Dora Anne Mills, MD, MaineHealth’s chief health improvement officer and former director of the Maine CDC, answers providers’ questions about vaccine availability and distribution in Maine (interview recorded on 1/25/21). Also, we explore a successful effort to establish “age-friendly care” at Maine Medical Center.
Julie: This is BACON, brief ACO news from the MaineHealth Accountable Care Organization, an air-fried monthly podcast for health care providers. I'm Julie Grosvenor.
Mike: And I'm Mike Clark. Julie and I are practicing physicians and liaisons with the MaineHealth ACO. In this episode, we'll learn how the model of age friendly care is being adopted by units at Maine Medical Center.
Julie: But first we talked to Dr. Dora Anne Mills about the current state of pandemic response in Maine and what to expect moving forward. That's our Meaty Topic for this month. So let's dig right in. All right, Mike, so what is going on out there with COVID? Everybody wants to know where we're at with this thing?
Mike: That is definitely the question on everybody's mind, including mine. So, you know with, what is it, hundreds of cases of COVID-19 reported now every day in Maine, and it appears we still continue to have a limited supply of vaccine, this pandemic is still dominating our lives and particularly us as health care providers. Well, to learn what to expect next, our producer Paul Santomenna spoke to Dr. Dora Anne Mills. Yes, the Dr. Dora Anne Mills, MaineHealth chief health improvement officer and former director of the Maine CDC.
Paul: We're going to ask some questions about pandemic response, the vaccines, etc. that we've received from some of our participants in the ACO. And just a note that we're recording this on January 25th so some of this information may be obsolete by the time you hear this, but we'll do our best. So, Dora, thanks for joining us.
Dora: Oh, thank you for having me.
Paul: So vaccine supply is top of mind for many people. What do you think we can expect with the supply chain in the weeks to come?
Dora: Right now, our supply is extraordinarily tight. I mean, just to give you an idea, there are 330,000 people in Maine who are eligible for vaccine right now. 200,000 of them are people 70 and older and 130,000 of them are first responders and health care workers. And yet we are right now getting between 17 and 18,000 doses a week. So you just do the math. And those are the first doses a week. So 330,000 people or so need vaccine. I think most of them seem to want it and we are getting 17 to 18,000 doses a week. So it is an extraordinarily small trickle compared with the vaccine demand. And we are really hoping that it starts loosening up soon because the demand so, so much outpaces the supply that it is extremely difficult right now for everybody on the front lines, particularly in health care, because you're getting questions on your phones and emails all the time: when can I get my vaccine? And we want to vaccinate everybody as soon as possible. But there's just the big issue right now that there just isn't much vaccine at all. And so the issue is, when are we going to get more vaccine? That's the biggest issue. And we just don't know at this point in time. But hopefully it will be soon. The good news is that we are being told that for the time being, that when we get first doses of vaccines, that 17 to 18,000 per week, that we are assured of getting the second doses, the same amount of doses, three to four weeks later, for second doses.
Paul: Are you were aware of any steps being taken to address the disparity in doses between, the availability of doses between the large health systems like MaineHealth and the smaller private practices?
Dora: Yeah I think, you know, that Maine CDC did announce recently that they would try to get vaccine out to smaller practices. I can tell you that helping to lead the efforts here at MaineHealth on vaccine, this is not like flu vaccine. This is not like . . . flu vaccine you can pretty much almost put in a backpack and go down to the street corner, start vaccinating people. That is not the case with this vaccine. So several differences that make it very hard, I think, to have to offer this vaccine in small practices or small pharmacies, any kind of small places. Number one is it comes in multi- dose vials without a preservative, I should mention. So you really have to use very good sterile technique. But mRNA is a biologic. So you also want to make sure you don't soak it in alcohol. You know, the vial top or the skin too much because then you're going to kill the mRNA. So you have to be careful with it. And it comes in these multi-dose vials that you can get five doses from or six doses or seven doses, and that's with Pfizer. With Moderna, you can get 10 or 11 doses. And once you puncture the vial, you have to use it within six hours. So in that six hour time period, if you're scheduling a vaccine clinic for a few patients, do you schedule five or six or seven? If you've got Pfizer, or 10 or 11 if you have Moderna, and you know, people arrive and expect vaccine, and then you have to say, well, we don't have enough. A lot of complexities there that make it challenging when you're doing a small clinic. And then the second issue is that people come with a lot of questions. We ran into that with our health care professionals when we were vaccinating them, but even more so now that we're vaccinating patients and they're eager to get the vaccine. But then they see the screening questions and suddenly now they have a lot of questions to ask. So you have to be prepared to have conversations with