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Transcript from May 4 online chat on community care proposal

May 7, 2010

Following is a transcript of an online chat held May 4, 2010, about MIT Medical's proposed community care model. The transcript from the May 5 chat is also available.

Kim Schive: Welcome to our chat about MIT Medical's community care proposal. My name is Kim Schive. I'm the communications coordinator at MIT Medical, and I'm going to be moderating the discussion this evening. When I get a question or comment, I'll direct it to one of our panelists, who will respond to each one as quickly as possible. We will also be responding to some pre-submitted questions, and those will be identified as such.

I'd like to begin by introducing our panelists for this evening. First, we have William Kettyle, M.D., our medical director; David Diamond, M.D., our associate medical director; Kristine Ruzycki, A.N.P.-B.C., who is chief of nursing services and director of student health services; Maryanne Kirkbride, clinical director for campus life; and finally, to respond to questions about insurance coverage, Lucy Walsh, manager of the MIT Health Plans.

lupis: Is it possible to get sound?

Kim Schive: No, sorry, no sound with this chat. Just typing.

Olesya: I think the idea of this community chat is great! I don't feel comfortable with the proposed reorganization of Urgent Care at MIT. I'm a graduate student here, and it makes me feel infinitely better knowing that if something happens, there are caring people on campus that can help right away. While I did not have to use Urgent Care during night hours yet, I did bring a friend with a broken ankle once. And it was very nice to have him fixed up, and both of our minds eased. I am sure the reorganization is meant to save money. And that's a good thing. However, before people take a side in the issue, we should be informed. Is the Urgent Care utilized during night hours? Where can we find the statistics? Is it a necessary service, or not? If there are people coming to Urgent Care at night, we should keep it. Money is important, but health is paramount.

David Diamond: Thank you for your question. We plan to keep Urgent Care open until 11 p.m. every night. Utilization statistics show that only ~1.5 visits per night occur between midnight and 7 a.m. on average. Some of these visits are convenience visits that could wait until the morning; some are directed to a hospital. We will have clinicians on call to advise those needing care as to how to manage their care during the hours on-site care is closed.

Kris Ruzycki: Olesya, thanks for joining us and submitting your question. Urgent Care will continue to be open everyday from 7 am to 11 pm. From 11 pm to 7 am there will still be the availability to speak with a registered nurse by phone who will ask you questions about what your problem is and will either instruct you in some self care, or instruct you not only about what to do now, but when to follow-up with someone at medical or they will instruct you to go to the hospital. They will be able to help facilitate that transfer to the hospital for you. At the hospital they will be able to meet any acute, urgent or emergent needs for you even better than we could have in Urgent Care as they will have laboratory, x-ray and other diagnostic services available to you at night that we would not have. Does that answer your question?

[Pre-submitted question]: If my child or I need urgent (but not emergency) medical care between 11 p.m. and 7 a.m., would I be referred out to a hospital after calling in to MIT Medical? Which hospital(s) would that be?

David Diamond: We have arrangements with Mt. Auburn Hospital to care for our adult patients and use Children's Hospital Boston for our urgent pediatric care at night; however, in the case of a true emergency, we would want you to go the facility that is nearest to you. If you have an urgent but not emergency situation during the overnight hours, you would still call the Urgent Care number (617-253-4481). When you call, you'll speak with a triage clinician who will help you assess the situation and offer advice about what to do next. Often, with advice, the problem can be handled at home during the overnight hours and the patient can wait until the next morning to be seen by a clinician, but if the triage service has questions or concerns about the seriousness of the problem, MIT Medical clinicians in internal medicine and pediatrics will be on call.

patientwb: Aren't the cutbacks really driven by edicts from MIT to save money to compensate for endowment losses?

