Author Archives: MidMichigan Health

Why Virtual Care is Flourishing During COVID-19 and Why We Can Never Go Back

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Have you ever woken up with a sore throat and used your phone to get a virtual visit? The odds are it’s not available to you, and there is a reason for that. You may be hearing about how virtual care, often described as telehealth or telemedicine, is beneficial during COVID-19 and how health systems are offering virtual access like never before. There’s a reason for that, too.

For the past few weeks I’ve seen Facebook posts daily from former nursing colleagues in metro Detroit, one of the hardest hit areas in the country, as they provide front-line care to patients with COVID-19. It makes me very proud to call these nurses my friends. As a former emergency department nurse, I recall the feeling of satisfaction knowing that I’ve helped someone on the worst day of their life. One of the best parts of being a nurse is knowing you matter to the only person in health care that truly matters: the patient.    

Several years ago I made the difficult decision to no longer perform bedside nursing and become a nurse administrator. The biggest loss from my transition is the feeling that what I do matters to the patient. COVID-19 has forced a lot of us to rethink the role we play in health care and what the real priority should be. Things that were top priorities three months ago have been rightfully cast aside to either care for patients in a pandemic or prepare for the unknown future of, “When is our turn?” For me, COVID-19 has reignited the feeling that what I do matters as virtual care has become a powerful tool on the forefront of care during this crisis. It has also shown that many of the powerful rules and regulations that limit virtual care are not needed and should be discarded permanently.      

When I became the director of virtual care at our organization in 2015 I knew nothing about telehealth. Sure, I had seen a stroke robot in some Emergency Departments, and I had some friends that told me their insurance company lets them FaceTime a doctor for free (spoiler alert: it’s not FaceTime). I was tech-savvy from a consumer perspective and a tech novice from an IT perspective. Nevertheless, my team and I spent the next few years learning as we built one of the higher volume virtual care networks in the state of Michigan. 

We discovered a lot of barriers that keep virtual care from actually making the lives of patients and providers better and we also became experts in working around those barriers.  But, there were two obstacles that we could not overcome: government regulation and insurance provider willingness to cover virtual visits. These two barriers effectively cripple most legitimate attempts to provide value-added direct-to-consumer virtual care, which I define as using virtual care technologies to provide care outside of our brick-and-mortar facilities, most commonly in the patient home.

The need to social distance, cancel appointments, close provider offices, keep from overloading emergency departments and urgent cares and shelter in place created instant demand for direct-to-consumer virtual care. In all honesty, I’ve always considered direct-to-consumer virtual care to be the flashy, must-have holiday gift of the year that organizations are convinced will be the way of the future. If a health system wants to provide on-demand access to patients for low-complexity acute conditions, they will easily find plenty of vendors that will sell them their app and their doctors and put the health system’s logo on it. What a health system will struggle with is to find is enough patient demand to cover the high cost. Remember my friends from earlier that told me about the app their insurance gave them? Nearly all of them followed that up by telling me they’ve never actually used it. I am fortunate that I work for an organization that understands this and instead focuses on how can we provide care that our patients actually want and need from the doctors they want to see.

Ironically, this fiscal year we had a corporate top priority around direct-to-consumer virtual care. We wanted to expand what we thought were some successful pilots and perform 500 direct-to-consumer visits. This year has been one of the hardest of my leadership career because, frankly, up until a month ago I was about to fail on this top priority. With only four months left, we were only about halfway there. The biggest problem we ran into was that every great idea a physician brought to me was instantly dead in the water because practically no insurance company would pay for it. 

There are (prior to COVID-19) a plethora of rules around virtual care billing but the simplest way to summarize it is that most virtual care will only be paid if it happens in a rural location and inside of a health care facility. It is extremely limited what will be paid for in the patient home and most of it is so specific that the average patient isn’t eligible to get any in-home virtual care. Therefore, most good medical uses for direct-to-consumer care would be asking the patient to pay cash or the physician to forgo reimbursement for a visit that would be covered if it happened in office. Add to that the massive capital and operating expenses it takes to build a virtual care network and you can see why these programs don’t exist. A month ago I was skeptical we’d have a robust direct-to-consumer program any time soon and then COVID-19 hit.

When COVID-19 started to spread rapidly in the United States, regulations and reimbursement rules were being stripped daily. The first change that had major impact is when the Centers for Medicare and Medicaid Services (CMS) announced that they would temporarily begin reimbursing for virtual visits conducted in the patient’s home for COVID-19 and non-COVID related visits. We were already frantically designing a virtual program to handle the wave of COVID-19 screening visits that were overloading our emergency departments and urgent cares.  We were having plenty of discussions around reimbursement for this clinic: Do we attempt to bill insurances knowing they will likely deny, do we do a cash clinic model or do we do this as a community benefit and eat the cost? The CMS waiver gave us hope that we would be compensated for diverting patients away from reimbursed visits to a virtual visit that is more convenient for the patient and aligns with the concept of social distancing. Realistically we don’t know if we will be paid for any of this. We are holding all of the bills for at least 90 days while the industry sorts out the rules. 

