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The BMC Brief

The BMC Brief Volume 6, Issue 11

November 30, 2017

Preparing for Accountable Care With a Concept Borrowed from the Tech World

When Boston Medical Center moves to an accountable care organization model for MassHealth patients in March 2018, a full 80 percent of patients in the Pediatrics Department will be treated under this model. Many of these patients are not just medically complex, but often have complex social needs, which means BMC needs to think creatively about to how provide them with the right care, while also reducing costs. The Pediatrics Department is encouraging its  team members to take on this challenge and many have heeded the call, presenting their ideas for innovative care in a recent "hackathon" event – a concept borrowed from the tech world where people come together to transform ideas into actionable projects.

"In moving to an ACO model, Massachusetts wants to spend less money and improve quality of care," said Robert Vinci, MD, chief of the Pediatrics Department. "If we're going to be serious about reform, it's time for us to think differently about how we deliver care. Our goal with the hackathon was to provide an opportunity for significant and creative brainstorming about how to do that."

"There are a lot of changes happening and people are concerned about what the future looks like," says Ted Constan, senior administrative director of Pediatrics. "We're giving our clinicians ownership over those changes and helping them focus on the right care at the right time."

The hackathon started with a preliminary round in which approximately 25 ideas were presented to Vinci; Melissa Gillooly, senior project manager in Pediatrics; Tami Chase, pediatric associate director of nursing; and Constan. Project teams were encouraged to address specific ACO metrics and think concretely about what changes in care will look like. After the preliminary round, leadership chose eight groups to move forward with presenting their ideas to an audience that included leadership across hospital departments and administration. This included merging teams with similar projects across disciplines.

Following the hackathon, a Pediatrics committee decided that all projects will move forward in some capacity, but the department will put particular focus on asthma and attention deficit hyperactivity disorder (ADHD) models of care, due to their focus in ACO quality metrics and high expenditures associated with these common conditions.

The focus on asthma will expand a project that featured an asthma checklist for better integrated care across hospital departments and community providers. The project will help reduce acute health care utilization for asthma and increase the proportion of children with asthma who achieve the ACO quality benchmarks. 

A team from Primary Care, Developmental Pediatrics and Psychiatry came together to propose the implementation of a collaborative care model for ADHD. Patients with ADHD are frequently lost to follow-up during the process of diagnosis and initiation of medication. The inconsistent care results in poor outcomes such as increased emergency department visits and need for acute psychiatric care. The ADHD collaborative care model will allow for better treatment of ADHD in primary care.   

This project is also the foundation for a learning collaboration model that could be expanded to support ADHD care for all of the BACO health centers. The goal of the model is to create a platform for health education and care coordination that can help community doctors better manage ADHD in their practices and avoid unnecessary specialty care visits. The Pediatrics team hopes that the model can be used as a framework to provide education and consultation for a variety of specialty conditions.

Once projects are up and running in Pediatrics, the team hopes that they can work across BMC to help expand relevant programs and inspire other departments to think creatively to meet their own individual needs. While some of the projects – such as the asthma checklist – are directly applicable to adults, others – such as a care transitions project – require proactively working with other departments to improve continuity and communication.

"We get caught up in responding to regulations, finding funding, and seeing more patients," says Constan. "By cutting out the background noise to develop these projects, we can all help support BMC's reputation as a creative and guiding academic medical center."

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What do you do, Nausheen Singh?

Name: Nausheen Singh
Title: Citizenship and immigration rights navigator (CAIRN)
Time at BMC: Three months

Q: What do you do at BMC?
A: I work in the Immigrant and Refugee Health Program in Adult Primary Care, where I help patients with immigration legal services navigation. We get a lot of asylum seekers and refugees who come into the clinic and are looking to be connected to legal resources in the community. For example, a lot of times they need help with green card applications or filing for asylum. My role is to help connect these patients with immigration legal resources in the community

First, I meet with patients to do a little bit of background research on who they are. Then I give them different options for pro bono lawyers or other community resources. Sometimes I go with them to appointments to make sure they get the information they need. As a navigator, I can't do paperwork for patients, but I can help them find the appropriate people to help them with the process.

The CAIRN program has worked with 82 patients in the past year. So far, most patients have been from Adult Primary Care, but I provide the same services for patients throughout the hospital. Providers can refer patients to me by flagging me on Epic or emailing [email protected]

Q: What brought you to BMC?
A: I recently graduated college and knew I wanted to be in Boston for this year. I came across the CAIRN position while applying to different AmeriCorps positions. I've worked with refugees in the past and really liked working with that population.

It was perfect because I'm hoping to go to medical school in the future, so being in a hospital is a great learning experience and a way to see different aspects of what you can do in health care.

Q: What is the role of a citizenship and immigration rights navigator at a hospital? How does it fit into health care?
A: When you have an appointment with a patient and only have a short amount of time to see them, it's hard to treat their health problems if what they want to talk about is whatever issue is the current stressor in their lives. For many of our patients, that current stressor is immigration status. Primary care is an access point to connect people to the services that can help them address those stressors.

Having CAIRN is also a nice way to communicate with patients instead of just sending them out with a list of resources, especially when there are language barriers. It allows us to more tightly integrate addressing social determinants of health into health care.