Bill Kettyle: Hello -- In addition to decreasing overnight, on-site staffing, our proposal involves increasing community care services -- increasing the availability of care management and nursing care while at the same time rebalancing the deployment of our staff. There will indeed be some fiscal savings, but the most important drivers are staffing to meet the clinical needs of our community. Utilization of overnight services -- both the Inpatient Unit and Urgent Care -- during the night is quite low and the resources we use during those hours could be more effectively used during daytime hours. Please see our background data at: http://medweb.mit.edu/about/news/article/community-care-background-100304.html. In fact, during the proposed transition period, we will increase our spending!

[Pre-submitted question]: I am a student. I have experienced my friends getting drunk to a state where I had to call Medical, and I did it as friends would do because I knew they would be helped without their parents ever finding out. Now, with the new policy, when my friend is in need, I would have to think twice before calling and decide whether my friend is in a fatal state or whether he/she would hate me for putting the incident on his insurance record (same with drugs, as everyone knows some students overdose at MIT). What happens if my non-medical judgment is wrong and tragic consequences result?

Maryanne Kirkbride: Thanks for asking this question. You should know that we have heard from students, staff and faculty alike. We understand that there are two main issues of concern: parental notification and medical expenses. We are actively working with our partner hospital, Mt. Auburn, to identify solutions to each of these. We have also been working closely with student leadership as we have developed our plan and will continue to do so in the coming months.

It is interesting to note that in many (in fact, most) cases of alcohol intoxication, there will be no change in our plan of care. Students (or anyone) sick enough to require any kind of urgent blood tests have always been taken to a hospital during off hours. This has been the standard of care and has worked well for those students who have needed it. Lastly, because our plan is to keep our overnight services open until we are sure that the new system is working, we will have a chance to test everything out.

[Pre-submitted question]: Several years ago I had to come to the 4th floor every 8 hours to receive antibiotic intravenously. How will this service now be handled?

Kris Ruzycki: You will still be able to receive your antibiotics at our Community Care Center, where the Inpatient Unit is presently located at MIT Medical, during the hours that it’s open. We would also look at what antibiotic you were on and whether it was feasible and medically appropriate to place you on another antibiotic that maybe you would only need one or two times per day. If that was not possible, we would help make arrangements for you to receive the third daily dose from another health care provider. Hope that answers your question.

itsme: How much Med Dept budget is being cut? How much will be saved by the closure of the Inpatient Care Unit as we knew it?

Bill Kettyle: After implementation of the proposed plan, the annual decrease in spending will be approximately $1,000,000 or ~2.5%. This is the net of decreased expenses for overnight staffing and increased expenses for daytime staffing to provide enhanced services for our community. These numbers include both the Inpatient Unit changes and the decrease in 11 p.m.-to-7 a.m. Urgent Care staffing.

don: Hi, I am concerned about the loss of urgent care service overnight. We are expecting our first child next month and I am worried about having to go to an ER, with the high co-pay associated with that.

David Diamond: For your delivery, you would of course be speaking with the obstetrician regarding when to go to the hospital, etc. With your newborn, we will have clinicians here until 11 p.m. every day and pediatricians on call around the clock. Advising parents in the middle of the night as to how to assess and care for their children can often can be accomplished by phone advice, but if the child is really sick, then a hospital ER (usually Children's Hospital Boston) is the place to be and that has always been our clinical advice. Best of luck and good wishes for your new family!

[Pre-submitted question]: A few years ago, I had a moderately bad infection and spent two nights in the infirmary to get “high-test” antibiotic treatment. How would that situation be handled under the proposal? Would that involve going to a hospital? (Bad, in my opinion.) Could you give the patient one of those pumps? (Complex, but MIT people can probably handle.) Are oral antibiotics improving to the point they might be used?

Kris Ruzycki: Good question. You would be able to get the IV antibiotic treatment at the Community Care Center during the hours that it’s open. You and your treating physician would also discuss the possibly of changing you to an oral antibiotic if it was medically feasible. Again, if you needed the IV antibiotic more frequently, than we could accommodate you, the nurse care manager would help arrange for you to get service from a facility or company that could supply that service to you.

