Category Archives: Uncategorized

September 4, 2016

“Upstreamist” reduces healthcare utilization by providing a lawyer!

In an effort to reduce demand for healthcare services among high utilizing homeless vets,  Rishi Manchanda, MD did NOT ask to hire more health care professionals.  Instead, he successfully persuaded the West LA Veterans Administration Medical Center to bring in a public interest lawyer once a week.

The purpose was to identify vets with unmet legal needs that were in turn creating / driving demand for health care services.   That bet paid off.  Healthcare utilization decreased by 24% among the 139 homeless vets who participated.   The pilot program cost an average of $525 per person, and the vets gained access to more than a half million dollars in increased disability and other cash benefits.    Helping the vets resolve stressful legal, administrative, or financial barriers to housing, for example, made a big difference.

Manchanda is an advocate for moving “upstream” in order to achieve the so-called “quadruple aim” of healthcare:   better care, lower total medical costs, as well as increased patient and physician satisfaction.   [The Institute for Healthcare Improvement uses the term “triple aim” which ignores the issue of professional satisfaction.]  In Manchanda’s view, the KEY to achieving the quadruple aim is the integration of “social determinants” in health care.

Manchanda asserts that physicians are forced to work  with one hand behind their backs unless social determinants are addressed.  “Unlike all of our peer nations, we have more spending on health care than social services.  That actually creates a scenario where you have DOCTORS talking about moving upstream.”  In fact, he now calls himself an “upstreamist.”    You can read more about his remarks which were made at an AMA conference on radical redesign in health education.

Public health researchers have been intently studying what is called health inequalities or health inequities.  The country of Ireland has a particularly straight-forward definition:  “Health inequalities are preventable and unjust differences in health status experienced by certain population groups. People in lower socio-economic groups are more likely to experience chronic ill-health and die earlier than those who are more advantaged.”  In the U.S., health status varies with race and culture as well as with socio-economic status.

In the US, the phrase “social determinants of health” refers to the EXTERNAL CONTEXT in which a person lives such as safe housing, local food markets, access to educational, economic and job opportunities, access to healthcare services, public safety, cultural and social norms and attitudes, exposure to crime and violence; housing and community design, natural environment, etc.. All of these things have been shown to have an impact on health status.  (See more below).

Social determinants do not include INTERNAL PERSONAL FACTORS like a person’s life philosophy, the things they or don’t know, their past life experiences, preferences, attitudes, motivations, intentions, values, beliefs, emotions, or other psychological dynamics.  Obviously, both internal personal and external factors influence people’s behavior and what happens (outcomes).  Thus, our more comprehensive BPSE model of sickness and disability includes the ENTIRE context:  BOTH external AND internal personal factors.  (BPSE = bio-psycho-socio-economic)

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From the U. S. Government’s Healthy People 20/20 website:

Understanding Social Determinants of Health

Social determinants of health are conditions in the environments in which people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes and risks. Conditions (e.g., social, economic, and physical) in these various environments and settings (e.g., school, church, workplace, and neighborhood) have been referred to as “place.”5   In addition to the more material attributes of “place,” the patterns of social engagement and sense of security and well-being are also affected by where people live. Resources that enhance quality of life can have a significant influence on population health outcomes. Examples of these resources include safe and affordable housing, access to education, public safety, availability of healthy foods, local emergency/health services, and environments free of life-threatening toxins.

Understanding the relationship between how population groups experience “place” and the impact of “place” on health is fundamental to the social determinants of health—including both social and physical determinants.

Examples of social determinants include:
•    Availability of resources to meet daily needs (e.g., safe housing and local food markets)
•    Access to educational, economic, and job opportunities
•    Access to health care services
•    Quality of education and job training
•    Availability of community-based resources in support of community living and opportunities for recreational and leisure-time activities
•    Transportation options
•    Public safety
•    Social support
•    Social norms and attitudes (e.g., discrimination, racism, and distrust of government)
•    Exposure to crime, violence, and social disorder (e.g., presence of trash and lack of cooperation in a community)
•    Socioeconomic conditions (e.g., concentrated poverty and the stressful conditions that accompany it)
•    Residential segregation
•    Language/Literacy
•    Access to mass media and emerging technologies (e.g., cell phones, the Internet, and social media)
•    Culture

