Cartoon – Exit Strategy vs Escape Plan
Category Archives: Strategy
In a Boston acute care matchup, home beats the hospital
https://mailchi.mp/f3434dd2ba5d/the-weekly-gist-december-20-2019?e=d1e747d2d8
Despite all of the recent hype, the idea of “hospital-at-home” is hardly a new concept. The first randomized, controlled study on the topic, published over 20 years ago, showed that the model was safe, finding that patients with five common conditions who would normally have been admitted to the hospital experienced similar outcomes when treated at home.
This week a new randomized, controlled trial from researchers at Boston-based Brigham and Women’s showed that hospital-at-home had better clinical outcomes and was a whopping 38 percent cheaper than equivalent management in an acute care hospital. Yes, the study was small (91 patients) and probably had some selection bias (just 37 percent of eligible patients chose home care).
Drilling into the data, length of stay for home-based patients was a little longer, but at-home patients received dramatically fewer lab tests, imaging studies and specialist consults—raising the question of whether all those daily chest x-rays, CBCs and curbside consults in traditional hospitals really provide value.
And 30-day readmissions and ED visit rates for home-based patients were less than half of the control group. Selection for clinical appropriateness and family support is critical, but experts estimate that up to a third of medical admissions could be managed in the home setting.
As growing evidence shows hospital-at-home to be safe, effective and lower cost, the lack of a reimbursement model to support investments in home-based acute care is now the greatest obstacle to widespread adoption.
Get ready for the “Yolds”
https://mailchi.mp/f3434dd2ba5d/the-weekly-gist-december-20-2019?e=d1e747d2d8
In a recent discussion on consumer strategy, a health system executive relayed a surprising data point: the system’s most “digitally activated” market was a local retirement community. The residents of this over-55, master-planned community, designed for active seniors, had the system’s highest rates of patient portal activation and online appointment scheduling.
Growth of this cohort of “young old” consumers (YOLDS) —over 65 but still active—will explode as the peak of the Baby Boom joins their ranks. And with a median wealth of $210,000, they’ll have tremendous spending power, so much so that the Economist recently dubbed the next ten years “The Decade of the Yold”. Many “Yolds” will keep working well into their 70s, and those that do will experience slower rates of health and cognitive decline.
For health systems, the next few years are critical for deepening relationships as the Yolds transition into Medicare. What do they want today? Technology-enabled care, and access and communication that works right out of the box, as they have little patience for troubleshooting buggy software. Customized, high-touch services, like they’ve come to expect from everything they consume.
And a focus on helping them maintain their active, productive lifestyle for as long as possible. But they’re not brand switchers: once they join a Medicare Advantage plan, there’s a 90 percent chance they’ll stay. Building loyalty with the Yolds can be the found
Britain’s Bold Move Toward Healthcare
Just days after a landslide election victory for the Conservative Party, Britain’s Prime Minister Boris Johnson just made a massive and bold announcement: He’ll get laws passed to guarantee plenty of cash for the state-run healthcare system.
The official announcement will likely come Thursday when the Queen, who is the official head of state, will reopen Parliament and outline the coming legislative agenda. Tucked within her speech will be a call for £34 billion ($45 billion) in annual taxpayer money for the National Health Service (NHS).
While other countries embrace their private health systems, the British love their publicly funded NHS, an employer of 1.5 million people, which services the population of 66 million. In general, the people are concerned about the quality of care provided by the NHS and look to the government for solutions, says Mary Macleod, a senior client partner for Korn Ferry’s Board and CEO Services practice and a former Conservative Party MP. “The NHS does become a bit of a political football,” she says. “And to a large extent, everyone in the UK feels that they are stakeholders in it.”
The pledge to secure NHS money will likely bolster Johnson’s political leadership versus the opposition Labour Party. And the move also neutralizes critics that have barraged the Conservative Party with allegations that it would sell parts of the NHS to foreign investors. In other words, pushing a new funding law through Parliament could partially neutralize political opponents.
But the politics of the matter is only part of the announcement’s strength, Macleod says. Promising the NHS years of generous financing will allow the organization to develop a strategy for how it will care for the country’s population for years into the future. In short, Macleod says, it sends a message to the NHS leadership: You can get busy now. “If you now know you are getting the funding, you can plan ahead,” she says.