[Pre-submitted question]: I'm a retiree, and I don't have family members nearby. There are a lot of people at MIT like this -- not just retirees but also students and employees. I've seen many friends hassled to return home after hospitalization or a medical procedure instead of sent to an inpatient rehab. Many insurers appear to believe that everyone has some additional personal support in their home -- spouse, adult child, significant other, etc. That's not true for many of us. When it comes to closing the Inpatient Unit, my biggest concerns are: 1) quality of recovery care, 2) availability of inpatient recovery/rehab care, 3) quality support for in-home recovery.

Maryanne Kirkbride: The first thing I want to clarify is that insurance coverage -- including coverage for inpatient rehab services -- is not changing. As far as your other concerns, while we would no longer have an Inpatient Unit for overnight stays, we would be expanding our team of community care nurse managers, whose primary responsibility is to ensure that our patients have the care and support they need, whether they are in a hospital, at a rehab center, or at home. For example, our team of community care nurse managers can help with arranging home care and working with insurers to find out how these services may be covered.

lupis: An MIT past president had tried to set up a "retirement" residence for MIT people and it was well recognized that the primary attraction was that of being near to MIT medical care. The two most important assets were 24-hour urgent care and the Inpatient Unit. I am surprised that these two are now on the point of disappearing. The small number of people using it does not impress me, as I consider it a valuable insurance. The best outcome of any insurance is one that is not cashed in! I, for one, would be prepared to pay a higher premium. Have you considered raising the premium for these options?

Lucy Walsh: Yes, we thought about that. But while there may some individuals who are willing and able to pay higher premiums, not everyone can afford to do so. Higher premiums may actually cause us to lose membership, and that would possibly result in more cost-cutting. We expect the availability of the nurse case managers to enhance the care coordination for our patients.

pchem4tw: Besides the hour reduction, are there other options being considered to both reduce Medical's costs and provide for students' health needs?

David Diamond: Actually, we are redeploying several nurses from staffing the Inpatient Unit overnight to working throughout the days helping students and our other patients (Health Plan members and retirees) get care in their residence or in a hospital as needed. These care managers will develop new methods of helping including making "house calls" to dorms, doing phone and online follow-up, and working with DSL and Student Support Services to meet the global needs of ill students. We have made numerous other administrative decisions in the last two years to improve efficiency and cost-effectiveness of our care while maintaining or increasing access to services.

[Pre-submitted question]: My main concern about closing urgent care overnight is not in the ability to get care quickly elsewhere, but rather the potential costs to which Traditional MIT Health Plan members might be exposed. If the 20% co-payment applied in this case, it would seem that even an overnight stay at a local hospital could result in a large cost to members on that health plan, who are mostly graduate students and postdocs. The effects of this change at MIT Medical should be clarified for those Traditional Health Plan members that have the co-payment for care outside of MIT Medical.

Lucy Walsh: I want to assure you that costs to patients would not increase under this proposal, because insurance coverage is not changing. However, I'm not sure I understand your question about a “20% co-payment,” because there is no inpatient copay for members of the Traditional or Flexible MIT Health Plans. Students currently have a co-pay for acute hospitalizations ($100, not 20%), if that's what you are asking about, and that would not change under the new proposal.

In the case of a subacute hospitalization, however, no copay will apply. In other words, if a student is admitted to the hospital for something for which he or she would have, in the past, been admitted to the Inpatient Unit, there won't be any copay. Both students and members of the employee health plans currently have a $100 emergency room co-pay, which is waived if the ER visit results in a hospital admission. That would also remain unchanged under the new proposal.

lupis: Have you considered the risk of having someone wait until 7 a.m. when time is indeed important? Especially when it comes to students, they could be very reluctant to go to a hospital instead of MIT.

Bill Kettyle: We do/have/are indeed consider(ed) (ing) the risks and potential for problems related to delays in getting appropriate care. The numbers posted at http://medweb.mit.edu/about/news/article/community-care-background-100304.html indicate that our overnight utilization is quite low and is frequently of the “convenience kind” -- truly emergent needs of high acuity would now, and in the future, be best cared for in an emergency room. Telephone support/advice and transportation to the hospital will be available under our proposed plan.

