch in awe. No tennis match going long into the night as the match point was elusive had as dedicated a competitor as Jamie.
And I saw Curt coaching this herd of independent but team oriented professionals do their job as a Olympic coach would. He was giving Michael positive feedback about the last client he helped while also exhorting Jamie to leave in order to take care of herself, letting her know that her own health and wellbeing was important in order for her to take care of those clients.
All this time, I was working “in” my office, on the phone and on the computer, working as a team with Melissa, a Clinical Health Assistant, Bob, a pharmacist and with the clinician at the Pharmacy Benefits Manager as well as with our Employer to address a pharmacy policy that had unintended consequences for a number of clients. That extended team was able to adjust that policy so as to maintain the quality of clinical decision making while also improving the policy so that the unexpected consequences would not occur again. I was working with Colleen, another Clinical Health Assistant who was helping a client with a problem that was extremely serious and urgent in nature as he was in danger of losing his leg due to circulation problems and his vascular surgeon was away. The surgeon who was present was not being helpful but by working with the clinical leadership of the hospital and building them into the team for this issue, we were able to get this man the care he needed provided by a different surgeon and possibly save his leg.
In other words, this was a normal day for a normal team at Accolade that play the team sport of health in a way that Olympians would envy. I have the wonderful fun and honor of being an occasional coach for our teams while also being a team member when needed for the broader staff and the communities we serve. Most of all I am a fan of our dedicated Health Assistants who help so many people on a daily basis. I love my job, my new office and especially the caring Olympic level professionals who are part of the Accolade team.