17 Reasons Why Care Management Is Probably Not Going To Be in a Clinic Near You Anytime Soon

Here's a good review of all the reasons why care management has not become a routine part of patient care. 

As policymakers, reformists, consultants and architects plan for a population and outcomes-based future, they'd be wise to think about the review's 17-point reality check.

1) Start-up costs are considerable;

2) Costly to maintain;

3) Multi-year time horizon for any return on investment;

4) Any success undercuts future traditional fee-for-service revenue;

5) Can't be broken down into discreet 'reimbursible" units for fee-for-service payments;

6) It's paid for with still-novel-experimental capitated payments and/or shared savings;

7) The link between increased quality today and downstream savings tomorrow is still tenuous;

8) Complicates primary care by introducing more uncertainty;

9) Non-physician manager training is time-consuming and costly;

10) It's a resource that is best reserved for high risk patients, not all patients;

11) Doesn't fit into long-standing clinical workflows in established clinics;

12) Primary care already has enough challenges and implementing care management is not a priority;

13) Most EHRs are not configured to document or support non-physician care;

14) Decision-makers need additional information on expected net savings;

15) It relies on a lot of outside-the-doc-comfort zone behavioral, vs. "medical" health interventions;

16) It requires considerable data support;

17) It's often balkanized by multiple payers.

But be of good cheer. Jimmy Cliff reminds us that half the battle is knowing what you're up against.

Gluten-free (Sliceable) Pizza Crust

Though I’ve never been one for pizzas, I’ve caught myself craving one like crazy more than once these past few months (and no, I’m not pregnant), which got me thinking. What if I made a gluten-free pizza crust based on my recipe for buckwheat wraps? Hmm, that might actually work. So I grabbed my buckwheat flour, chia seeds, herbs, salt and almond milk and just played it by ear. Out came a crust that exceeded my highest expectations! And I'm only exaggerating a little!

First of all, it does not crumble into oblivion when you cut a slice, as I’ve heard many other gluten-free pizza crusts do. You can actually pick up a slice and eat it like that if you want to (although I prefer to roll them up and eat them like “pizza snails” hehe). Second of all, it’s super easy to make and doesn’t require a gazillion different ingredients. Lastly, it tastes pretty good, at least in my own, not-so-humble opinion. Let me now if you give it a try, I’d love to hear how this recipe works for other people than myself!

Gluten-free (Sliceable) Pizza Crust

Serves: 1

50g or about 1/3 cup buckwheat flour

1 chia egg (1 tbsp ground or whole chia seeds + 3 tbsp water)

4 tbsp almond milk

½ tsp psyllium husk (optional but recommended)

Salt and herbs of choice, such as dried oregano or basil

Toppings: A thick tomato sauce loaded with oregano, sliced mushrooms, aubergine, zucchini, bell peppers, artichokes, vegan cheese… it’s up to you!

How to:

1. Pre-heat your oven to 220C. 
2. In a bowl, mix all dry ingredients then whisk in the wet until they’re all evenly combined. 3. Pre-heat a non-stick frying pan (or a skillet with a drizzle of oil on the bottom*), to medium to high heat, pour in the runny "dough" and make a big circle using a spoon. Leave it thicker around the edges for an authentic pizza feeling.

5. Fry for 4-5 minutes or until it’s firm enough to move from the pan, then transfer the crust onto a lined baking tray. 
6. Brush the crust with a bit of oil if you want to (I didn’t but this can prevent soggy bottoms). Spoon on the tomato sauce and desired toppings, then bake the pizza in the oven for 12-15 minutes.

Slice it up, sprinkle generously with nutritional yeast and eat to your heart’s content!

*Note: I have not tried frying the crust in a normal frying pan but I’m sure it’d work just as well as long as you have enough oil in there! It might burn quicker so make sure to watch it carefully and turn down the heat if you must.

Love, Tilda

The Just Right "Sweet Middle" of Care Management

Finding the "just right" middle

If you're interested in care management (definition here), there's a supportive case report in the August 7 edition of the New England Journal.

But it also makes a important point that appears to have been missed by the Editors.

The Population Health Blog explains.

The case revolves around a fragile cancer patient with abnormal blood chemistries and distributed locations of care. The author describes how care management successfully improved the patient's safety, required a lot of physician-to-physician communication and relied on care management's "reach" outside the four walls of the primary care clinic.

All good points.

However, what's also true is that prior to the cancer diagnosis, this was an otherwise well patient with post-discharge needs that were amenable to care management intervention.  In other words, this patient was "high risk, high impact." These individuals make up the narrow middle in the span of patients who range from otherwise well (destined to do OK) to disastrously complicated (destined to do poorly no matter what). 

The Population Health Blog doubts the case would have been so meaningful or successful with a routine surgery patient (stable and OK) or someone with metastatic spread of the cancer (a disaster).

