Aine Cryts

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COVID-19 is not an equal-opportunity illness. Older people and patients with chronic conditions are, on average, far more vulnerable to suffering serious illness and death from the disease than younger people without ongoing health problems. Although the data are not as clear, cancer patients are also among those vulnerable to the SARS-CoV-2 virus that causes COVID-19 and more likely to suffer its serious consequences.   

Oncologists around the country, supported and informed by guidance from healthcare leaders and professional associations, are reviewing the available research and carefully weighing treatment decisions. Many patients, with their physicians, are wrestling with question of whether the risks associated with putting off their cancer treatment are greater than the risk of COVID-19. 

Randall Oyer, M.D., a medical oncologist at Lancaster General Health, a health system in Lancaster, Pennsylvania, says that in addition to understanding that cancer patients are a vulnerable group, healthcare leaders need to recognize that cancer patients are at  heightened risk of contracting COVID-19 in the hospital.  

Oyer says research from early COVID-19 hot spots such as China, Italy and the Seattle area suggests that patients with lung, liver and some types of gastrointestinal tumors, as well as hematologic malignancies, are at greater risk of suffering COVID-19 than patients with other kinds of cancer. Sparse as these data may be, they should still guide decision-making by oncologists and healthcare leaders, Oyer says. Many professional associations are providing guidance to oncologists during the outbreak, including the Association of Community Cancer Centers (Oyer is the president), the American Society of Clinical Oncology, the American Society of Hematology, the American Society for Radiation Oncology and the American College of Surgeons. 

Patients with cancers of the lung, the liver and possibly the gastrointestinal system are at increased risk of COVID-19 because the SARS-CoV-2 virus attaches to the angiotensin-converting enzyme 2 (ACE2) that is highly expressed in these organs and system, explains Oyer. ACE2 “paves the way” to cancer cells in these areas and acts as a “welcome mat” for SARS-CoV-2, he says.  

It’s a different story with hematologic cancers, which include the leukemias, the lymphomas and multiple myeloma. The cancers themselves reduce immunity and make people vulnerable to infection because they interfere with the production of healthy levels of lymphocytes. In addition, the treatment of hematologic cancers targets the immune system and the bone marrow to get rid of the malignant cells, but it also affects noncancerous cells, further suppressing the patient’s immunologic defenses. Oyer describes the process as one in which “the bouncer’s (been) removed from the door” and can’t defend against the virus.

Masumi Ueda, M.D., M.A., assistant medical director for inpatient blood and bone marrow transplant at the Seattle Cancer Care Alliance, a hospital in its namesake city, says patients with compromised immune systems should adhere to the core recommendations for preventing COVID-19: Wash your hands, and maintain social distancing. “Aside from that, there’s not much more than we can do in the absence of a vaccine,” she says. 

Ueda was the lead author of an article in the April 2020 issue of the 

Journal of the National Comprehensive Cancer Network

 describing the changes that the Seattle cancer hospital made in response to the COVID-19 outbreak. The title is telling: “Managing Cancer Care During the COVID-19 Pandemic: Agility and Collaboration Toward a Common Goal.” Ueda and her colleagues mingled advice with brief accounts of the steps they took to respond to COVID-19:

The first step is robust infection and environmental control. Patients with respiratory symptoms need to be triaged. In Seattle, wrote Ueda and her colleagues, they had early access to testing and could perform nasopharyngeal swabs on symptomatic patients that met COVID-19 testing criteria.

Healthcare leaders need to strictly reinforce “stay at home when ill” policies and establish other policies for testing staff, tracking exposures and defining when people can return to work.

Forming an “incident command” structure is necessary to centralize information. Leaders need to hold virtual town halls.

Outpatient well visits were rescheduled or handled through telemedicine visits, and telemedicine capabilities and training were ramped up. Hours of operation were added to make sure that emergency departments and hospital resources were used only by those needing high-level care.

Adjuvant therapy with curative intent for patients with solid tumors should likely proceed.

Decisions about delaying treatment should factor in whether delays may lead to inpatient admissions for symptom palliation that would burden hospitals.

Stem cell transplants and cellular immunotherapies provide curative treatment and can’t be delayed in many cases.

By speaking to patients on the phone, surgeons optimized decision-making about delays in surgery.

Oncology disease groups were given the job of determining which treatments might reduce the risks of immunosuppression. They also weighed whether treatments might be moved from an inpatient to outpatient setting or delayed.