Examples of physical determinants include:
•    Natural environment, such as green space (e.g., trees and grass) or weather (e.g., climate change)
•    Built environment, such as buildings, sidewalks, bike lanes, and roads
•    Worksites, schools, and recreational settings
•    Housing and community design
•    Exposure to toxic substances and other physical hazards
•    Physical barriers, especially for people with disabilities
•    Aesthetic elements (e.g., good lighting, trees, and benches)

By working to establish policies that positively influence social and economic conditions and those that support changes in individual behavior, we can improve health for large numbers of people in ways that can be sustained over time. Improving the conditions in which we live, learn, work, and play and the quality of our relationships will create a healthier population, society, and workforce.


June 9, 2016

My detailed analysis of “The Present” video

Here’s my detailed deconstruction and analysis of why The Present video is so touching — what was going on with the puppy, the kid, and also with us the viewers.

The facts:   A boy is sitting home in the dark on a sunny day, intently playing video games. We don’t know why.  His mother gives him a box with a gift inside:  a puppy.  When the boy notices the missing leg, he angrily rejects the dog and throws it to the ground with a dismissive hiss and curled lip.  Momentarily stunned, the puppy spots a ball and bounces up, full of happy busy energy.  He starts pursuing the ball — like any puppy would.  He doesn’t pay attention to the rejection or to his own mobility difficulties.  As the boy watches the dog, the expressions on his face soften, and he decides to take the dog outside.  When he arises, we hear the sound of metal — and see that he has a missing leg.  The two cooperate to open the door and go outside to play fetch.

My analysis of the dynamics:  Basically, the puppy’s joie de vivre was infectious and it changed things.  First it altered the physical environment as well as the emotional tone in the room — and then it altered the kid’s head and his heart.  As things transpired and his view of the puppy started changing, the fact of the puppy’s missing leg (and his stumbles and falls) became less and less relevant/important.

What the kid learned by watching the puppy was that the puppy was determined to enjoy life and have fun, no matter what.  As the boy absorbed the puppy’s joie de vivre, he also noticed how the puppy’s stumbles and falls and momentary pain didn’t stop it from getting right up again — because the puppy was focused on normal puppy stuff:  he REALLY wanted to bounce around, explore, and engage the boy to play with him and the ball.  Its innocent enthusiasm for life warmed the boy’s heart.  The pup’s energetic intention to have fun and DO stuff is what warmed the boy’s heart, energized him, and got him up off the couch.

From a scientific point of view, those dynamics are biologically realistic.  We have learned that watching someone who is happy (or sad) influences our brains, and makes us happier or sadder.  We have “mirror cells” in certain parts of our brains that fire while we are moving an arm, wincing in pain, or crying with sadness — and those EXACT SAME CELLS fire while we are watching someone else do those things too.  Mirror cells are thought to be the source of the inner experience we call empathy — the deep understanding and connection with another living thing’s experience in the moment.

I re-watched the video after learning that it was created by a student team at an animation “college”.  Like some of you, I had failed to notice the missing leg at the same time the kid did.  This time I did see it.  Watching the kid’s and dog’s facial expressions more carefully the second time revealed how artfully they are done.  The dog’s expressions are almost a caricature of generic “enthusiastic puppy” with only two exceptions:  He does express pain one time when he really falls down hard, and he never communicates ANY sign of discouragement.

The really MASTERFUL animation is the human’s facial expressions.   In fact, that’s really the PROFOUND part of this video because his expressions are our window into the kid’s inner experience.  And those expressions are what trigger OUR mirror cells, the reason why WE are touched by what we see.

The transformation in the kid is gradual and we watch while it unfolds.  But, as a testament to the subtlety and power of the artist,  our intellectual understanding of what has happened arises mostly in retrospect after the “punch line”:  the surprise ending when he gets up and we hear, then see, his crutches and his own missing leg.