I was excited by the reimbursement announcement because I knew we had eliminated one of the biggest direct-to-consumer virtual care barriers. However, I was quickly brought back to reality when I was reminded that HIPAA (Health Insurance Portability and Accountability Act) still existed. I had this crazy idea that during a pandemic we should make it as easy as possible for people to receive virtual care and that the best way to do that was to meet the patient on the device they are most comfortable with and the application (FaceTime, Facebook, Skype, etc.) that they use every day. The problem is nearly every app the consumer uses on a daily basis is banned by HIPAA because “it’s not secure.” I’m not quite sure what a hacker stands to gain by listening into to my doctor and me talk about how my kids yet again gave me strep throat but apparently the concern is great enough to stifle the entire industry. Sure, not every health care discussion is as low-key as strep throat and a patient may want to protect certain topics from being discussed over a “non-secure” app but why not let the patient decide through informed consent? Regulators could also abandon this all-or-nothing approach and lighten regulations surrounding specific health conditions. The idea that regulations change based on medical situation is not new. 

For example, in my home state of Michigan, adolescents are essentially considered emancipated if it involves sexual health, mental health or substance abuse. Never mind that this same information is freely given over the phone by every office around the country daily without issue, but I digress. While my job is to innovate new pathways for care, our lawyer’s job is to protect the organization and he, along with IT security, rightfully shot down my consumer applications idea. A few days later I legitimately screamed out loud in joy when the Department of Health and Human Services announced that it would use discretion on enforcing HIPAA compliance rules and specifically allowed for use of consumer applications. The elimination of billing restrictions and HIPAA regulations changed what is possible for health care organizations to offer virtually. Unfortunately both changes are listed as temporary and will likely be removed when the pandemic ends.

Six days after the HIPAA changes were announced, we launched a centralized virtual clinic for any patient that wanted a direct-to-consumer video visit to be screened by a provider for COVID-19. It allows patients to call in without a referral and most patients are on-screen within five minutes of clicking the link we text them. They don’t have to download an app, create an account or even be an established patient of our health system. It saw over 900 patients in the first 12 days it was open. That is 900 real patients that received care from a physician or advanced practice provider without risking personal exposure and without going to an already overwhelmed ED or urgent care. 

To date, 70 percent of the patients seen by the virtual clinic did not meet CDC testing criteria for COVID-19. I don’t believe we could have reached even half of these patients had the consumer application restrictions been kept. A program like this almost certainly wouldn’t exist if not for the regulations being lifted and even if it did, it would have taken six to 12 months to navigate barriers and implement in normal times. Sure, the urgency of a pandemic helps but the impact of provider, patients, regulators and payors being on the same page is what fueled this fire. 

During the virtual clinic’s first two weeks, my team turned its attention to getting over 300 providers across 60+ offices virtual so they could see their patients at home. Imagine being an immunocompromised cancer patient right now and being asked to leave your home and be exposed to other people in order to see your oncologist. Direct-to-consumer virtual care is the best way to safely care for these patients and without these temporary waivers it wouldn’t be covered by insurance even if you did navigate the clunky apps that are HIPAA compliant. Do we really think the immunocompromised cancer patient feels any more comfortable every normal flu season? Is it any more appropriate to ask them to risk exposure to the flu than it is to COVID-19? And yet we deny them this access in normal times and it quite possibly will be stripped away from them when this crisis is over. Now 300 to 400 patients per day in our health system are seen virtually by their own primary care doctor or specialist for non-COVID related visits.  Not a single one of these would have been reimbursed one month ago and I am highly skeptical I would have gotten approval to use the software that connects us to the patient. Lastly, recall that prior to COVID-19, our system had only found 250 total patients that direct-to-consumer care was value-added and wasn’t restricted by regulation or reimbursement.

COVID-19 has been a wake-up call to the whole country and health care is no exception. It has put priorities in perspective and shined a light on what is truly value-added. For direct-to-consumer virtual care it has shown us what is possible when we get out of our own way. If a regulation has to be removed to allow for care during a crisis then we must question why it exists in the first place. HIPAA regulation cannot go back to its antiquated practices if we are truly going to shift the focus to patient wellness. CMS and private payors must embrace value-added direct-to-consumer virtual care and allow patients the access they deserve. COVID-19 has forced this industry forward, we cannot allow it to regress and be forgotten when this is over.