Ueda’s area of expertise is in stem cell transplant. She says not much data exist about whether patients undergoing the procedure, which involves a period of severe immunosuppression, do in fact have a higher risk of experiencing serious COVID-19-related illness. But as a rule, she notes, patients undergoing immunosuppressive cancer treatments such as stem cell transplants are more vulnerable to infection and serious illness from viral diseases like COVID-19.

The number of patients with cancer and COVID-19 has been relatively low at Seattle Cancer Care Alliance. “I think we were lucky as an institution,” says Ueda, noting the center’s relatively early access to testing. Still, she’s cautious about what the future holds. Her hospital is preparing to revamp its cancer care operations once the worst of the pandemic has subsided. Among the changes in the offing might be greater use of telehealth.

The COVID-19 outbreak has put nearly every medical service on hold and forced patients and physicians to do some cost-benefit thinking about diagnosis and treatment, now and later. But the decision to delay cancer treatment is especially fraught, and the seesaw of cost-benefit, huge. Delay could give an aggressive cancer an opportunity to progress, but treatment may lower immunity. J. Leonard Lichtenfeld, M.D., MACP, deputy chief medical officer at the American Cancer Society in its Atlanta headquarters, says the society’s around-the-clock call center has received questions from many patients whose cancer treatments have been stopped or put on hold. “Every cancer center is struggling with this,” he says.

Richard Van Etten, M.D., Ph.D., a stem cell transplant specialist at the University of California, Irvine, and director of its Chao Family Comprehensive Cancer Center, says the decision to delay care depends on the type of treatment. For autologous stem cell transplants, which involve using the patient’s stem cells, continuing treatment is plausible if the patient doesn’t have COVID-19. Maintenance therapy is also an option for these patients and would allow them to undergo the procedure later. 

Allogeneic stem cell treatment, which involves using stem cells from a donor, presents a greater challenge, says Van Etten, because these patients can be profoundly immunosuppressed for up to a year after treatment. Many of these patients can’t wait long for a transplant, so moving forward with the procedure, and ensuring the patient is isolated afterward, may make sense, provided they don’t have COVID-19. 

Oyer, a practicing oncologist for 40 years, describes himself as an optimist. He is challenging healthcare leaders and oncologists to use this experience with COVID-19 to transform cancer care. For example, patients undergoing treatment might be given the option of checkups using telehealth, which will increase convenience, he says. Oyer also notes how quickly medical journals have published articles about COVID-19. The evidence they have presented has helped professional organizations keep their guidelines timely and relevant.

Healthcare organizations should start planning now for when the worst of the outbreak is over, says Lichtenfeld. “There’s going to be an incredible rush to the door of patients seeking treatment,” he notes, and careful triage of patients is going to be important. He also recommends proactive communication with patients about when they will resume treatment. In addition, healthcare leaders must support staff members with employee assistance programs, he says. 

“Everyone has a story,” Lichtenfeld says. “Everyone wants to be comforted, and staff will have emotional and community-based issues they have to deal with.”   

Aine Cryts is a healthcare writer based in Boston.   

Articles

Patients and their oncologists are weighing the pros and cons of delaying treatment. Once the outbreak subsides, how might the practice of oncology change?

Cancer Care in the Time of COVID-19 and After

Medical and dental care in the United States are like estranged colleagues: nominally on the same team but rarely, if ever, in touch with each other. Some value-based payment arrangements may start to mend the rift, which could both improve overall health and reduce healthcare costs. 

“Health system leaders now have evidence that was not around five years ago showing (that) investing in dental care can have offsetting medical care cost savings,” says Marko Vujicic, Ph.D., chief economist and vice president at the American Dental Association’s Health Policy Institute. Vujicic has published research showing that periodontal care can lower the healthcare costs of people with Type 2 diabetes. 

One notable value-based dental agreement is between Blue Cross Blue Shield of Massachusetts (BCBSMA) and 42 North Dental, a large dental group headquartered in Waltham, Massachusetts, outside Boston, comprising 24 practices. The two organizations signed a value-based contract, which they announced in February.  

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Under the agreement, BCBSMA will pay an incentive to 42 North Dental for the provider’s delivery of dental services to members with several conditions, including diabetes, some heart conditions and oral cancer, says Robert Lewando, D.D.S., MBA, executive director of BCBSMA’s Dental Blue plan. Pregnant women are also included. The additional services include extra dental cleanings and periodontal treatments, according to Lewando. 

In September 2019, 17.8% of BCBSMA’s patients with diabetes received periodontal treatment at 42 North Dental, says Michael Scialabba, D.D.S., vice president of clinical affairs at 42 North Dental. By January 2020, that percentage had edged up to 20.5%. Scialabba wants it to improve to 50%. Incentive payments will be commensurate with 42 North Dental’s ability to improve that and other metrics, says Lewando.