Johnson’s lack of specifics about how the NHS should spend the money could be a strength. In a sense, he has empowered the organization’s leadership to make the decisions that they deem suitable. “What the prime minister is not doing is defining the solutions,” Macleod says. But she also notes that he will want results in the form of improved service from the organization. “He will hold them accountable,” she says.
While there are benefits when leaders take bold steps, there are also risks, says Christina Harrington, Korn Ferry’s head of advisory services in Stockholm, Sweden. She says it is good for leaders to act quickly and with conviction, as the public expects that of its leaders. But that alone isn’t enough. She says the problem comes when there’s too much ego involved. “You need an egoless conviction to drive a decision making the greater good,” she says.
Ideally, the driver of proposed changes needs to have a long-term vision of something better than the current situation. If that vision is lacking, then the leader may lack the required stamina to get the job done. Indeed, if headline-grabbing is all that the boss wants, then he or she might wind up doing a U-turn. “If there isn’t a long-term vision, then another fast decision may come in the other direction,” Harrington says. “And that’s what we see a lot of.”
Hospitals and health systems: 6 trends and issues
https://www.beckershospitalreview.com/strategy/hospitals-and-health-systems-6-trends-and-issues.html
This article discusses the current state and issues of hospitals and health systems for several different areas. First, this discusses types of hospitals and health systems. Second, it addresses what’s working and what’s not for health systems. Third, this discusses the mix of access, quality and cost as well as the shortages of different kinds of providers fourth. Fifth, this discusses policy issues and political issues. Sixth, we address threats and challenges.
1. 5,200+ acute-care hospitals. Currently, there are approximately 5,200 acute-care hospitals in the country. This number changes a little each year, with more closures than openings.
We view the landscape as one with seven core types of health systems.
First, there’s what we think of as the very elite health systems, which are often academic medical centers. This usually includes the top 20 to 30 systems as ranked by U.S. News & World Report. These are typically great research institutions that provide great care in some of the most critical, life-threatening areas. This category may include hospitals like NewYork-Presbyterian, UChicago Medicine, Cleveland Clinic, Mayo Clinic, Northwestern Medicine and a number of other institutions that typically comprise the top 20 to 30 in the U.S. News & World Report’s Best Hospitals.
Second are regionally dominant systems. These systems are so important to a given area that they are often the focus point of care in said area. There are also situations where it’s very hard for payers and patients to go around these institutions — even if they wanted to. This might be an institution like Carilion Clinic or Sentara Healthcare in Virginia, Northwell in New York, Ochsner in Louisiana or NorthShore University Health System in the north suburbs of Chicago. It may be Advocate Aurora Health in the Chicagoland area and Eastern Wisconsin, Hartford HealthCare in Connecticut, Intermountain Healthcare in Utah and Idaho, and a number of institutions regionally strong in their areas.
A third type of system is the community hospital, typically the single- or two-hospital system. This could be rural, urban or suburban. Here, this may be a health system that has served as the core of primary care — and at one time tertiary care — for a community, but more and more has to have a certain reason for being, something that its really great at to remain relevant and open.
A fourth type of hospital is what we think of as a specialty hospital, usually built around a certain specialty like pediatrics, behavioral health, oncology or some other area. It is a hospital that has a specific focus and is just great at what it does, much like Hospital for Special Surgery in New York, which U.S. News & World Report has ranked as the No. 1 hospital in the country for orthopedics for the past 10 years.
National chains of hospitals and health systems make up the fifth type of system. This can be for-profit or nonprofit, and they come in a couple different varieties. First, they can pursue a strategy of being in lots of different markets, but regionally dominant in the markets they’re in. This has typically been the strategy for success. Second, they can pursue the strategy of having the most hospitals possible. This has typically not been a strategy for success. Market strength or market dominance and excellence in certain areas is far more important than having lots of different hospitals.
The sixth type of hospital that we think of as Kaiser Permanente. Here, we put Oakland, Calif.-based Kaiser Permanente in its own category. It is a regionally dominant system in certain parts, but more importantly it is vertically integrated with its own insurance plan. This has allowed Kaiser to do things in the cost savings areas and the efficiency area that many other systems have not been able to do. We have also found over the last decade that it is much harder for other systems to replicate what Kaiser has done, in terms of fully integrating insurance, than expected.
