Monday, February 23, 2015

A Tale of Two Sore Throats: On Retails Clinics & Urgent Care

[This post was first published on The Health Care Blog on 1/28/15, and was re-posted to KevinMD on 2/21/15. The comments are worth reading at both sites.]

Six years ago, just after arriving in Baltimore for a winter conference, I fell sick with fever and a bad sore throat.

After a night of feeling awful, I went looking for help. I found it at a Minute Clinic in a CVS near the hotel. I was seen right away by a friendly NP who did a rapid strep test, and prescribed me medication. I picked up my medication at the pharmacy there. The visit cost something like $85, and took maybe 30 minutes. They gave me forms to submit to my California insurance. And I was well enough to present my research as planned by day 3 of the conference.

Fast forward to this year. After feeling a bit blah on a Monday evening, I developed a sore throat, headache, and fever overnight.

I figured it was a winter viral pharyngitis, rearranged my schedule, and planned to make it an “easy day.” Usually a low-key day plus a good night’s sleep does the trick for me.

But not with this bug. This one gave me chills, a splitting headache, body aches, a fever of 102, and a sense of serious misery. Plus that awful sore throat. A dose of ibuprofen 400mg would beat back the symptoms a bit, and allow me to eat and sleep. But after about four hours, I’d find myself shivering and feeling horrible again.

And the following day, Wednesday, I felt even worse. I started wondering if maybe I had the flu, or could it be strep throat, since I didn’t have a cough?

I thought about going to the doctor, but I felt so sick and I didn’t want to go through the hassle unless there was a decent chance of benefit.

Because in truth, even though I get my care from a large well-regarded health system that offers online appointment scheduling, a portal to review my outpatient lab results, telephone advice nurses, and other conveniences, I still don’t like going in because it’s a big place and the experience never feels…delightful, shall we say.

I looked through UpToDate online and tried to figure out the likelihood that a doctor’s visit would change management (most adult pharyngitis is viral) but my mind was too fuzzy and so I stayed home in bed.

However, that night my husband said he was starting to get a sore throat. I also spoke to a doctor friend on the phone. She thought my symptoms sounded an awful lot like strep, and urged me to go in and get a rapid strep test. I decided that if I didn’t feel a lot better by the next morning, I’d go in.

I was a little better the next morning (day #3 of my illness) but not a lot. The body aches were better, but I’d developed a killer earache, and it still hurt too much to eat unless I had recently taken ibuprofen. My temperature off ibuprofen remained 101-102.

So I called the phone appointment line, explained my symptoms, and was given an appointment to see my own assigned doctor. (No urgent care clinic available I was told; this health system encourages open access to your own doctors.)

As I had expected, it was a miserable hassle.

Friday, February 6, 2015

7 Types of Help People Want from Healthcare

What do people want from their health care, and their medical care?

In my last post I shared a rough taxonomy of patient types, based on stage of life and type of chronic health problems.

Similarly, I think it's useful to sketch out the types of help that people seek from the healthcare system. So far I've come up with seven.

But before I share them, let's step back and consider the big picture of health care.

What's the point of health care and our healthcare system?


The overarching purpose of health care, and the overall thing people want from healthcare, is:
To optimize the ability to participate in life, today and in the future
This is the underlying reason that people want help with their health. 

(What is health? See my practical definition here, and yes I'm still hoping for feedback on it!)

Just what it takes help optimize a person’s abilities depends on the details of their health situation. For instance, for a person who has recently suffered a stroke, it might be things like speech therapy and physical therapy to optimize function, adaptive equipment and home modifications to facilitate getting around safely, treatment of post-stroke depression, and medical management to reduce the risk of a future stroke. 

7 ways the healthcare system helps people with their health


In terms of the ways one might optimize people’s health, I see people requesting or expecting the following seven types of help from the healthcare system:

Friday, January 23, 2015

Flipping the Clinic: On Brainstorming Innovation by Patient Type

Last week I attended the Flip the Clinic Lab event in San Francisco, which was co-hosted by the UCSF Center for Excellence in Primary Care, and sponsored by RWJF. (See my Storify of related tweets here.)


