Real Change Through Advocacy:

A Cure for Moral Injury

The WorkshopACEP BalancED Conference

Aisha Liferidge MD, MPH02.19.2019

Workshop Objective:• To teach and discuss targeted advocacy strategies – at the

institutional, state, and federal levels - to be used to ameliorate the effects of moral injury.

THE PLAN:• Introduction and Background (13 MIN)• PART I (institutional): Coordinated Care/Integrated Services (25 min)• PART II (state): Social Determinants of Health (25 min)• PART III (federal): Mental Health Care Reform (25 min)• WRAP UP (2 min)

OUR PATIENT:

76 y.o. Afr. Am. male veteran presents to ED by ambo, status post self-inflicted GSW to the L anterior chest wall

PM/SurgHx: HTN, CAD, DM, s/p CABG 6 months ago

Meds: metoprolol, metformin, ASA, colace Allergies: NKDA

SHx: remote tobacco hx; widowed, 3 grown children, lives alone

Vital signs/PE: 138/74 80 14 99% on RA A&Ox4

PART I:

COORDINATED CAREAND

INTEGRATED SERVICES

ACA’s Plan for Coordination• Hospital Readmission

Reduction• Hospital Value-based

Purchasing • Pay for performance• Bundled payments• Accountable Care

Organizations • Patient-Centered Medical

Home bonus payments

“Health care should be safe, effective, patient-centered, timely, efficient, and equitable. “

- Institute of Medicine (IOM); Crossing the Quality Chasm

Patient Centered Medical Home

Capacity Accountability

ED-based Care Coordination CriteriaEnsures incorporation of information from prior health care visits.

Provides educational services on continuing care needs after discharge.

Develops post-ED treatment plan and next steps for appropriate aftercare.

Transfers current ED visit information to continuing care providers.

-Katz et al. Ann of EM. Vol 60, No 1, July 2012.

4 Ways to Coordinate Care Through the ED

1. Resource Allocation

2. Primary Care and Specialist Communication

3. Facilitating the Execution of Discharge Plan

4. Frequent Utilizer Care Planning

PART I:CREATE INSTITUTION-BASED CARE

COORDINATION / INTEGRATED SERVICES PLAN FOR OUR PATIENT

(15 MIN)TIPS:• Consider public health and policy-based interventions which

acknowledge social determinants of health.• Consider use of data, value of registries, multidisciplinary teams,

community outreach, interventions addressing care transitions.• Consider ED-based care coordination criteria and techniques.

PART II: SOCIAL DETERMINANTS OF

HEALTH (SDOH)

Source: Schroeder S N Engl J Med 2007; 357:1221-1228.

40% 45%30%

MEDICAID AND THE SDOH’S• Joint state-federal insurance program, state-based with

federal funding assistance• ~ 30% of ED visits from Medicaid payer source• For those with limited income, physical ability, and

resources; Medicaid mission naturally relates to SDOH’s• Medicaid ACO’s incentivized to address SDOH’s• Seeks and rewards state innovation

• Waivers (i.e. 1115, 1332)• Immigrant coverage• Emergency Medicaid

PART II: DESIGN PLAN TO ADDRESS SDOH

THROUGH STATE-BASEDMEDICAID ACO’S

(15 MIN)TIPS:• Consider state-based efforts• Consider encouraging or requiring SDOH interventions• Consider developing risk adjustment strategies• Consider recruiting and incentivizing SDOH-saavy ACO’s• Consider encouraging or requiring community partnerships• Consider providing continuum of care for pediatric populations

PART III: MENTAL HEALTH CARE

REFORM

ED Psychiatric Boarding

Legal Action: Due Process

Mental Health Parity

Mental Health Parity

Congressional Health Committees

•SENATE•Appropriations•Health, Education, Labor, & Pension

•Finance•Budget

•HOUSE•Appropriations•Energy & Commerce

•Ways & Means•Budget

PART III: CREATE FEDERAL-BASED STRATEGY

TO ADDRESS ED PSYCHIATRIC BOARDING

(15 MIN)TIPS:• Consider due process concerns• Consider mental health parity• Consider improved Medicaid coverage of inpatient services • Consider Psychiatrist reimbursement • Consider use of specific congressional health committees

TAKE HOME POINTS:• Health status is determined by multiple socioeconomic

factors (i.e. SDOH) and is minimally influenced by clinical care alone.

• Moral injury results from repetitive insults which hinder ability to provide patients with care and resources needed to achieve health; it undermines physicians' professional purpose and skillset – often leading to symptoms of burnout.

TAKE HOME POINTS:• Development of institution-based coordinated care/integrated services

initiatives and innovative state-based Medicaid strategies are effective means of health policy advocacy.

• Effective mental health reform can be achieved by addressing several policy issues such as due process, parity, insurance coverage, and provider reimbursement.

• Moral injury and burnout symptoms can be healed through effective advocacy efforts.

“ PHYSICIAN, HEAL THYSELF ” (Luke 4:23)

… THROUGH ADVOCACY

Thank You!

Real Change Through Advocacy:

A Cure for Moral InjuryACEP BalancED Conference

Aisha Liferidge MD, MPH02.19.2019

aliferidge@acep.org