The seventh category of hospital we think of as the safety-net hospital. The safety-net hospital can really be in any of the above categories. We largely think of safety-net hospitals as those that are serving a huge percentage of Medicare and Medicaid patients. The safety-net hospital is a very important part of the fabric of American healthcare and the delivery system, and at the same time they often struggle to ensure they have the finances to make the system go.
2. What has worked the last 10 years? The three types of categories that have really worked the past 10 years are as follows.
First, one prescription for success has been to be regionally dominant. Whether a Novant Health or an Atrium Health, both based in North Carolina, or a system like Advocate Aurora in Wisconsin or ProMedica in Ohio, being regionally strong has been a prescription for success. It allows one to stack resources, invest in talent, invest in systems and get better and better.
The second prescription for success the last decade and for a long time is being an elite health system. As much as the world changes, these elite systems — whether Stanford Medicine, Mayo Clinic, Cleveland Clinic or UCLA Health — continue to be sought out for care and continue to recruit great physicians, researchers and providers. This may also include being elite in certain areas like Rush University Medical Center in Chicago in orthopedics, MD Anderson in oncology or a number of other actors that are elite.
The third type of category that has worked is clearly the Kaiser Permanente category. This is a situation where Kaiser is almost its own vehicle, led famously by the late Bernard J. Tyson. Over the years, Kaiser grew into being a great integrated system and was able to do things on the value-based side and make major investments to address social determinants of health that really no one else was able to do.
3. Access, quality and cost. There is constant discussion of access, quality and cost. As we look as things evolve, we see things as follows.
On the quality side, the American healthcare system seems to do a pretty good job of delivering pretty good care to a huge percentage of people. In essence, compared to other countries, the U.S. is providing care to more than 325 million people. While imperfect, it is pretty good. There are pockets of care in other countries that are certainly better and more advanced than it is here, but often in pockets versus an entire system.
In terms of access, the American healthcare system seems to be challenged in numerous ways. As shortages evolve, particularly among specialties and subspecialties, it is harder and harder to find access to the right type of provider when one needs that provider. Access can also be a challenge in many different ways for poor communities in our country and, of course, there is no quality without access.
A third issue in terms of the American healthcare system is cost. As costs continue to grow at a percentage higher than inflation, particular pockets of costs remain very challenging, specifically on the pharmaceutical side, technology side and labor side.
4. Shortages of doctors and allied health professionals. As we look at access challenges in the country, there is a perspective that it is very hard to solve without the minting of a great deal more of physicians and allied health professionals. Even as the ways care is delivered evolve, the physician shortage remains. We will see a shortage of up to nearly 122,000 physicians by 2032 as the population grows and ages and demand continues to grow faster than supply, the Association of American Medical Colleges.
There are different structural elements in place that make it hard to add on providers at a fast clip. For example, medical school, residency and fellowship take many years. In efforts to modernize medical education, there is a question as to whether that much education is needed. The American Medical Association is one body that is working with major institutions for accelerated programs, like a six-year model at University of California, Davis School of Medicine. The school offers a six-year path to practice — three years each of medical school and residency — in partnership with Kaiser Permanente Northern California.
As we look at our society, we probably need more incentive for people to go to medical school and graduate with medical degrees than are currently in place. The more one tries to attack some of benefits of being a physician, the harder it is to encourage the next generation to become physicians. In response, we do see a growing number of medical schools being opened, including those at Kaiser Permanente and Hackensack Meridian. We think this is absolutely critical. It is also critical that we develop more and more allied health professionals and those allied health professionals are largely able to practice at the top of their license.
Finally, there is this concept in medical school and in premed of “weed out” classes. We believe this is somewhat overdone and overemphasized, and many bright, talented people are weeded out that would be perfectly great physicians. As one resident at Stanford University School of Medicine put it, “Today we ‘weed out’ potentially wonderful doctors through a demoralizing maze of basic sciences that more often resembles the Hunger Games than a sensible recruitment process.”
5. Political polarization. In healthcare, and the hospital sector specifically, we see a great deal of political polarization. There are largely three different types of systems that people think about in terms of reform.
First, there is the “Medicare for All” perspective. While this would provide adequate “access” at a certain level for everybody in terms of health insurance coverage, there is concern from providers that reimbursement would be so low it would not encourage people to pursue medicine, thus flattening or denting the supply of physicians needed to provide the care that is needed.