An original comic strip by Brazilian artist Fabio Coala entitled “Perfection” provided the basis for the video.  It has been translated into English.  The strip makes the kid’s thoughts more explicit.  He rejects the dog initially, saying that it is sick, he hates it, and the dog just exists to make people feel sorry for it.  In retrospect, after we see the last frame, we realize he was projecting his own situation onto the dog, reflecting his own bitter views about the meaning of his own life with a disability. The dog’s refusal to behave that way, to be sad or act pathetic, is what cracks open the kid’s thinking.

The comic strip has also had a profound impact on readers, one of whom spontaneously described what happened to him: “My eyes, they are leaking the salty water. .I am a disgusting mess…whose heart just grew ten times and fell out of my butt. I don’t know how that works but this comic isn’t allowing me to use the rest of my brain for thinking.”  That’s what mirror cells and empathy do for us — enable our “hearts” to feel on a much deeper level than our eyes can see.

 


May 11, 2016

Best & worst states for people with disabilities who want to work

Have you heard of RespectAbility?  When I went to their website, I found a COOL CHART showing some HOT NUMBERS:  the best and worst states for people with disabilities who want to work.

Before you look at the chart (I’ve pasted it below):
•    Guess which state has the highest employment rate for people with disabilities – 50.1%?   Do you think it’s a blue or a red state?
•    Guess which state has the lowest rate – 25.6%?   Is it blue or red?
•    Answer:  Almost all of the best AND the worst states for people with disabilities with regard to employment are in the red zone of the USA.

So, what else might be the reason for the differences between states?   Hmmmmmmmm. Is it the underlying health of the state’s economy?  I went to Mr. Google to find a ranked list of state economies.  This list on Business Insider was the first one I found.  Yay, here’s the answer, I thought (for a moment).   The WORST state for people with disabilities is the LAST state in the ranking – the state with the weakest economy over all (West Virginia).

BUT then I noticed that two other states among the bottom 10 of Business Insider’s list of state economies are in RespectAbility’s the TOP FIVE for employment of people with disabilities:  North Dakota and Wyoming.    And at the other end, of the 10 states that Business Insider ranked most economically healthy, only 1 was also in RespectAbility’s top group for people with disabilities (South Dakota).

I started to wonder whether Business Insider’s list was the “right” one, and found three other lists, here, here, and here — all of which purported to describe the health of state economies.  Each one has a VERY DIFFERENT RANKING of the states!!   The difference seems to be the method they used:   the underlying data sources and the formula used to calculate the results.

So I said uncle.  As an economic babe-in-the-woods who is unable to sort through this stuff, I have given up my extremely short amateur quest to understand WHY some states are better places to be if you have a disability and want to work!   For now, it is what it is, to use the jargon of today.

CLICK ON the table from RespectAbility pasted below and check out the numbers.  Then go to the full article on the RespectAbility website to read their analysis of why the numbers look the way they do – and what it all means.  And while you’re there, RespectAbility has also asked the current candidates for President of the USA to answer questions about their position on people with disabilities.  Their answers were NOT all the same!

Table-Best and worst states for disabled employment


October 10, 2015

Some specifics: Our proposal for a Health & Work Service

In our August 2015 proposal to the SSDI Solutions Initiative sponsored by the Committee for a Responsible Federal Budget on Capitol Hill, we recommended that a community-focused Health & Work Service (HWS) be established.  The services to be provided by the HWS are generally not available in our country today, particularly to lower-wage workers and those who work for small firms.This service would be dedicated to responding rapidly to new episodes of health-related work absence among working people in order to help them:

— Minimize life disruption and get things back to normal as quickly as it is medically safe to do so
— Focus attention on treatments and services to restore ability to function at home and at work
— Understand and navigate through the healthcare and benefits programs and systems
— Avoid being abandoned; learn how to be a squeaky wheel and get their needs met
— Communicate with all parties to expedite both medical care and the return to work process, including resolving non-medical obstacles to recovery and return to work, making temporary adjustments or arranging reasonable accommodation when appropriate.
— Keep their jobs or promptly find new ones if that is necessary.

(The material below summarizes our written proposal.  If you’re interested in the scientific research that underlies these ideas, the 30+ pages and 3 appendices of our “real deal” formal report support all key assertions with literature citations and an extensive bibliography.  Along with the 12 other proposals commissioned by the SSDI Solutions Initiative group, it is scheduled to be published electronically in late October, and in print in January 2016.)