them, which can take some time. The other thing is, the third big issue is, whereas with flu vaccine, they're getting it every year, they don't usually have many questions about it. The third big challenge, that's different from flu vaccine is this 15 to 30 minute wait after the jab. So it's 15 minutes. But if they have serious allergies, you know, history of anaphylaxis, that kind of thing, you really want to watch them for 30 minutes and see. But they have to be waiting in a place where they're spaced out with other people. So they're spaced out at least six feet. And that's actually been a bottleneck because if you have patients coming into the clinic and they're waiting and then you have patients who, after their vaccine, are waiting, you pretty much have to close down your waiting room. In a small practice, I'm not sure how you would manage the flow. And then finally, the fourth issue is that, you know, with flu vaccine, unless you're getting some vaccine from the state, you don't have to put much into IMMPACT, into the state's vaccination information system. With this vaccine, you really have to report quite a bit of information and you only have 24 hours to do it versus flu vaccine, you've got two weeks. So, you have to get quite a bit more information and put it into IMMPACT and you have to do it very quickly. So these four changes: the multi-dose vials and that you can get an uncertain amount of doses from each time, the numbers of questions you get from patients, the 15 to 30 minute wait that has to be distanced and also the waiting beforehand for vaccine has to be distanced and then the additional information you have to obtain from patients and input into IMMPACT within twenty four hours, those, I think, are issues that are very different from flu vaccine that make it challenging to do a vaccine clinic at a small practice setting. That's my personal opinion. I'm not saying it's impossible, but just challenging. And one would wonder, you know, whether the juice is worth the squeeze, I mean, we all want people vaccinated. But now that we're going into bigger venues, publicly available clinics for all patients, it seems like that might be an option to send patients to. And I should just mention that MaineHealth patients do not have an advantage on these public clinics that we're running. So we have eight now public clinics that are open to everybody, insurance, no insurance, anybody from public, MaineHealth patients, non MaineHealth patients, MaineHealth patients are not given an advantage over non MaineHealth patients. So they're open to everybody. We decided early on that we are doing a population health approach and we want as many vaccines as possible in the arms, shots in arms as quickly as possible for everybody in Maine.
Paul: To that point, you know, getting access to appointments has been difficult in recent weeks. Do you have any any suggestions for providers on how to talk to their patients when they call and say, "hey, I've been trying forever to get an appointment and I just can't get through?"
Dora: It has been very, I've had conversations and emails with a number of people and it's been very painful. I'm sure that everybody I'm talking with has had the same similar concerns. And it's just it's very, very challenging to talk with people and it just breaks your heart, you know. People are very concerned, we've got a lot of older people who've been isolated for 10 months. They're just so anxious to get vaccine, as they should be. I mean, we want them to get vaccine, and it's very hard for them not to know. So one reason vaccinating about one to two weeks out is because we don't want to provide a lot of appointments for people and then have to cancel them. So we know particularly that older people, you know, once they get that date and time, that's something that they're hanging onto. The last thing we want to do is give them a date and time and then say, well, we don't have enough vaccine. So we're making sure we know we have, in effect, vaccine before we open up appointments. So anyway, one of the things that we're doing is we do have this phone number. I will put it out there, but it's 877, so it's a toll free number, (877) 780-7545. (877) 780-7545. And that is a number that people can use - any Maine resident or New Hampshire resident who gets their care out of Memorial Hospital. So any Maine resident could call it. It's a MaineHealth run number, it's a call center we set up. It basically registers you and puts you into this virtual queue. And it tells you that when we have vaccine available we'll call you back and make an appointment and there'll be a live person calling you back to make that appointment. And I've heard from people already who've registered and got put in the queue that they've gotten calls back. So as we open up new appointments, we're calling them back. It's a little bit of a leap of faith because I never like to leave, you know, register and think anybody's going to call me back, but they actually do. So that is what I would suggest people do. Northern Light Health, Maine General, Central Maine Health, they're all coming up with different scheduling systems. So it's a little bit confusing out there. But what I can do is talk about what MaineHealth is doing and we've created this IVR scheduling system. I think it's working very well, except that we just don't have enough vaccine. I mean, it would work much better when we have vaccine.
Paul: Can you give any guidance on what constitutes a high risk medical condition that's related to eligibility? There's some confusion there. It's kind of a vague term.