Second, there is the concept of the “free market.” Here, the concept of a total free market and free market alternatives is somewhat illusory. In reality nearly 30 to 50 percent of most providers’ revenue comes from Medicare and Medicaid. Thus, you are never really dealing with a free market in healthcare. There are free market incentives — like health savings plans and transparency — that can help, but one is not in total dealing with a free market.
Third, is the concept of a public option. One way to think about a public option is to think about it as akin to the post office. One can either go to the post office to mail something via the United States Postal Service, or one could use UPS or Federal Express. The idea of a public option is that you would not have to buy insurance from an insurance company. Rather, you could buy into the Medicare program through a public option. Washington signed a public option into law this past summer and will launch it in 2021, becoming the first state to test the policy.
Whatever the answer is for healthcare reform, it is clear that the general public prefers two things. First, they like the concept that you should be able to buy insurance regardless of whether or not you have a pre-existing condition. Second, a large percentage of the public seems to prefer that there be some sort of public option to access care.
6. Threats and challenges. Some the challenges healthcare systems face today are as follows.
First, the strength of payers and the power they hold, especially as they diversify and broaden their scope of business. Under the UnitedHealth Group umbrella, for instance, is Optum, the Advisory Board and Equian, among other arms. In 2018, Cigna acquired Express Scripts, CVS Health combined with Aetna, and Humana and private equity firms acquired Kindred Healthcare. Highmark, one of the largest insurers in the country, acquired the West Penn Allegheny Health System years ago. Each of these forays into technology, consulting, payment, pharmacy benefit management, post-acute care and provider spaces make health insurers more prevalent in the industry.
A second great concern is the growing number of access points that are providing threats to health systems and their margins and revenues. This may be things like the CVS’, Walgreens and Walmarts of the world, which are expanding the medical services and health hubs in their stores to provide consumers with an alternative access point for chronic conditions and routine care. This fall, Walmart even revealed plans to build its own healthcare workforce.
Third, powerful payers are developing provider networks and providing alternatives to health systems and their delivery systems. Blue Cross Blue Shield Association, for instance, will launch a national provider network in 2021 that spans across 55 markets to help large employers better control medical costs.
Fourth is the total costs of bricks and mortar and labor that hospitals and health systems carry.
Fifth is the development of new types of insurance programs by companies like Haven, which is JPMorgan, Berkshire Hathaway and Amazon’s effort to serve their combined 1.2 million employees. Currently, commercial insurance and payments from employed people ultimately subsidize what hospitals and health systems receive from Medicare and Medicaid. Thus, if these efforts like Haven are successful at peeling off good-paying patients, this will have a big negative impact on hospitals and health systems.
15 Doctors Fired From Chicago-Area Health System
Physicians “broadsided” by their termination.
At least 15 physicians have been fired from Edward-Elmhurst Health as the suburban Chicago-based health system moves to cut costs, sources told MedPage Today.
The doctors, who worked across its seven “Immediate Care” or urgent care sites, will be replaced by advanced practice nurses, according to an email sent by hospital leadership that was shared with MedPage Today. The physicians were informed late last week that they would be terminated as of April 1, 2020.
A physician who spoke on the condition of anonymity said the doctors were “broadsided” by the news. While they harbored some concerns that a few of the slower urgent care sites might be turned over to non-physician clinicians, they weren’t expecting so many of the sites to be impacted and for such a large number of doctors to be let go.
In their email, hospital system CEO Mary Lou Mastro, MS, RN, and Chief Medical Officers Robert Payton, MD, and Daniel Sullivan, MD, pointed to patient cost concerns as the reason for eliminating the jobs: “Patients have made it very clear that they want less costly care and convenient access for lower-acuity issues (sore throats, rashes, earaches), which are the vast majority of cases we treat in our Immediate Cares.”
“Beginning in the spring of 2020, we will move to a delivery model in which care is provided by Advanced Practice Nurses (APNs) at select Immediate Care locations,” they wrote.
Leadership also stated in the email that they are “working closely with these physicians to assist them with finding alternative positions within Edward-Elmhurst Health or outside our system,” but doctors noted that they face a saturated Chicago healthcare market and they’re likely to have to relocate.
When asked to confirm the layoffs, Keith Hartenberger, a spokesperson for Edward-Elmhurst Health, said in a statement: “We continue to assess our care delivery models in the interest of providing cost-effective care to our patients. We shared with physicians that we have plans to change the model next year at some outpatient sites and are working with anyone affected to find alternative placement.”