It was a fun and engaging day, but it left me thinking something that I often find myself mulling over at health innovation conferences:

Is it possible to constructively brainstorm about healthcare when thinking about everyone's health needs at the same time?

In other words, are we likely to come up with good ideas when we're striving for ideas that work for all patients? Are we likely to come up with really useful ideas when a pediatrician and a geriatrician and a 30 year old Type 1 diabetic get together and envision a better patient-clinician experience?

The difficulty, of course, is that different types of people need different types of help from the healthcare system.

A generalist pediatrician presumably has many patients who are overall fairly healthy. They do need monitoring, and health education, and also help when a new health problem comes up. Many of them might be struggling with weight and healthy eating, and some are at risk due to their social determinants of health. Some of these patients will develop a chronic disease like asthma, and will need ongoing help with their chronic illnesses. And a minority of pediatric patients have the kinds of health problems that require frequent hospitalizations.

A geriatrician like me, on the other hand, cares for older adults who tend to have multiple "mundane" chronic illnesses. Many of them have chronic impairments of the brain or body. Many of them have caregivers assisting them with life tasks, including "self-healthcare" such as symptom monitoring. Many of them experience hospitalizations, and life-threatening health crises.

The truth is that when we brainstorm flips for our clinic, or any other kind of improvement to healthcare, we generally aren't thinking of everyone at once.

Instead, we are either thinking of our own needs as patients and families. Or if we're a healthcare provider, we're thinking of the needs of those patients that we spend the most time with, or are most interested in.

Common Types of Patients

Friday, January 9, 2015

Resolve to Become Fit for Frailty & Do Great Things in 2015

This week I came across a fantastic resource that I want to recommend to any and all who are serious about solutions to support aging adults. (Or healthcare, for that matter, since older adults are the power users of healthcare.)

It is the Fit for Frailty report, the second part of which was recently released by British Geriatrics Society.

Part 2, "Managing Frailty" is particularly important, as implementing good care is generally much harder than identifying those in need of better care. (Focus on the constraint, people. Implementation is almost always the constraint.)

For geriatricians, this is a nice resource summarizing the best of what we do. If you're in geriatrics, read it and enjoy.

But I think this is especially valuable for the entrepreneurs, innovators, and health problem-solvers who are interested in aging.

Your job, as I see it, is to take the best of what we know and do in geriatrics, and make it more easily doable by everyone: older adults, families, communities, clinicians with no particular training in geriatrics, and even geriatricians. (I am eternally in need of tools that will make doing what I'm trying to do easier.)

Now here is a wonderful document that outlines how we go about modifying healthcare so that it's a better fit for frail older adults.

Thinking you're interested in older adults but not frail older adults? Think again.

Although frailty does have its own characteristics and isn't the same as being old, or having multiple chronic conditions, products and services that meet the needs of the frail are the healthcare equivalent of universal design.

That is to say, the approaches we've developed for frail older adults -- like carefully weighing the benefits and burdens of medications, and tending to the needs of the family -- are generally good for all patients.

Plus, frailty is strongly correlated with healthcare utilization, so if you develop tools to better help frail older people, someone might be willing to pay for them.

Must-reads from the Fit for Frailty report

Friday, December 19, 2014

The Trouble with Home Health Care & Care Coordination


Home health care is in many ways a fantastic service, especially for those Medicare beneficiaries who are essentially home bound due to frailty or illness.

But it's often feels surprisingly hard to synergize with home health care.

The main problem, as I see it, is that home health care agencies have set themselves up to provide only administratively required communication with the ordering doc. (There are rules governing home health care, you know!)

Now, what I need is clinically relevant communication. As in, how is the patient clinically doing, so that you and I can coordinate our efforts together. This has apparently not been built into the home health care workflow.

And things get even more complicated when it's a patient in assisted living, because then you have the facility nurse who should be kept in the loop as well.