Tom Wood is the director of trauma and virtual care for MidMichigan Health, a non-profit health system headquartered in Midland, Michigan, affiliated with Michigan Medicine, the health care division of the University of Michigan. The views and opinions expressed in this commentary are his own.

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The Most Useful Pieces of Adaptive Equipment

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Occupational therapists strive to help their patients be as independent as possible with meaningful activities. Often times, when a patient sustains a bodily or neurological injury, they are left with weakness or paralysis. Other times, after a joint replacement or bone fracture, there are restrictions placed on the person that limits their safe movement.

Adaptive equipment presents a great way for occupational therapists to help people develop compensatory strategies in order to complete the tasks that are most meaningful to them. The items can be temporarily used until the person returns to their previous functional level, or they can be used indefinitely as a way for the patient to regain independence and control of their environment and self.

In my opinion, the top 10 most useful pieces of adaptive equipment are:

  • Built-up foam grips: These grips can be added to utensils to make the handles bigger, which helps people who’ve suffered from strokes, arthritis or hand weakness.
  • Long-handled reacher: These are great for getting dressed and managing the surrounding area around a person.
  • Sock aid: These allow people to get their socks on. It’s especially helpful for those who have had hip surgery with flexion precautions. Many people struggle to bend down for a variety of reasons, and this allows for the person to load the sock, and pull the sock on without leaving the seated position.
  • Universal cuff: This is a staple within the OT community. This cuff can substitute for grip dexterity and strength by strapping around the hand and allowing a utensil to be inserted. This way, the person can use the ability they have in their arm to feed themselves, brush their teeth, shave or comb their hair despite a weakened grip or dexterity. It’s often used in patients who have muscle atrophy or spinal cord injuries.
  • Scoop plate with suction pad: This is good to be used in tandem with a universal cuff, but can also be used on its own. It allows a person who has an upper extremity that is somehow affected to feed themselves with one hand, as the food can be pushed to one side for easier scooping. Models with a suction cup are nice, but otherwise using a non-slip material can help the plate not slide easily.
  • Adaptive cutting board: This is great for someone who is limited to one arm for functional use. It allows for the item to be fixated with the nails so chopping/slicing is easily accomplished. It can be used in a sitting or standing position.
  • Dycem (name brand non-slip material): This is another therapy staple, and a cost-effective, easy way to introduce more control with devices. It can be used as a grip to open jars. It can go underneath scoop plates so they don’t move on the table when eating. Basically, if you don’t want the item to slide, this material can be placed underneath to prohibit movement.
  • Elastic shoelaces: These are a great solution for those who struggle to tie their shoes. They can be used from pediatrics to geriatrics, and for anyone who might be struggling with hand weakness or dexterity issues. It can also be used for those who have cognitive delays or problems, so that the complex process of tying shoes can be bypassed.
  • Button hook/dressing aid: This is used to apply buttons with one hand when dexterity is an issue. Often they are equipped with a hook on the end that can be used to pull up a zipper.
  • Rocker knife: A great way to cut food with one hand. Often, this is used when the person does not have the strength to push/slice food conventionally. It can be used in tandem with the cutting board or scoop place, or normal plates.

Sam Penkala, O.T.R.L., is an occupational therapist at MidMichigan Health.

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What’s the Difference Between Occupational and Physical Therapy?

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While occupational therapy (OT) and physical therapy (PT) might both be familiar terms, many of us aren’t quite sure of the difference between the two.

The role of a physical therapist is to diagnose and manage movement dysfunction and enhance physical and functional abilities. Their goal is to restore, maintain and promote not only optimal physical function but optimal wellness, fitness and quality of life as it relates to movement and health. In addition, a physical therapist works with his or her patients to prevent the onset, symptoms and progression of impairments, functional limitations and disabilities that may result from diseases, disorders, conditions or injuries.

Occupational therapists, as their name suggests, focus on occupations. Occupations aren’t just jobs, however. They’re meaningful activities that patients do in daily life. The goal of an OT is to get their patients regain skills to complete these occupations, as well as help them modify their occupations to make them achievable.

Some areas of occupations that an OT might focus on during treatment could include activities of daily living, rest and sleep, work, play, leisure and social participation. Daily activities can consist of anything from driving to shopping, managing finances, meal preparation, home management and more.

An OT will help patients focus on getting back to work, if that’s the goal. They’ll look at workplace ergonomics, and help patients prepare for any pertinent life changes.

Sam Penkala, O.T.R.L., is an occupational therapist at MidMichigan Health. Those who would like to learn more about MidMichigan’s comprehensive rehabilitation services, including PT and OT, may visit www.midmichigan.org/rehab.

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Important Facts about Sleep Health

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Scott Ross, M.D., family medicine physician, identifies some common issues that keep us from sleeping well and offers tips to help combat those problems that may affect our getting quality rest.