Dora: There are some people thinking about this and looking at these high risk medical conditions. The U.S. CDC has a list of them. There's ones that, there's data that show that people are at high risk for severe disease. And then there is another list that U.S. CDC has of conditions that may put you at risk. So different states are handling this differently. Some are just using the top list of conditions that we have data that show these put you at high risk. But the "may" category is challenging because there are some on the "may" category, such as cystic fibrosis, that there just aren't enough data because there haven't been enough people sick with, thankfully, sick with COVID who have CF. But clearly, if you've got a patient with CF, I mean, you just want them to get vaccine as quickly as possible. So a lot of states are cherry picking from the "may" category, "may put you at risk." The problem with including all of them, the "does put you at risk" list and the "may put you at risk" list is it's a long list and it's a lot of people. So the "may put you at risk" list includes anybody who's overweight, this is like most of the population! Whereas what definitely puts you at high risk is obesity and high obesity. So 35 or 40 BMI or greater. And I should just mention that of the risk factors for severe disease, by far the biggest, single biggest risk factor is age, age over 50 and the higher you are, the older you are over 50, the higher the risk. So age is by far. And that's why many states, including Maine, have chosen age as a category to start out with, with patients. And also we can easily verify their age. The second biggest risk factor for severe disease is actually a high BMI, is high obesity over 40 BMI and over 35. So it is something that I think has not been talked about to me out in the public. Although I hate to say this, but it's sort of visible. And you see national reports on stories from people who've died of COVID who are younger. And you you look at the TV reports and so many times you can just tell that they were, you know, highly obese. So I think it's an issue that I think a lot of times they're very focused on those with, and rightly so, with heart disease and hypertension, diabetes and pulmonary disease. And yet obesity, I think, is one that we just need to really appreciate that the data are quite compelling of the risks, that it puts you at very high risk, that it puts one for COVID, particularly the higher end obesity like 35 or 40 BMI or greater.
Paul: Suggestions for talking to patients who are getting a little weary of masks and maintaining distance and staying home for 10 months, even after they've been vaccinated? Of course, there's still a period of time where they're not all that well protected. So how do how do you think providers can deal with a weary patient?
Dora: Vaccine is our ticket to getting back to a more normal life as a population, but that's different than an individual person. So if an individual person has been vaccinated, you know, there's still a lot of COVID around. Once we get more close to herd immunity, it's going to be a lot easier to have a more normal life. But we're nowhere near that. So right now, the one way I try to explain it is that we know these vaccines have extraordinary efficacy and safety profiles. I mean, they are extraordinary. Ninety five percent efficacy. It's just unbelievable. But that still means five percent, that's one in 20 people, aren't fully immune as a result of the vaccine. So that normally sounds like a small number. But when you look around and you see so many people with COVID, that means that if you're that one in 20 and you fling your mask off and start going into indoor spaces and parties and all that, you're not going to know that you're that one in 20, and you're going to contract COVID. Now, you may not have as severe a disease from it because you've got perhaps some immunity, but you're not fully immune. So right now, the person with the vaccine really cannot afford to be, you know, partying hearty like they were in twenty nineteen. The other issue is that we don't know whether if you're vaccinated, you can still harbor the virus in your nasal or oral pharynx. So in other words, the vaccine prevents disease. It doesn't necessarily prevent infection. So if you're vaccinated and you could be fairly immune you could still contract the COVID virus and it could harbor in your nose and your mouth. You could test positive for it and you can transmit it.
Paul: So we're almost out of time. Just one final question about the variants that have emerged. How worried are you about those?
Dora: So here's my prediction. This is going to end up being like influenza at some point. I mean, what COVID virus is showing us is that it mutates sort of like influenza, probably not as rapid of a rate as influenza, but it's mutating. It's going to mutate in ways, probably, that the vaccine is not going to fully be impactful. And so here's my unofficial prediction: we'll end up having to have booster shots with COVID vaccine based on the mutating virus. And just like with flu, it's not unexpected, influenza virus, as we know, it mutates all the time and there's always differences in each year's vaccine. So my prediction is we're going to end up getting COVID vaccine boosters based on new variants, maybe not necessarily really soon, but sometime in the next few months or a year or two.
Paul: Well, Dora, thanks so much for your time. I know you're extremely busy now.
Dora: We all are. Thank you, everybody on the front lines, thank you so much for taking care of patients in Maine and all the work that you're doing on the front lines. And I hope you've been vaccinated and we really hope we can get vaccine for your patients, all people in Maine, as soon as possible. Thank you.