Scialabba says 42 North Dental promotes the program in several ways: posters, automated messages and, among the staff, at team huddles. He notes that each practice includes periodontists and oral surgeons, in addition to general practice dentists, which encourages accountability across the team. “If you have five other colleagues in the group practice, you get criticized a lot. It holds you to a higher standard,” he adds. Typically, each 42 North Dental practice has about a dozen BCBSMA patients with these conditions, so the numbers aren’t overwhelming,
	says Scialabba. 

Lewando says the agreement with 42 North Dental is a pilot project. If it’s successful, he hopes to expand it to all 6,300 dental providers in Massachusetts that have contracts with BCBSMA. 

DentaQuest, a dental and vision benefits company headquartered in Boston, has set up value-based metrics for 323,000 members in Oregon’s Medicaid program; the metrics are designed to emphasize preventive care, such as additional cleanings for people with diabetes. The program has been in place since 2012.

Advantage Dental, which is part of DentaQuest, contracts with 200 dentists to provide dental assessments, sealants and fluoride varnish to 50,000 children in schools and other settings in Oregon. Dentists are rewarded for achieving certain metrics, such as providing children and adults with access to dental services, timely dental assessment for children in foster care and comprehensive dental care for adults with diabetes. Kevin Boie, chief operations officer at Advantage Dental, says the practice has seen a 35% increase in dental sealants delivered to children over the past four years.   

Medical and dental care in the United States are like estranged colleagues: nominally on the same team but rarely, if ever, in touch with each other. Some value-based payment arrangements may start to mend the rift, which could both improve overall health and reduce healthcare costs.

Value-Based Care Takes On Dentistry

They say healthcare is a team sport, but teams can sag, get discouraged, lose focus, and stop functioning as, well, a team.  Anyone in a leadership position must stay attuned to how the team members are feeling and keep people motivated. Keeping your team motivated and maintaining enthusiasm requires attention, creativity, and planning.

Here are five examples of how healthcare organizations have worked to keep motivation high: 

UMass Memorial Health Care, in Worcester, Massachusetts, uses the “idea system” to motivate teams to transform care delivery and save lives. For example, the neonatal intensive care unit’s (NICU) pharmacy team wanted to reduce the time it took to provide antibiotics to its most vulnerable patients. The changes included streamlining the process for a clinician to order an antibiotic and having it verified and prepared by a pharmacist. As a result of the NICU pharmacy team’s work, the time to get critical medications to sick infants dropped from 75 minutes to 53. Since the idea system started six years ago, team members at UMass Memorial have submitted more than 78,000 ideas, says Eric W. Dickson, MD, president and CEO. 

Kelly M. Johnson, PhD, RN, NEA-C, former vice president of patient care services and chief nursing officer at Stanford Children’s Health in Palo Alto, California, brings together members of the patient care services team at the end of the fiscal year at a retreat to reflect, recharge, and connect. “We share and celebrate accomplishments in the division and solidify priorities for the coming year. More importantly, the time is critical for team building, self-care, and reflection on the important work we do,” says Johnson, who’s also chief nursing officer at the hospital, which provides pediatric and obstetric care in the San Francisco Bay area.

She acquired a new position in March 2020 as vice president, chief nursing officer, UCSF Benioff Childrens Hospital, ACNO, UCSF Health at the University of California, San Francisco.

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Cigna finalized its acquisition of Express Scripts in December 2018. During the integration, the company featured a “Thursday Thank You” segment on its intranet to celebrate team members’ successes, says Kristen Gorodetzer, senior vice president of total rewards, talent acquisition, and employee services at Cigna. The intranet posts focused on a different team each week and garnered significant engagement because “people want an opportunity to say thank you to pat each other on the back,” says Gorodetzer.

Patients calling to schedule appointments with UMass Memorial’s call center were waiting an average of 11 minutes, up from between 40 to 50 seconds. That spike in wait time was driven by the healthcare system’s electronic health record  implementation, says Dickson. He credits a dedicated leader on the call center team with using daily team huddles to sustain team members’ enthusiasm for streamlining the call greeting, activating an auto-answer feature to remove the 18-second ring cycle, and shortening the prerecorded appointment information. 

The end result is that the average call wait is now 5.6 seconds; it has been maintained by continuing to meet daily, review metrics five times a day, and provide training when necessary.

Sujata Sanghvi, deputy chief financial officer at AllWays Health Partners, a Somerville, Massachusetts, not-for-profit payer, says recognition of employee success is crucial. 