The first few days and weeks after onset are an especially critical period during which the likelihood of a good long-term outcome is being influenced, either favorably or unfavorably, by some simple things that either do or do not happen during that interval. It is the optimal window of opportunity to improve outcomes by simultaneously attending to the worker’s basic needs and concerns as well as coordinating the medical, functional restoration, and occupational aspects of the situation in a coordinated fashion.

The best opportunity for basic intervention appears to last about 12 weeks or three months, although some data shows it ending by 6 months.  Many studies have show that a modest set of simple services—that embody an immediate, systematic, pro-active, integrated, and multidimensional approach—can mitigate the potentially destructive impact of common injuries, illnesses, and chronic conditions on quality of life among the working population.

In the USA today, a large and growing fraction of Social Security Disability Insurance (SSDI) awards are being made to people deemed totally unable to work due to conditions that are among the most common health problems in America and the world, but which only rarely cause permanent withdrawal from the workforce. Low back pain and other chronic musculoskeletal conditions (MSK), and common mood disorders (CMD) —particularly depression and anxiety—are the most prominent conditions in this category.

Near-immediate assistance from a community-focused Health & Work Service will allow people with these kinds of common conditions to avoid the kind of adverse secondary consequences they too often experience today. Those consequences are usually not obvious until months or years later, after unfortunate things have happened. The unlucky ones have received sub-optimal health care, been left with under-treated or iatrogenic impairment,  become dependent on opioids, found themselves socially isolated, lost their jobs, withdrawn from the workforce, lost economic independence, and ended up on long-term disability benefits programs or SSDI in order to survive. Anticipatory programs that ensure the right things happen from the start and include early identification of those needing extra support are the simplest and most effective way to prevent later adverse secondary consequences of these conditions.

As we envision it, the HWS will build strong collaborative relationships with referral sources in local communities: treating physicians, employers, and benefits payers. Service delivery in individual cases can be largely telephonic and internet-based because these technologies are proving to be as or more effective than face-to-face care delivery. The quadruple goal is to maximize service quality, optimize outcomes, minimize logistical challenges, and control costs. The HWS service will:

(a) — get its referrals from affected individuals, local treating physicians, employers, benefits payers and others when work absence has lasted or is expected to last more than four weeks;

(b) — champion the stay-at-work and return-to-work (SAW/RTW) process from the time of referral through the end of the immediate response period (usually 12 weeks post onset);

(c) —  quickly evaluate the individual’s situation, screen for known risks for poor outcomes, help them make a SAW/RTW plan and support them in carrying it out;

(d) —  facilitate communications among all involved parties as needed to get everyone on the same page and driving towards the best possible outcome.;

(e) — expedite and coordinate external medical, rehabilitative and other kinds of helping services, including referrals for specialized services as needed to address remediable obstacles in a variety of life domains;

(f) — take a problem-solving approach in collaboration with affected individuals, their treating physicians, employers, and payers.

Of course, developing the HWS will first require a commitment to funding, either by the government or by a foundation that is committed to system change. Once that has been obtained, the initiative will unfold in a series of steps including design, prototyping, development, and field-testing in different geographies, followed by a large randomized controlled trial.  After that, the HWS can gradually roll out across large geographic areas.

What does this mean for you?   First, if you like the idea of working people getting the kind of support they need and deserve — and when it is most likely to make a difference,  please support this idea in whatever way you can.  Why not call or email your Congressman?  Second, if you are a professional with the expertise and passion required to help people get “right back on the horse” — and are now stymied and frustrated by the current system’s inadequacies / dysfunctions, you have probably realized that the HWS service might create a lot of fulfilling and satisfying jobs for specialists like you.  If so…. that’s another reason to call or email your Congressman!


August 12, 2015

Who will address working people’s reasonable concerns when illness or injury disrupt their lives?

What do working people wonder and worry about when their lives (and work) have just been disrupted by a new illness, injury, or a change in a chronic condition?