Q: What's the top thing you want people to know about citizenship and immigration as it relates to our patients?
A: Having a basic knowledge of different immigration statuses is very helpful for providers. It helps them make appropriate referrals. In addition, patients are often confused about their immigration status and might ask providers they trust. Therefore, having some basic knowledge will help providers answer these questions.

Q: What do you like the most about working at BMC?
I love BMC. I didn't really know what the hospital was like before I came in, and I thought it would be the same as the hospital where I got my primary care at home. It's actually quite different. It really is a community. It's such a welcoming environment and really provides wraparound care to patients.

A: My favorite part about BMC are the patients. The patients who come into our clinic really feel like a family. They are truly wonderful people. I hear so much about the difficulties patients have gone through, and yet they come and give me a big smile and are just so happy and lovely. I'm continuously inspired by them.

Q: What do you do for fun outside of work?
A: Two of my best friends from college also live in Boston. We all moved to a new city, so we try to go and find fun events in Boston. It feels like there's always something going on. My brother and sister-in-law are also here and I see them frequently. My sister-in-law is a fantastic cook, and I've been trying to learn some recipes from her.

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Blurry Bribes? A Doctor's Cautionary Tale in Accepting Cash for Referrals

As part of Compliance and Ethics Week 2017, the Compliance Department hosted a special event on November 8 featuring guest speaker Michele Martinho, MD. The event was open to the BMC and BUSM community and held in the Hiebert Lounge.

For more than two years, NYC doctor Michele Martinho regularly accepted envelopes of cash in exchange for referring tests to a New Jersey lab. While the act of taking the payments in cash set off some red flags for Martinho, she did not feel she was doing anything unethical by her patients or her fellow physicians by accepting compensation for referrals. That was until she got a phone call that changed her life.

On the other end of the line, a friend and professional contact warned Martinho that the lab where she had been sending her tests was being investigated and she likely would be as well.

Sharply dressed in a black suit on November 8, Martinho addressed a group of clinicians and staff from the BMC and BU medical community. Later she would reveal that, under that suit, she was wearing an ankle monitor – a condition of her house arrest.

She implored the audience to look beyond the headlines. In her case, the story was much more complicated than a case of a physician taking an obvious bribe from a rep.

In 2010, Martinho was approached by a rep from Biodiagnostic Laboratory Services. He presented her with the idea of receiving a flat-rate, monthly referral bonus in return for Martinho sending all tests to his employer. He offered to provide software for her practice that would help facilitate the process and assured her that the lab would accept all insurance providers. As the sole practitioner at the medical practice she owned, Martinho jumped at the opportunity to streamline the time-consuming lab test process.

Unaware that taking payment for referral was both unethical and illegal, Martinho told friends of her new arrangement. A friend who worked in real estate was thrilled for her – as a realtor, referral bonuses were a way of life and one hundred percent legitimate. But Martinho would soon learn that was not the case in medicine.

In medical school, she'd been cautioned against kickbacks. She'd learned of insurance fraud and the dangers of ordering unnecessary tests. But she'd heard nothing about referral bonuses.

Martinho acknowledges that choosing to take the payments in cash was a major misstep; it is a decision that she'll have to live with forever. But not only were the cash payments illegal, accepting referral bonuses was as well under federal law.

Martinho emphasized that throughout the time she sent tests to the lab, she did not compromise patient care, never once ordering unnecessary tests or taking needless blood draws. In the end, however, she recognizes that her actions did violate the oath she took as a physician, harming fellow doctors and patients by damaging trust in physicians and other caregivers.

5 Ways to Protect Yourself and BMC
As an academic medical center, BMC holds itself to high standards in interactions with industry, which includes pharmaceutical and biotechnology companies, device and medical equipment manufacturers, and other health care suppliers. The hospital has a detailed policy for interactions with industry as well as resources dedicated to ensuring that all of our decisions are in the best interests of our patients. Here are five things you can do to protect yourself and BMC:
  1. Read the BMC Code of Conduct.
  2. Never accept monetary incentives.
  3. When signing contracts, have them reviewed by the BMC Legal Department.
  4. Beware of "free" offers and other business courtesies – as healthcare professionals we must hold ourselves to higher standards than in other industries.
  5. If you have questions on whether something could be improper or unethical, contact the Compliance Department at [email protected] or use the anonymous Compliance Hotline: 1-800-586-2627.

The phone call she received began a series of events that would eventually lead to Martinho pleading guilty to one count of accepting a bribe and being convicted as a felon. In June of 2017, she was sentenced to two years of probation, one year of house arrest, and mandated to continue sharing her story with others as part of her restitution. Prior to her sentencing, Martinho had conducted dozens of speaking engagements at schools, hospitals, and other institutions, in hopes that others could learn from her mistakes. In the end, the payments she took totaled $155,000, which she has since paid back. Martinho continues to practice medicine in New York but says her digital footprint makes it challenging.

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Performers, Artists, or Patients? At Yearly Concert, They're All Three.  

If you ask Boston Medical Center's Neurology Department which clinic or program throughout the hospital has the most creative and talented patients, they would defend their group as the worthy title holders.