The Population Health Blog is all for patient safety, doc-to-doc communication and distributed care management.  However, they're not going to be of equal benefit for every patient.  If the intent is to "save money" by reducing avoidable health care utilization, it's best aimed at the patients in the middle.

Like this one.

Cheezy Chickpea Balls

Yesterday, I received a big bag containing Lupin flakes, sent to me by Rhiannon over at Lupin Foods, all the way from Australia. So, what are Lupin Flakes then? The first thought that popped into my mind was Remus Lupin from the Harry Potter books. Ehrm, obviously not the case here. I did a little research on lupin Foods’ website and here’s what I found:

·      Lupins are part of the legume family and are mostly produced in Western Australia

·      Lupins are one of the best sources of vegan protein ON THE PLANET with 40g of protein per 100g dry flakes! (yes, I’m as shocked as you are)

·       If you’re looking to incorporate more fiber in your diet, look no more. Lupin flakes contain 37g of protein per 100g dry flakes. That’s almost 4 times the fiber content of whole wheat flour!

·      There’s no risk of Lupin poisoning when you’re consuming Lupin Flakes; the Australian Sweet Lupin contains only miniscule amounts of the toxic alkaloids found in the bitter varieties so no need to worry.

·      Is one of few vegan foods that contain all the 9 essential amino acids.

The packaging

Those are pretty amazing stats as far as I’m concerned and I really do look forward to using Lupin Flakes in more of my recipes!

This was my first attempt at a lupin recipe and I must say I was pleasantly surprised. These chickpea balls are crunchy on the outside, soft on the inside and provide a wonderful, savoury contrast to the sweet potato fries. Plus, one serving  contains 18g of protein! I mostly stick to a low-protein diet as I don’t believe the overconsumption of protein, that is so common these days, does any good to our bodies. Still, it’s absolutely vital to get enough protein when you’re on a plant-based diet and these balls are the perfect way to do so.

Cheezy Chickpea Balls

2/3 cup chickpeas (canned, drained and rinsed)

2 tbsp Lupin flakes*

1 tbsp nutritional yeast

1 tbsp almond milk

½ tsp psyllium husk

½ tsp dried oregano

Pinch of garlic powder

Salt and pepper to taste

*if you don’t have access to Lupin flakes, you could make the balls without them.

How to: 

1. Pre-heat your oven to 180C. Blend all ingredients with a hand blender and shape meatball-sized balls with your hands. Bake in the oven for 30 minutes or until they’re crisp and golden on the outside.

Easy-peasy Sweet Potato Fries

1 medium sized sweet potato

That’s it!

1. Pre-heat your oven to 170C. Cut your sweet potato into long strips and trim off any thin, sharp edges that might burn in the oven. Place the fries on a lined baking tray and bake in the oven for 40-50 minutes, turning them halfway through for an even bake.

Serve your fries and chickpea balls with lots of veggies and a yummy sauce to dip in if you wish!

Love, Tilda

The Lessons and Benefits of Health Equity Impact Assessment

Erika Espinoza, is the Knowledge Exchange Lead for the North Region of Ontario within CAMH's Provincial Systems Support Team. The interview was recorded as part of the Health Equity Impact Assessment (HEIA) Tool Community of Interest with funds from the Evidence Exchange Network (EENet).

Health Equity: Lessons &; Benefits of HEIA from CAMH Education Network on Vimeo.

Quality Improvement Ver. 2.0?

Throughout its medical career, it's safe to say that the Population Health Blog has been quality-improvement ("QI") averse. While the PHB "got" the need for measurable outcomes, the jargon ("barrier analysis"), expertise (careerism) and culture (heavy on "administration") made it treat QI like an EHR alert: something to be tolerated, not embraced.   

After reading this on-line AHRQ manuscript on primary care QI, however, the PHB is reconsidering the topic.

Naturally, for all the wrong reasons.
 
The PHB explains.

According to the brief:

1) QI can be defined as continuously assessing performance over time to make ongoing adjustments in care processes  Like it or not, QI is being increasingly linked to licensing, accreditation, public reporting, media scrutiny, payor involvement and growing patient consumerism. It's true for hospitals, and it's just a matter of time until that extends to the outpatient arena.

2) Unfortunately, QI needs the three things that are in short supply in most outpatient settings: staffing, resources and commitment. Two other challenges include the never-ending work of patient care and the lack of any direct or indirect financial benefit. 

3) As a result, if primary care practices are going to meaningfully "do" QI, they'll need external support.  That means personnel/consultants who can train, provide technical assistance, find resources or suggest best practices. Large health systems may be able to adapt this from their hospital QI programs.  Smaller or independent clinics may have to turn to the overlapping regional alphabet soup of AHECs, RECs, QIOs, PBRNs, payer, employer and professional initiatives paid for by the Feds, states, insurers and foundations.  The chances of success will be greater if there are financial incentives (such as a piece of any shared savings) and networked learning involving other like-minded clinics.

