Uninsured patients trained to self-administer IV antibiotics achieved favorable outcomes despite barriers and suggests that self-care could have other applications.
This is the second of a two-part interview. Read part one.
In the second half of an interview with Bhavan, she discusses the success of Parkland's program, including how it saved $40 million, how it could be applied to other settings, and the importance of executive support. The transcript of her remarks has been lightly edited.
On human potential:
Our CEO, [Frederick P. Cerise, MD, MPH] wrote a wonderful piece for the Harvard Business Review, saying that safety net providers can be leaders in healthcare innovation.
This program, in the study period when we looked at it for the first four years, saved over 27,000 inpatient days. That's huge a cost savings of approximately $40 million for the hospital. We weren't investing in electronic equipment… It's just IV bags, and plastic tubing, and things like this.
What we're really investing in, in my mind, is human potential; it's your most natural resource. And it's trusting that if you properly screen and train, educate the right patient population, they can do it themselves.
And what that's done, essentially, is not just the cost savings, but it's improved our resource utilization by freeing up those 27,000 beds in those years for the more acutely ill patient.
On giving patients control:
A patient who was featured in a [news] piece… said having the IVs [and] administering at home 'gave me the self confidence that I'm still somewhat in control.'
That made him feel good. That's a huge thing for people when they're sick and things are happening to them.
More recently I had a patient who had some coverage and really could have had a home health nurse come out… and opted not to. I was surprised, this was a younger patient dealing with an invasive infection.
He told me he wanted 'independence without the expense or the inconvenience of waiting for a home health nurse and her schedule.' I hadn't thought about that…that was a theme I kept hearing: "I want to regain control of my life."
On whether this could be replicated:
That needs to be further explored. These are people who represent different segments—not just the uninsured—but they're showing me that maybe there are stakeholders in other areas in healthcare that need to be looking at this...
If we can save $40 million in one setting and you can replicate this in other places, you're talking about… in the billions of dollars in savings. And more important than just savings [is] the triple aim that we all talk about.
We want to be able to improve value and patient satisfaction and lower cost in healthcare. I think the program has shown that this really can happen. And the area I really want to see explored further [is] how would you move this to different settings and/or different segments of the population.
This program is functioning out of Parkland Hospital. It's a large safety net hospital; it's supported by the taxpayers of Dallas County. We pay for the medications, we pay for the IV tubing, and the bags. But when you think about the costs, we'd be paying for that anyway and a hospital bed, if they were staying in the hospital.
Yes, we do provide for those things because we are supported by the tax payers of Dallas County for the uninsured to receive this option. But it wouldn't work if they didn't actually do it.
Patients are really showing us that if you give them the tools, they can really rise to the occasion, and they can get back to their lives. I was hoping for [outcomes] as good as the standard of care—but actually, surprisingly, at least in this population in the study, they came out better than the standard of care.
On trusting patients with their own health:
One of the big, big, big lessons that I've learned [is that] there is a huge discord between physician perception and patients' abilities. I think most doctors… we underestimate our patients and we make assumptions. There is also a [gap] between traditional literacy and health literacy.
You don't have to be a college grad or a high school grad to successfully go through the steps of putting your IV together and doing this safely at home… if you're properly instructed.
I've had patients from all over the world, speaking very uncommon languages. A Burmese refugee [who] spoke [only] a dialect of Burmese called Chin was able to do all of this… with the help of an AT&T…telephone operator who was instructing over the phone…weekly visits were done that way and he successfully completed the program.
We make assumptions about people from developing countries, we make assumptions about people from low levels of education or poverty in this country. And what we're seeing over and over again is we have patients who are living 200% below the poverty level in my population…and they're doing fantastic.
On administrative support:
We've got a terrific administration at Parkland, a really supportive CEO in Dr. Cerise, in our CMOs, and the whole administration has been incredibly helpful and supportive with this program.
By allowing us the freedom to just try this out we've now shown that this is a viable alternative.
And the impact is not just local, it's hopefully going to be a little bit more than local, hopefully a little bit more widespread. I'm working with the Infectious Disease Society of America clinical guideline panel for OPAT. So it's kind of exciting to be a part of that and to share our Parkland experience with colleagues from around the country.
On other applications:
Just recently I was talking to some folks about heart failure. For example, there's a large population of patients… we see 30-day readmissions and hospitalizations due to heart failure. Could we think about ways to get creative with diuretics, diuresis, and engaging them in self-care processes?
I've heard from other people since the paper's been published that there are products being developed right now that would be hugely [reliant] on self-care, for example, that would help a patient do diuresis.
The populations that you really help with this are, of course, the urban population and the uninsured. But I think also of people who are living in rural areas and can't get to their doctor's offices quickly.
Alexandra Wilson Pecci is an editor for HealthLeaders.