The move is becoming a more familiar one as some health systems try to save money by relying more heavily on non-physician clinicians.
Last year, 27 pediatricians at a chain of clinics in the Dallas area lost their jobs and were replaced by nurse practitioners — even though the chain subsequently changed its name to MD Kids Pediatrics.
Rebekah Bernard, MD, wrote in Medical Economics that she spoke with three of the pediatricians who were fired: “They told me that they and their physician colleagues were completely shocked by the sudden firing. ‘We thought we were going to retire from this place,’ one told me.”
Also in 2018, Charlotte, North Carolina-based Atrium Health ended a nearly 40-year contract with a 100-member physician group, signing up instead with Scope Anesthesia, which says it’s dedicated to forming partnerships with certified registered nurse anesthetists. Atrium said it too was looking to reduce patient costs.
“This trend of shuttering hospital departments and firing physicians to save money is dangerous and short-sighted,” Bernard wrote.
Purvi Parikh, MD, of NYU Langone Health in New York City, and a board member of Physicians for Patient Protection, which advocates against other healthcare providers replacing doctors, said that although non-physician clinicians “are vital members of the healthcare team, they are not trained to be substitutes of physicians and as a result diagnoses are missed and improper treatments and tests [are] prescribed.”
Parikh said patients “have the right to choose a facility that is physician-only or one with physician-led care. In Chicago, luckily there are other options among competitors.”
Cartoon – A Long Term Quick Fix
Cartoon – Modern Strategy Execution
Healthcare delivery is moving “up and out”
https://mailchi.mp/699634d842fa/the-weekly-gist-november-1-2019?e=d1e747d2d8
Our graphic this week captures a phenomenon that we’ve observed in our strategy work with regional, “super-regional” and national health systems. We call it the “up and out” phenomenon—healthcare delivery is increasingly being pulled up and out from local, siloed hospitals. The traditional hospital enterprise, operating in what we refer to below as the “fee-for-service zone”, has typically pursued a service approach that delivers all things to all people. Commonly, the combination of reimbursement incentives and health system governance structures has encouraged hospital executives to prioritize facility profitability over system performance.
One important source of value creation for regional systems is service line rationalization—essentially, consolidating key services in one facility rather than performing duplicative services in every hospital. Centralizing open heart surgery, for example, in one “center of excellence” in a region often results in both lower cost and higher quality, thanks to clinical and operational scale economies. But the economies of scale don’t necessarily run out at the regional level—for some high-end specialty services (transplants, for example) it makes sense to consolidate at a super-regional or national level. For a better outcome and lower price, consumers will be increasingly willing to travel to receive the best value care.
Meanwhile, many services currently performed in the hospital can be more efficiently performed in non-hospital settings and should be distributed across the market in ways that are more convenient and accessible for patients. Traditional hospital economics make the “inpatient-to-outpatient shift” problematic, but as price and access become important consumer engagement levers, there’s little use fighting that shift. Indeed, the logical setting for much care delivery is in the patient’s home itself. This puts systems in the position of pushing care delivery to the hyper-local level, a strategy that can be powered by digital medicine delivered at a national level. All of this raises an important question for the regional health system: as hands-on care is increasingly pulled “up” to the national level (centers of excellence) and pushed “out” to the community setting (home-based care), and as national providers of digital health services can deliver services to anywhere, from anywhere, what is the value of the regional system? We’re working with a number of members to better understand and prepare for this new operating model.
5 WAYS HEALTHCARE ORGANIZATIONS CAN ADDRESS SOCIAL DETERMINANTS OF HEALTH
The National Academies of Sciences, Engineering, and Medicine has published a detailed report on implementing efforts to address the social needs of patients.
KEY TAKEAWAYS
Social needs play a pivotal role in patient outcomes.
Before setting strategies to address social determinants of health, healthcare organizations should assess their level of existing social needs activities.
Partnerships are a crucial component of addressing the social needs of patients.
Healthcare providers can address social determinants of health through five approaches—awareness, adjustment, assistance, alignment, and advocacy, according to a report from the National Academies of Sciences, Engineering, and Medicine.
Social determinants of health (SDOH) such as housing, food security, and transportation can have a pivotal impact on the physical and mental health of patients. By making direct investments in initiatives designed to address SDOHs and working with community partners, healthcare organizations can help their patients in profound ways beyond the traditional provision of medical services.