We think that the enhancement of care and nursing services will be of great benefit for our community. As you suggest, there are some risks in making the changes we propose, but we think they are relatively small and that the potential benefits for our community are great.

patientwb: Isn't this really the tail wagging the dog? Yes, you could make provisions for people needing overnight care, antibiotics, etc. But it sounds like the decision is made and now you are rationalizing it. Am I wrong?

Bill Kettyle: A rational approach to looking at our service model and resource utilization has been ongoing for the past several years, but has been intensified over the past several months. We took and are taking a long, careful, analytic look at the best use of our resources in the context of the needs of our community. We are sharing our proposals and are actively seeking community input. We have received important comments, reactions and suggestions which we will incorporate into our planning. It is not a done deal -- it is a “doing” deal, informed by community reaction and community needs.

lupis: I have stayed at the Inpatient Unit and visited there many friends and colleagues. I also have had friends who died there, surrounded by other friends and colleagues. While they may be well cared for in other hospitals, a feeling of real community will forever be lost.

Maryanne Kirkbride: Thank you for your poignant comment. Unfortunately, the way our community has used the Inpatient Unit has changed rather dramatically over the past few years. Patients who previously may have used our Inpatient Unit as hospice are now choosing to use home hospice services. Colleagues who may have stayed for short periods of time to recuperate from surgery are now able to go directly home, thanks to surgical advances.

Even though we have had an infirmary for many years, health care has changed so much that it is no longer used in the same capacity. Our Community Care Center will be staffed by some of the same nurses who have worked for MIT for years in our Inpatient Unit. We trust that the warm community feel will remain!

itsme: I believe reducing the Medical Dept.'s expenses has been looked at several previous times. Has MIT's senior management given any indication if additional future budget cuts will be expected?

David Diamond: Indications are that MIT senior management does not intend future budget cuts and that there is a strong commitment to the mission of MIT Medical and the services we provide. Our efforts to provide the best care in the most cost-effective manner is appreciated and highly valued.

Adam: It seems like this proposal is planning on ignoring that 3% of the traffic that comes through Urgent Care after 11 p.m. (where telephone triage would not be sufficient) -- but to those 3% of the students, that care is critical. How can MIT Medical justify cutting off these students and forcing them to rely on the often cramped, delayed ER at hospitals such as MGH or Mt. Auburn?

Kris Ruzycki: Adam, Good question. Patients (whether they are students, health plan members or retirees) who are sick enough that they must be seen during the night, more often than not need to be at a hospital where diagnostic testing is available any time of the day or night and specialist, such as surgeons or orthopedists are available to assess and treat the patient. We are working very closely with Mt. Auburn Hospital on processes to ensure that all our patient get the care they need in the most efficient and medically safe manner.

lupis: A teleconference would be much preferable... At least we would hear all the questions and answers and it would save a lot of time. Also, you get much more in a voice than in a written statement...

Kim Schive: This is just one form of outreach. We're also going out into the community and meeting with various groups. If you'd like to set up such a meeting, you can submit that request through the feedback form on the MIT Medical website -- the purple box on the right-hand side of this page.

Adam: Hi Dr. Kettyle, I am wondering what happens to the students that fall into the middle ground when Urgent Care closes after 11 p.m. -- those that aren't in an emergency urgent enough for the ER at MGH, but are sick enough to warrant seeing a doctor. I submitted a question in advance of this chat regarding this experience with my wife, and would love to know how telephone triage would address this issue.

Bill Kettyle: Hello Adam, The overnight numbers for those seeking care are small, but the clinical needs may indeed be significant (see http://medweb.mit.edu/about/news/article/community-care-background-100304.html for some data). Most of the patients we now see during overnight hours are not true emergencies, nor do they actually need to be seen immediately. Under the new proposal, patients who call when Urgent Care is closed would be offered advice and/or next-day appointments.