While creating a course to train doctors how to meet their patient’s needs, we realized we had to know what those needs were.  It seemed obvious that patients would want to know what is wrong with them and what kind of medical care they need.  But beyond those things, we came up with a list of predictable and totally reasonable issues:

How long am I going to be laid up (out of commission)?
How long do I have to take it easy?
When I can go back to doing my usual stuff?
In the meanwhile, what can I still do? What shouldn’t I do?
What can I do to speed my recovery?
If I can’t work, how will we pay our bills next month?
When will life be back to normal? …..if ever?
What does this mean about me?   My future?
What is this going to do to my livelihood?  What will this do to us financially?
Who will help me?  Who can I trust?  Who has my best interests at heart?

I often show this list when I am speaking to groups about how to improve outcomes for people with common health conditions like back pain.  It always rings true with the audience.  After one presentation, an influential executive (in a wheelchair with quadriplegia) told me that she had had all of those concerns immediately upon awakening after her accident.

Here’s my question:   How are people getting these questions and concerns answered — when and by whom?  The standard design of a medical visit (memorized by all physicians during our medical training) DOES NOT include a time for doing it.  There is no sub-heading in our report format called:  Patient Education,  Instruction, and Guidance.  If it is happening, it is spotty at best.

So if most doctors are not answering these questions, who is?   Which of the other professionals who are responsible for responding to life & work disruption in working people IS going to address them?   Unless one of these “experts” does so, the people will have to come up with their own answers.  Yet how many are prepared to do that?   They will come up with their own best guesses (which may be wacky) or may turn to their family, friends, co-worker, neighbor, union steward, or a lawyer for answers (who may or may not give them a bum steer).

What does this mean for you?  If you are committed to better service (and/or want to avoid the trouble caused by bad advice), figure out a way to meet people’s totally reasonable needs for information and advice.   If you are a treating clinician, consider making a revision to your standard visit protocol and report templates by adding that missing section:  Patient Education, Instruction & Guidance.

Another simple idea for healthcare providers, employers or insurers is to create a standard operating procedure to mail out or hand out a brochure.  The 60 Summits Project developed a fact sheet for employees whose health conditions have just started to disrupt their work — and a fact sheet for supervisors on how to manage the situation in the workplace..  Feel free to use these sheets as is, or remove the 60 Summits logo and revise them to suit yourself.  But please do SOMETHING!

 


August 7, 2015

Who should be accountable for NEEDLESS job loss due to medical conditions?

Who do you think should be held accountable when workers needlessly lose their jobs because a newly-acquired or changed health condition or disability?

Right now, none of the professional participants who play front-line roles in the stay-at-work/return-to-work process feels a responsibility to prevent unnecessary job loss.  Doctors, employers, insurance companies, lawyers and so on simply think it’s a shame when it happens — if they are even aware of it.  Unnecessary job loss is being viewed as a private tragedy rather than a sentinel indicator of service and system failure.  A lot more sunshine is needed to illuminate this dark corner.

Gap

Even though OSHA ensures that employers record the number of work-related injuries, lost work-days and deaths, there is no requirement that they record job loss.  Why isn’t it being tracked?   It will almost always be a much worse consequence than the injury itself.   Job loss, especially in someone who was previously healthy but now has some degree of impairment, can be DEVASTATING.   Few people are prepared to deal with this double- barreled challenge.   For the unlucky ones, this means losing their footing in the world of work forever.

We do not even KNOW how many people lose their jobs as the result of work-related injuries much less personal health conditions — and how many fail to find new jobs. I personally don’t think it matters what the cause of the health condition is.

These days, more than a HALF of the people entering the Social Security Disability Insurance program are doing so because of adverse secondary consequences of common health conditions like back pain, joint pain, anxiety, and depression.  But notice this:  there are literally MILLIONS of people who keep working DESPITE back pain, joint pain, anxiety and depression.  These conditions should NOT be forcing people into a bleak future of on-going worklessness, especially because unemployment and poverty will WORSEN their health and well-being — and that of their families.