“The consistent and compelling evidence concerning how social determinants shape health has led to a growing recognition throughout the healthcare sector that improvements in overall health metrics are likely to depend—at least in part—on attention being paid to these social determinants,” the National Academies report says.
The report outlines the “5As” strategies that healthcare organizations can implement to address SDOHs in the communities they serve. The strategies were developed by the National Academies’ Committee on Integrating Social Needs Care into the Delivery of Healthcare to Improve the Nation’s Health, Board on Health Care Services, Health and Medicine Division.
1. AWARENESS
The committee says awareness should focus on identifying the social risks and assets of specific patients and populations of patients.
“On the clinical side, patients visiting healthcare organizations are increasingly being asked to answer social risk screening questions in the context of their care and care planning. In some places, screening is incentivized by payers. As part of the MassHealth Medicaid program, for instance, Massachusetts accountable care organizations now include social screening as a measure of care quality,” the report says.
2. ADJUSTMENT
Instead of addressing social needs directly, healthcare organizations can pursue a strategy that focuses on adjusting clinical care to address social determinants of health.
“Many examples of adjustment strategies were identified in the literature, including the delivery of language- and literacy-concordant services; smaller doctor-patient panel sizes for cases with socially complex needs (e.g., teams caring for homeless patients in the U.S. Department of Veterans Affairs health system have panel sizes smaller than the size of other VA care teams); offering open-access scheduling or evening and weekend clinic access; and providing telehealth services, especially in rural areas,” the report says.
3. ASSISTANCE
Healthcare organizations can pursue strategies to connect patients with social needs to government and community resources.
“The literature contains descriptions of a variety of assistance activities that have been undertaken by health systems and communities. These assistance activities vary in intensity, from lighter touch (one-time provision of resources, information, or referrals) to longer and more intensive interventions that attempt to assess and address patient-prioritized social needs more comprehensively,” the report says.
Intensive interventions include relationship building, comprehensive biopsychosocial needs assessments, care planning, motivational interviewing, and long-term community-based supports.
4. ALIGNMENT
Healthcare providers can pursue an alignment strategy that assesses the social care assets in the community, organizes those assets to promote teamwork across organizations, and invests in assets to impact health outcomes.
“The committee defined alignment activities to include those undertaken by healthcare systems to understand existing social care assets in the community, organize them in such a way as to encourage synergy among the various activities, and invest in and deploy them to prevent emerging social needs and improve health outcomes,” the report says.
5. ADVOCACY
Healthcare providers can form alliances with social care organizations to advocate for policies that promote the creation and distribution of assets or resources to address social determinants of health. For example, healthcare organizations can call for policy changes to overhaul transportation services in a community.
“In both the alignment and advocacy categories, healthcare organizations leverage their political, social, and economic capital within a community or local environment to encourage and enable healthcare and social care organizations to partner and pool resources, such as services and information, to achieve greater net benefit from the healthcare and social care services available in the community,” the report says.
IMPLEMENTING THE FIVE STRATEGIES
Assessing the level of existing social needs activities should be a starting point for healthcare organizations that want to address social determinants of health, the chairperson of the National Academies committee told HealthLeaders.
One of the first steps healthcare organizations can take is identifying activities they may already have underway that fit the 5As, then expand or enhance those activities through greater commitment from leadership, investment of resources into supporting infrastructure, and strengthening of engagement with patients and community stakeholders, said Kirsten Bibbins-Domingo, PhD, MD, MAS, professor and chair, Department of Epidemiology and Biostatistics, UCSF School of Medicine, University of California, San Francisco.
“Healthcare organizations may not have activities in all of the 5As and should use this framework to develop strategies that will work within their local context. In all cases, it is critical to be aware that addressing health-related social needs of their patients is essential to achieving goals of high quality and high-value care,” she said.
“Partnerships are crucial,” Bibbins-Domingo said.
“Activities in the clinical setting should be designed and implemented in a way that engages patients, community partners, frontline staff, social care workers, and clinicians in planning and evaluation, as well as in incorporating the preferences of patients and communities. Establishing linkages and communication pathways between healthcare and social service providers is critical, including personal care aides, home care aides, and others who provide care and support for seriously ill and disabled patients.”
HENRY KOTULA 