The PHB's knows the AHRQ authors mean well, but wonders if it isn't time to start thinking about QI Ver. 2.0.  It would involve some of the following elements:

Turn key: easy to import with absolute minimum fuss, time to implementation, workflow disruptions and reliance on human guidance.

A contracted entity can remotely tap computerized billing, insurance claims or electronic record systems in a matter of days, letting the docs continue to focus on patient care.  If patient surveys are necessary, use text messaging or interactive voice response.

High tech: Cloud-based data collection, storage and reporting.  All the better if it's automated and scalable.

Once the data are collected, computers can calculate trends, means, standard deviations and statistical significance.  The process can be standardized and auditable.

Decision support: Link any insights to the artificial intelligence that guides patient care.

As point-of-care guidance on diagnosis or therapy grows more sophisticated, it can use the clinic's QI data to change processes and improve outcomes.

By the way, the PHB suggests one entity that is best able to champion this are the population-health care management programs.  They understand the need, possess much of the technology and could use QI to further their value proposition.

Image from Wikipedia

SABOTAGE STEALS SUCCESS

Sabotage is a strong word to describe the behavior that can sneak into our life and steal the success that healthy eating and exercise has provided our bodies.  It can come in the form of our own thoughts, an unsupportive spouse, friend, and even co-workers. The important thing is to be on guard so that the forms of sabotage can be recognized and dealt with in a way that is healthy, and keeping us on track with our fitness goals. I am not addressing the occasional cheat meal or even day, I am talking about a chronic issue of falling into a trap of being swayed away from a healthy lifestyle, and allowing that to happen.

Living a healthy lifestyle takes mental strength and a loving commitment to maintain our best self through consistent healthy choices each day. Let’s address self-sabotage and how it can creep into our mind and try to convince that “just this once” or “just a few bites” can become part of the healthy plan.  The issue with this type of sabotage is that it does not stop at the “just once or a few bites”.  Often times, this mindset flows into several days, weeks, and even months, and before it is over, the weight loss achieved is back up to where it started, and possibly more than the initial weight. Convincing ourselves that eating crap on a regular basis is never a good thing for our bodies, and remaining on guard so that self-sabotage can be recognized and dealt with immediately is crucial to stay on track with our fitness and health goals. Keeping a daily fitness journal is a helpful accountability tool to keep us on track.

Another sabotage culprit is that wonderful person you live with until death do you part.  Love has nothing to do with sabotage of this type and the non-supportive spouse may not get the whole new health thing or does and is struggling with acceptance of your new healthy lifestyle.  There are many relationships like this and living a healthy lifestyle becomes difficult, as the processed foods and other temptations continue to hide in your pantry and refrigerator.  Sometimes, a spouse turned healthy and leaving the other behind can cause friction in the relationship as guilt trips occur over the change in lifestyle.  It is so important to realize that each person is ready when they are ready and force-feeding a new healthy lifestyle on your spouse will only drive a wedge in the relationship.  As the one wanting to live a healthy lifestyle, model by example, and when the cupcakes come calling, politely say “no thank you” and grab a yogurt and piece of fruit to eat along with your partner. Mental strength has to be on overtime in these circumstances as there will be a daily guarantee of temptation.  Keep that promise of creating your best healthy self and great positive attitude, and almost assuredly your spouse will eventually join you.  Patience will be your best friend here.

Sabotage among friends exists and it can be ugly.  Creating a healthy lifestyle will mean making hard choices and dismissing ourselves from possible temptations that will steal our accomplishments. Some friends may not understand that you no longer want to eat processed foods or drink alcohol all night long, and are happy to provide the peer pressure to get you to fold on your commitment to self.  A strong mental game is definitely a requirement and sometimes a request of support from your friend will be necessary.  A true friend will understand and come alongside of such an important decision and one that does not care will continue to sabotage your efforts. If you continue to hear that it is OK to let your hair down and relax with your program on a continual basis from a so-called friend, you may want to re-think the motives of this friend.  It is unfortunate, but jealousy does exist and can rear an ugly head during such times, and some may not be able accept that your body is changing in beautiful positive ways.  The important thing in this type of situation is to be true to you, regardless of what is said or pressure felt.  Going out can be limited to a glass of wine and water in addition to healthy food selection.  Continue to enjoy your life and implement the healthy choices and the rest will take care of itself.

It seems like there is no safe place for the healthy person to hide from the forms of sabotage and the workplace is no stranger to being involved.  Do you have a break-room filled with daily temptation, or that co-worker who always brings the donuts and gladly sets one on your desk? Put up the mental defense when it comes to accepting sabotage at work because you do have more control here.  Bringing a cooler filled with your healthy planned meals will keep your fingers off the bagels and cream cheese with a side of cookies.  Be stronger than the saboteur and say “thanks but no thanks” to the invitation of work indulgence eating.  If a strong mental game is not put into play, visiting the break-room can become a daily occurrence with the results showing up on the waist line, and a complete derail of the healthy lifestyle you want to implement.

WIN A FITNESS TANK

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Stay Healthy!

Darla