Julie: For a transcript of this interview. Go to MaineHealthACO.org/BACON and look for Episode 22. It's time for The Sizzle, the segment where we highlight the good work of ACO participants. This month, we focus on an effort to spread age friendly care across the MaineHealth system. Our producer Paul Santomenna spoke to the leaders of the effort, Dr. Emily Carter and Molly Anderson. Emily is associate director of inpatient programs at MMP Geriatrics and Medical Director for the Hospital Elder Life Program, or HELP. Molly is manager of Maine Medical Center Geriatric Program.
Paul: So what motivated you to launch the Age Friendly Care Initiative?
Molly: So 10,000 adults turn 65 every day, and the U.S. Census data show that the population ages 65 and older is expected to nearly double in the next 30 years. And so here in Maine, we know that we're one of the oldest states in the nation. And for fiscal year '18, 32% of total encounters here at Maine Medical Center were geriatric, so adults ages 65 and older, And that's expected to increase about nine percent in the next four years. So the population is aging and life expectancy is increasing, growing the number of adults, particularly with multiple chronic conditions. And that's a real challenge for the current health care system and one that they're not necessarily able to rise to. And so this age friendly health systems framework, which is the joint effort between the Institute for Health Care Improvement and the John A. Hartford Foundation, is a way to take a diverse, challenging and at times overwhelming population and help us break it down in ways we can measure and make improvements to impact outcomes and improve quality of life. And so the focus is really on wellness and strength rather than solely the disease.
Paul: You mentioned the IHI framework, so can you just describe that a little bit more specifically?
Molly: So we refer to this as the 4Ms framework. And so when implemented together, these 4Ms represent a broad shift by health systems to focus on the needs of older adults. And so these four Ms are What Matters, so knowing and aligning the plan of care with what matters to the older adults, that means explicitly asking and documenting what matters most by saying, you know, what matters most to you, this hospital stay, for your overall healing. Is there anything important we'd like to know about you? And then also this ties in to advance care planning so making sure that advance directive, POLSTs, things like that are documented on file. And so the next M is Medication. And so this is really taking a critical look at medications. If it's necessary, we want to use an age friendly medication, not going to interfere with What Matters or the other Ms, which are Mentation - we want to prevent, identify, treat and manage dementia, depression and delirium across all settings of care - and Mobility is the final M so ensure that older adults move safely every day in order to maintain function and do what matters. So we have What Matters, Medication, Mentation and Mobility. And for each of these 4Ms we need to assess, meaning, know about the 4Ms for each older adult that enters our health care system and then act on, meaning we need to incorporate the 4Ms into the plan of care.
Paul: So that's the model, can you talk about how you put that model to work and talk about the actual initiative?
Molly: Yes. So here at Maine Medical Center, we started in the late fall of 2018. We started small. We wanted to get our feet wet in this movement, this age friendly movement. And we started with the program here at Maine Medical Center called the Hospital Elder Life Program, which is an inpatient program designed to prevent delirium in hospitalized older adults with an evidence-based national program. We've had our program here at Maine Medical Center since 2002. And so we first implemented this framework, the 4Ms framework, with the Hospital Elder Life Program and IHI has two recognition levels. Level one is participant level status. Level two is committed to care excellence. And we were able to get that second level of recognition with the Hospital Elder Life Program to kind of learn and understand. And then we spread the 4Ms to the outpatient geriatric center, which is an MMC consultative clinic down the street at 66 Bramhall. And then this this past year, in the context of the adult service medicine line clinical transformation project, we spread the 4Ms framework to R6, a trauma unit, and R7, a cardiology unit. I’ll let Dr. Carter talk a little bit more about our work.