Needless job loss can occur because of decisions that doctors and employers make as well as decisions made by workers, their lawyers, and insurance companies. Anyone who COULD have actively supported a worker in staying at work but DIDN’T plays a part in unnecessary job loss.  Doctors may thoughtlessly select treatments that worsen instead of improve function, or impose work restrictions that “over-limit” someone who COULD actually perform their job.  Employers may refuse to make temporary adjustments that WOULD permit recovery “on the job” — and as a result workers sit home and begin to believe they really are “too disabled to work”.   Employers can refuse to engage in a real problem-solving discussion with workers that WOULD have let them come back to work with a very minor modification.  Employers can neglect to ask for help from a return-to-work expert who COULD have told them about a $200 piece of equipment or work process alteration that WOULD have made it possible for the worker to keep doing her regular job.  Insurers COULD routinely (instead of occasionally) make career counseling and job finding services available to workers who appear headed for job loss or have already been terminated.  Etc. Etc.

So, who DO you think should be held accountable for job loss in those situations?  You and I as taxpayers are going to pay benefits for the rest of these people’s lives if they end up on SSDI because the right things didn’t happen.  Less than 1% of SSDI beneficiaries ever come back off the rolls.

Here’s a place to see and comment on my DRAFT recommendations for what the government can do to create a lot more visibility for unnecessary job loss due to acquired health conditions and disabilities.  You can also contribute your own ideas on this matter at:  http://workashealthoutcome.epolicyworks.org/


July 7, 2015

Free on-line CBT course helps Australians living with pain feel better

An Australian study in the journal Pain reports that a FREE on-line course that employs CBT techniques has worked well in helping patients with chronic pain reduce both distress and other symptoms  — no matter how much contact the patients had with a clinician during the several week course – and it clearly outperformed “usual care.”

The Pain Course was developed by psychologists as part of a non-profit initiative of the Centre for Emotional Health, part of Macquarie University in Sydney, Australia.  Their tagline reads:  “Developing effective, accessible and free psychological treatments …”   Before you get TOO excited, this particular course and the other on-line offerings of ecentreclinic.org which developed it are only open to residents of Australia.

Here’s a bit more about this group from their website:   “We comprise a team of psychologists, psychiatrists, and research staff….The eCentreClinic is a specialised research clinic that develops and tests state-of-the-art free online treatment Courses for people with symptoms of worry, panic, social anxiety, OCD, PTSD, stress, depression, low mood and other health conditions including chronic pain. We built the eCentreClinic because millions of Australian adults suffer with these symptoms and conditions each year. But, most do not seek help or see a mental health professional. We believe that people have a right to helpful information and to know about practical, proven, skills that help. We hope that by providing this information and supporting people to learn these skills via the internet more people will learn to master their symptoms and conditions. By doing this we hope they will also improve their quality of life and that of their families and communities.

Here’s a link to the abstract.   It is is an open access (free) article, so you can also download a pdf of the entire article here.


June 5, 2015

Why aren’t we saying and doing THESE THINGS about the ADA?

I’ve been listening to the prevailing conversation about the Americans with Disabilities Act, as amended (ADA), in workers’ comp and disability benefits circles. Most often it has a negative tone: the ADA imposes obligations and creates complicated legal dances that can get us in trouble unless we do things exactly right. I almost never hear ANYONE in these industries (other than disability rights advocates) talking about what we can do to FULFILL the social purposes for which that law was created!

I am also a member of the US Dept of Labor’s Stay-at-Work and Return-to-Work Policy Collaborative, As a result, I met the EEOC‘s Senior Legal Counsel Aaron Konopasky, PhD, JD.  He opened my eyes to the fact that the ADA now applies MUCH EARLIER and MORE FREQUENTLY in health-related employment disruptions (both workers’ compensation and short / long-disability benefits cases) than has traditionally been thought. (See the mini-white paper Aaron and I co-authored on this issue.)

Seems like one of the key purposes of workers’ comp and disability benefits programs SHOULD BE to help workers who get injured or sick or who lose functional ability over time to KEEP THEIR JOBS / LIVELIHOODS and if needed, FIND NEW WAYS TO EARN A LIVING appropriate for their changed capabilities so they can MAINTAIN THEIR ECONOMIC INDEPENDENCE.  If that is so, then it seems like EMPLOYMENT OUTCOMES should be included in the metrics by which effectiveness / success / value of these programs is measured.   (I don’t see this being done now — do you?)

Now let’s look at the flip side:  bad outcomes.  (more…)