Several patients showcased their talents in front of dozens of BMC physicians and staff members earlier this month during the sixth annual When Patients Heal You concert.

An Arts | Lab program, the concert is a unique musical collaboration with students from the Boston University College of Fine Arts (CFA) School of Music and BMC. This year, patient performances ranged from jazz to Creole music and were dedicated to the neurology physicians and hospital staff and to patients' family and friends.

"I don't feel as ashamed of my disability as I did in the past because of the support you could feel from those who attended the program, my doctor, and all of the different staff members at BMC," said Denise Taylor, who at the concert sang and gave a special tribute to Georgia Montouris, MD, director of epilepsy services.

Denise has had epilepsy since she was an infant, but as Dr. Montouris' patient for the past seven years, her seizures have occurred less frequently and are less severe. She has gone without any seizure at all for as long as two to three years.

Dr. Montouris can take much of the credit for the idea behind When Patients Heal You, as she first noticed that some of her patients were frequently singing and sharing their artistic visions.

"That was the inspiration – she (Dr. Montouris) saw there was undeniable talent going on," said Moisès Fernández Via, director of Arts | Lab at the medical campus. "The concert offers patients the possibility to present themselves as artists, but from the beginning they always wanted to dedicate it to the staff and physicians who take care of them."

Now part of the culture of the clinic, says Via, staff members collect ideas throughout the year and support patients any way they can. Arts | Lab provides the framework and venue for the performances – this year's concert was held at the CFA's Concert Hall – but patients and staff bring everything together. Patients also played the saxophone, bass and electric guitar, and played and sang their own composed music with the support of a student musicians, including a violinist and a pianist, as well as singers.

And patients don't simply show up and play; they organize their performances ahead of the concert during a day-long conference, where patients chose what they wanted to do and collaborated with the CFA students to learn how to best showcase their talent.

"The bonds and friendships between the patients and musicians are another incredible takeaway from this project," said Via. "All of the preparation helps things click during the concert."

Between six and eight patients have performed at every When Patients Heal You concert, giving dozens of patients the opportunity to perform over the years. While some patients give repeat performances, Via and Taylor both see room for the concert's growth.

"I would encourage anyone who is thinking about being involved next year to do so because they will truly be touched!" said Taylor. 

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Awards and Accolades

BMC Physicians Featured on Annual "Top Docs" List
Boston Magazine published its annual list of "Top Docs" which included 109 BMC physicians. As in years past, BMC is strongly represented in numerous fields and specialties.

BMC Employees Win Awards from the Association for Medical Education and Research in Substance Abuse
Three BMC employees were honored with awards from the Association for Medical Education and Research in Substance Abuse. The awards are

  • The Betty Ford Award, given to Colleen LaBelle, MS, RN-BC, CARN, director of Boston Medical Center's Office-Based Addiction Treatment (OBAT) program. LaBelle presented the Betty Ford plenary session talk entitled "Can Nurses be a Secret Metropolitan Weapon Against Opioid Addiction?"
  • The W. Anderson Spickard, Jr. Excellence in Mentorship Award, given to Alexander Walley, MD, director of the addiction medicine fellowship program.
  • Best Research Abstract Award, given to Marc Larochelle, MD, MPH, a general internist and clinical investigator specializing in addiction medicine, for "Mortality After Nonfatal Opioid Overdose: Medication for Opioid Use Disorder is Associated with Lower Risk."

RED Protocol Article Wins National Association of Healthcare Quality Award
Suzanne Mitchell, MD, MS, was awarded the Journal for Healthcare Quality Impact Article of the Year Award from the National Association of Healthcare Quality for her article, "How Hospitals Reengineer Their Discharge Processes to Reduce Readmissions," published in the March/April 2016 issue. The award recognizes an article that highlights research and ideas promoting excellence in healthcare and significantly impacts the profession of healthcare quality.

The award-winning article outlined the development of the re-engineered discharge toolkit used for implementing the Re-Engineered Discharge program (the RED protocol) in 10 hospitals. The team's work also identified best practices and challenges that organizations may follow and overcome in order for successful implementation of the RED protocol.

Desmond Brown, MD, Wins Life Without Limits People Who Care Award
Desmond Brown, MD, the director of pediatric orthopedics at BMC, received a Life Without Limits People Who Care Award from United Cerebral Palsy of Metro Boston. The award honors his 12 years of work in Siem Reap, Cambodia providing free surgery and care for pediatric patients.

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News of Note

BMC Autism Program Finalists in Arc Tank Competition
Staff members of the Autism Program at BMC reached the final round of Arc Tank, a competition designed to find innovative ideas that will help positively disrupt disability services to improve the lives of people with intellectual disabilities and/or autism and their families.

The team's project, which was one of seven (out of over 100) chosen as a finalist, focused on a video series that would use the Solomont Simulation Center to role model care scenarios with patients and care providers across the hospital. The goal would be to distribute these videos to providers both inside and outside BMC, including at community health centers and autism support groups. The idea for the video series grew out of a BMC-wide survey conducted by the Autism Program, which found that staff members want more training in autism care.

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