Emily: R6 and R7 were starting at very different places. So when we looked at the data from R7, the four things that, well for both units, the four things that we were focusing on. For What Matters, we looked at advance care planning. So do the patients have advance care documentation that tells us what matters most about end of life decision making for them? We looked at, for Mobility, we looked at something called the BMAT, which is a bedside mobility assessment that nurses perform to figure out how independent is this patient in their physical functioning. And we looked at, for Mentation, we looked at the CAM or the confusion assessment method and trying to increase adherence to performing the CAM as well as accuracy of the CAM. And then for Medications, we looked at high-risk medication prescribing. So the Beers List is one list that's generated by the American Geriatrics Society looking at medications that aren't necessarily well tolerated in older adults or alternative should be considered, and then also looking at medications like sedatives and antipsychotics. So we developed a data pool and a score card that gave us information about R6 and R7 and how they were doing with these four different Ms, four ways to look at patient care. And we saw with R7 actually that they they were doing quite well in several of these markers. They were doing very well with assessing the confusion assessment method, using the CAM, and they were doing really well with mobility. They were also doing really well with advance care planning. So we actually used R7 to understand why those things were going so well. And then we did a lot of work with trying to just kind of get them up to the maximum that they could be doing and to maintain. R6 had a little bit more ground to cover and we did some really amazing work with them. So when it came to What Matters, in order to increase our advance care documentation, we worked with the trauma team to develop a dot phrase that would be meaningful to them. So using Epic, we wanted to develop a way that would be helpful for the trauma providers to talk to their patients about advanced care planning and what matters in the setting of a traumatic injury. So they had developed that dot phrase as a team and are kind of still working on rolling it out and taking it to make it most meaningful for them. So they thought with the development of this dot phrase, which we kind of built on what was being used by cardiology, we saw an increase of more than 50% of patients 65 and over who have advance care planning documentation. For mentation, there's actually an institutional standard that 90% of all patients will have a CAM documented. Molly, is it daily or twice a day. I can never remember.
Molly: It is daily.
Emily: Daily, OK. And so when we first started this, R6 was down at about 42%, which was significantly lower than the institutional standard. And so we worked with the nursing staff on R6 and they developed a KPI to assess why the CAM wasn't being performed and then to really increase this assessment as a priority. We also developed posters and brochures and a whole educational component. There was, we had a delirium teaching or I guess a delirium didactic that was previously developed, that was incorporated into the training for all nurses, and that was mandated by both the R6 and R7 nursing leaders. So that all new hires and all current nurses had to watch the didactic, learn about delirium and understand their role in it, and through these interventions we got them, they increased from 42% to 70%. And we're continuing to work on this. And R7 went beyond the institutional goal of 90%. We also had them go through the didactic and as I said, just tried to optimize where they were. For medication. We worked with our pharmacy team and developed a didactic that looks at high risk prescribing with feedback from trauma. We addressed polypharmacy and medications like narcotics, muscle relaxants, benzodiazepines that when prescribed, either individually and especially together, could contribute to delirium in older adults. And so with those interventions we saw a decrease of 10% of selected high risk medications for R6 and a decrease of 29% for R7, which is pretty incredible. And so for our last one, our mobility interventions, again, R7 was doing quite well with this already. We saw that their population was actually frequently ambulatory when they came in. They were coming in for maybe a cardiac intervention and discharging pretty quickly, whereas the R6 population with their high trauma rate and a lot of them being neurosurgical and orthopedic patients as well, mobility was a significant challenge for this patient population. So after many conversations with the nursing staff, we kind of got to the root of the matter which was that they really didn't feel like they had the staffing availability to mobilize these patients in the ways that they needed. So we were able to advocate and get them a mobility tool called the Sara Stedy, which decreases the number of people that are needed at bedside to get a patient up out of bed. So we have that intervention. They also had a new protocol put in place where they would send out a page from the secretary reminding nursing and CNAs to get their patients up and moving three times a day. And they did another KPI as well that worked on adhering to the bedside mobility assessment. So with all of these interventions R6 saw a 12% increase in patients' functional mobility, which leads to more patients being discharged home or home with services as opposed to a facility for rehab. And R7 was able to maintain their functional mobility at 80% or higher with a goal of a BMAT level of three or four within the last 48 hours of hospitalization. We also saw a really significant decrease in the number of falls on R6, which was really gratifying as well.
Paul: What's next really for this initiative?
Molly: The goal is for any older adult entering the system, the MaineHealth system, to receive 4Ms care. So we didn't really touch on it, but there was a lot of great work in the post-acute setting this year as well over at St. Joe's Rehab led by Dr. Richard Marino. And so we really are looking to spread the 4Ms across all settings.
Mike: An Institute for Healthcare Improvement case study of MaineHealth's project can be found at the web page for this episode. Check it out. Go to MaineHealthACO.org/BACON and look for episode 22. So thanks for listening to BACON this month, you can find all our episodes on your podcast app and at our Web page, MaineHealthACO.org/BACON.. And if you have questions, comments and suggestions, we'd love to hear from you. Please email us at BACON at MSgt. That's BACON at MSgt.
Julie: Bacon is produced by the MaineHealth Accountable Care Organization with help from MaineHealth Educational Services. Thanks for joining us out there. See you next month.
Mike: See you next month. Thanks.