“It’s not only important for leaders to recognize their teams but also to encourage their teams to recognize each other,” she says. Sanghvi has a few ideas to make it fun: tie it to a reward, a raffle, even a silly rotating “trophy” to highlight the recognition. 

“By integrating opportunities like these into your regular practices, you can help create a sense of camaraderie to build a high-performing team that takes pride in their work and can depend on one another,” she says. 

Clinicians at UMass Memorial Health Care recommend strategies to better motivate team members, transform care delivery and save lives. 

Five Ways to Motivate Your Team

COVID-19 has launched a massive natural experiment in work-from-home (WFH) policies and practices for employers and employees. Obviously, people involved in the direct provision of medical care can’t work for home, but, just as obviously, many people involved in office-based functions can.  

Here are six tips for healthcare executives who are managing WFH employees: 

Mary Anne Jones, senior vice president of finance and operations at Priority Health, a health insurer in Grand Rapids, Michigan, encourages healthcare leaders to communicate frequently and comprehensively. Every day during the COVID-19 outbreak, Priority Health’s executive team has communicated with employees about topics that range from staffing news to best practices to protect against infection with the SARS-CoV-2 virus to updates on resources available to WFH staff. Employees also receive information about compassionate and emergency paid-time-off opportunities.

Joe Tye, a former hospital administrator and founder and CEO of Value Coach, a consulting business, observes that healthcare workers are dedicated to their patients. One way to help remote workers feel connected, he says, is to share stories in a HIPAA-compliant manner on the organization’s intranet that illustrates how employees’ work affects patients. He offers the hypothetical example of a supply-chain clerk working from home who exceeded expectations to secure a shipment of surgical masks for the hospital. That effort might be acknowledged with a comment that “this shows how we are all caregivers and can all make a difference for the patient and for fellow caregivers,” says Tye.

Tina McKinney, regional vice president of human resources at Partners Healthcare in Boston, says WFH team members often need flexibility. Employees may need to start work early, before their children wake up, and then take a break to get their children involved in an at-home activity. McKinney says that Newton-Wellesley Hospital, one of the two hospitals where she heads up human resources for Partners, is extending the hospital’s employee assistance program to employees’ family members so they can get short-term counseling and other kinds of help. Employees have access to virtual spiritual care, where they can learn about yoga and meditation, for example. 

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Being “too hunkered down” in the house can be bad for mental health, says Sherry Rohlfing, principal at DeltaSigma, a healthcare consulting firm in Littleton, Colorado. “Go outside. Social distancing doesn’t mean you’re stuck in the house,” says Rohlfing. 

3. Set up staff with the home-office tools they need

Jones says many of Priority Health’s employees aren’t used to working remotely. In response, the health insurer gives staff the equipment they need to furnish a home-office environment. Employees were allowed to take home their monitors, docking stations, and other computer equipment. Priority Health employees also receive tips on contacting IT services, setting up equipment, and accessing virtual tools, such as online meeting software. 

Craig Pirner, a managing director at The Advisory Board, advises hospitals to use virtual-meeting technology, such as Zoom or Cisco Webex. He encourages managers to use video whenever possible to help reduce social isolation. Nonverbal communication is missing during phone-based team meetings, he explains. 

Tye says that launching a virtual book club can be a good way to increase engagement among employees. “Choose a book, either fiction or nonfiction, that’s not directly work related and that inspires the heart and soul. A good start would be “The Last Lecture” by Randy Pausch, says Tye. One way to run the club is to schedule a weekly conference call with each person assigned to provide a recap and their observations about different chapters. After the book conversation, the call can be used to check in on team members.

5. Maintain focus on other problems to solve

COVID-19 has swept attention on other problems aside, but those problems are still there: keeping people with diabetes healthy, improving outcomes for hips and knees replacements, managing high drug costs. “It’s so easy for executives not to see what else is going on. The challenge is to understand there are other crises they’re going to have to deal with,” says Don Hall, who is a principal at Delta Sigma with Rohlfing and a member of the 

COVID-19 is a serious public health crisis; you don’t want to make light of it. But that doesn’t mean that people can’t share some lighthearted moments. Managers should inject a little fun into their interactions with employees, says McKinney. Some employees at Newton-Wellesley Hospital have been sharing fun videos about what they’re doing with their kids or their dogs, says McKinney, and she is perfectly OK with that. 

How healthcare executives can manage employees who are working from home.

Author | Aine Cryts

Articles

Cancer Care in the Time of COVID-19 and After

Value-Based Care Takes On Dentistry

Five Ways to Motivate Your Team

Six Tips for Supporting, Connecting WFH Employees