Right now, I am trying to follow up on an elderly woman who lives in assisted living and has paid in-home aides (which are provided by a separate company).

I referred her to home health care a few weeks ago for help managing her skin. On one hand, she was starting to develop a pressure sore from sitting too much in the same position. And on the other hand, she had a fungal rash in her groin, under her incontinence brief.

I prescribed an antifungal cream to be used twice a day for two weeks.

Now it's been three weeks, and the pharmacy is requesting a refill.

Well...what's going on with that rash?

What I want to do is send an email to everyone who is involved and might know something. That means an email that would include:

Friday, December 5, 2014

Health Care for Dummies (and Innovators): In search of a practical definition of health

[This post was first published on The Health Care Blog on 11/26/14.] 

For a while now, I've been working on an ebook about making digital health more useful and usable for older adults.

(Don't hold your breath, I really have no idea when it will be done. I can only work on it for about an hour every weekday.)

In reflecting on the health innovation conferences and conversations in which I've participated these past few years, I found myself musing over the following two questions:

  1. What is health? 
  2. What does it mean to help someone with their health?
After all, whether you are a clinician, a health care expert, or a digital health entrepreneur, helping people with their health is the core mission. So one would think we’d be clear on what we’re talking about, when we use terms like health and health care.

But in fact, it's not at all obvious. In practical parlance, we bandy around the terms health and health care as we refer to a wide array of things.

Friday, November 21, 2014

What A Caregiver Said Was Hard About Hospice

[November is National Family Caregivers Month. In this post, I share the eye-opening letter I received from a Geriatrics for Caregivers reader who has cared for his mother -- now 100 years old -- in his own home for 3 years. She is now on hospice. 

The writer has given me permission to share this letter, noting that his mother, a former teacher, would have been glad to know people were learning from her story. Please note: all emphasis below was added by me.]

Howdy Dr. Leslie -
Mom has progressed quite a ways down the road and actually I am quite amazed that she is still with us. I think that, somewhere in the back of her head, she had the 100th birthday in her mind as a goal. She has deteriorated quite a bit in the last 10 days since her birthday.

Two months ago we placed mom on the local hospice program (we have one, run by the hospital) and we were just recertified for another 60 days. You may remember the difficulties our hospital was having and the possibility that it might actually close due to some incredibly bad CEO's and bad management. Fortunately, they have located a fellow who used to be the CEO here about 15 years ago and he has gone on to form his own hospital management company and they have several hospitals located around the country. Things appear to be on a new track.

Now to your question - the thing that has probably frustrated me the most in caring for my mother are two:
  1. the lack of resources and available training to function as a caregiver and
  2. the continuing lack of resources that I have received from our hospice program. 

As mom progressed, I had located several dementia units that I felt would be a good match and found that unfortunately 3 of them have discontinued their dementia care units due to rising liability issues. The remaining ones didn't make me feel comfortable.

Since mom has been unable to walk back in February, I have had one night off and I know it is beginning to affect me. I have found caregivers (including my sister when she is able to come up) but none will stay overnight and none will do any lifting. Even the hospice program offers volunteer caregivers but only for about a two hour time period and they do not do lifting. We tell caregivers to watch out for their health, but then don't provide the resources to accomplish that.

A local nursing home now offers respite care and our hospital has once again started accepting Medicare and Medicaid patients for respite care up to 5 days. (Prior to this, the other CEO refused to accept anyone except self pay for respite care).

Much of what hospice offered I didn't need: harp player, chaplain, social worker, respite volunteer (although I have utilized her 3 times when I haven't had a choice). What I have taken advantage of is a personal care individual who washes mom's hair and trims/cleans her fingernails as my eyesight made this difficult), a physical therapist to see if mom could improve her ability to stand on her own as an assistance to me when I was changing her and of course, the nurse. All of them, with the exception of the physical therapist seemed to come with their own agenda of what they wanted for mom's care - despite my stating and restating what I wanted done.