Q. How much sleep do adults really need?

A. On average, adults should get between seven and nine hours of sleep each night. Some people feel best with eight consecutive hours, while others do well with six or seven and a nap.

Q. What happens when we don’t get enough sleep?

A. Short-term problems can include lack of alertness, impaired memory, relationship stress, diminished quality of life and a greater likelihood for car accidents. Long-term problems can become serious. Chronic sleep deprivation is linked to high blood pressure, diabetes, heart attack, heart failure, stroke, obesity and depression.

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My Child Walks on their Toes – Should I be Concerned?

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While toe walking is normal for periods during early walking, toe walking that persists greater than six months from mastery of walking could cause issues as a child develops. We don’t know why some children persist with toe walking.

Often, a child will have shortening of their heel cords, because they don’t stretch out when they walk. This tightness increases as a child grows. To compensate, they may turn their feet out, and start to stand and walk with their heels down.

If a child walks on their toes, it can lead to changes in their foot structure due to abnormal forces from landing on their forefoot. This in combination with heel cord tightness can lead to foot and knee pain as an adult.

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The Benefit of a Warm-up Program for Athletes

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It is well documented that a warm-up program that is implemented correctly, with good form, has the ability to reduce the amount of injuries in athletes. The WellSport team has sifted through some of this research and has developed a warm-up program that can be adapted for athletes in many different sports.

Athletic trainer Jared Slater, A.T.C., and Physical Therapist Jacob Hart, P.T., D.P.T. were instrumental in implementing this program within their community. In the spring of 2018, they began working with a high school girls soccer team. First, the athletes participated in a dynamic test so the team could see how their bodies responded to the normal demands of sports.

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What is the Rotator Cuff, and Why are There So Many Issues with it?

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So, what is the rotator cuff? Cup? Rotary cup? While most people have heard some form of the term rotator cuff, less really understand what it is, how it relates to shoulder function and why there are often so many issues involving it.

First of all, what is it? The rotator cuff is comprised of four muscles in your shoulder. They are the supraspinatus, infraspinatus, subscapularis and teres minor. All of these muscles attach from your scapula (shoulder blade) to your humerus (arm bone).

What does it do? The primary goal of the rotator cuff is to provide dynamic geometric centering of the humerus. In other words, your shoulder joint is a very shallow ball and socket joint. When you attempt to reach out and move your arm, the rotator cuff muscles work to keep the ball and socket of the joint in the correct position. Without this, when you try to reach overhead, for example, your humerus would rise up instead of staying in position. This can cause shoulder pain and impingement.

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When Should I Worry About the Shape of My Baby’s Head?

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Congenital torticollis is a shortening of the sternocleidomastoid (SCM) muscle in the neck of infants. There is a small lump seen in the muscle at times. This can be genetic, or from the baby’s position in the womb. It’s commonly seen in twins or larger babies where space may be tight and the baby can’t move his or her head around as easily.

The SCM muscle performs two movements. It tips the head to one shoulder and turns it to the opposite shoulder. Most commonly, a doctor will notice a flattening on the back of the head on one side due to the baby keeping their head turned one way. The flattening may be worse in babies who spend a lot of time on their back, or in car seats and swings. As a baby’s head control improves, the tipping of the head to one side may become more noticeable.

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September is Pain Awareness Month

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Did you know that more people suffer from pain than cancer, heart disease and diabetes combined?

Nearly one fourth of Americans suffer from pain annually, making pain the major driver of primary care physician visits.

There are various factors that cause and create pain, such as:

  • Family history. You may be more likely to develop arthritis and some other conditions if you have a family history of the disease/diagnosis.
  • Age. The risk of many types of diagnoses and pain injuries increases with age.
  • Gender. Women are more likely than men to develop rheumatoid arthritis.
  • Previous injury. Some people who have experienced previous injuries have pain related to those injuries throughout their lives.
  • Obesity. Carrying excess pounds puts stress on joints, particularly your knees, hips and spine.
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Football Helmet Safety Tips

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There is a growing trend in high school and youth football where players are buying their own helmets for use at practices and games. Traditionally all equipment, including helmets, are provided by the youth programs or high schools where the athletes participate. The advantage of this is all helmets are required to be reconditioned following each season by a National Operating Committee on Standards for Athletic Equipment (NOCSAE) approved provider.

All helmets are required to have completed NOCSAE inspection and meet their standards before they can be used in competition. NOCSAE requires “the complete disassembly of all helmet parts, cleaning, sanitizing, replacement of worn parts and shell inspection” before a helmet can be released for use in another season. Helmet use is limited to 10 consecutive seasons if the helmet has suffered no shell damage. Helmets purchased by an athlete will have to undergo the same reconditioning and receive the NOCSAE approved sticker before they can be used in competition.

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