MIT Medical clinicians in internal medicine, Ob/Gyn, Mental Health and Pediatrics will also be on call if the triage nurse has concerns about how serious a problem is. We are solidifying arrangements with Mt. Auburn Hospital to care for our patients; the MGH emergency room is also available. However, in the case of a true emergency, we would want our patients to go the facility that is nearest to them.

If you have an urgent but not emergency situation during the overnight hours, you would still call the Urgent Care number (617-253-4481). When you call, you'll speak with a triage clinician who will help you assess the situation and offer advice about what to do next. Often, with advice, a problem can be handled at home during the overnight hours and the patient can wait until the next morning to be seen by a clinician, but if the triage service has questions or concerns about the seriousness of the problem, MIT Medical clinicians in internal medicine and pediatrics will be on call. I am not sure I saw your pre-submitted query, but you could send it again on our comment form on the right-hand side of this page? Thanks.

brighton: What is the opinion of the medical staff about this proposed arrangement? The opportunity to return to MIT Medical’s infirmary to recover from flu, surgery, etc., after a hospital admission is greatly valued. What now?

David Diamond: The primary care physicians generally agree that the infirmary has been a very nice option for those who needed a few days of recovery between hospital and home. However, in recent years, the number of people utilizing this service has dwindled, the options for home care and rehab have expanded, and in an era of constrained resources, providing overnight care to a few did not seem the best allocation to support the health care needs of the whole community. Our proposal to provide nurse care managers (3 new positions) to be available to our patients from pre-hospital planning to discharge planning -- including use of our Community Care Center during days and home care as appropriate -- will help fill many of the needs that inpatient residence provides at present. We will work closely with hospital staff to make sure that all our patient's care needs will be well met.

brighton: the hours between 11 p.m. and 7 a.m. are the most difficult hours of the day for people to feel without access to live care. I think the idea of being able to go to your home care/urgent care facility all throughout the night and day is something that is hard to measure. I agree that many problems can be resolved by a telephone call, but there are times when knowing you can go to your campus facility and find someone there is a great comfort to people. What do you do about students/staff working overnight in labs who have an accident? What about someone who just needs to see a welcoming face?

Maryanne Kirkbride: It’s great that you can see how useful the phone can be in helping people get the right care at the right time. The nurses answering our phone at night will be able to quickly identify the seriousness of the concern and help with transportation to a hospital or other care issues. Our regular on-call physician staff (including those in Mental Health) will be available as usual. The nurse can assist in making those connections overnight if MIT-specific questions arise or if support is needed.

patientwb: General comment about this chat: It would be more efficient to have a teleconference (as suggested earlier) than a chat. I have been involved in teleconferences with Fidelity and find there is more throughput. People talk faster than they type. Please consider this. Thank you.

Kim Schive: Thanks for your feedback. We're looking at all options for the future. I agree this is somewhat unwieldy.

patientwb: Moderator, my question seems to have been lost. Let me try again: Isn't this “cutback” being driven by an edict from MIT to save money to compensate for losses in the endowment?

Bill Kettyle: The Medical Department, along with the rest of the Institute, has experienced a reduction in funding. We have for several years been looking at our care model and resource utilization. The imbalance of resource utilization presents, we think, an opportunity to augment services in some areas while reducing staffing in areas of decreased utilization. Please look at the data in the our background article of March 4.

The endowment losses, and more importantly, the economy in general, have enhanced the need to look carefully at our resource deployment. We can, I think, improve care for many with the changes we proposed -- we will be spending more to provide care management and outpatient care services -- these are needs that are growing and for which we feel the realignment of resources is not only appropriate but needed.

brighton: As I have said in previous emails about this topic, there is a difference is automating services in the Registrar’s Office, the Admissions Office, the Student Financial Services office, etc., and doing so in the Medical Department. Some expenditures cannot and perhaps should not be measured by the bottom line, but rather on the contribution to the wellbeing, both physically and mentally, they make to the population. You can work very hard with Mt. Auburn to make MIT feel special there, but it is not the same as having people employed by the place the care is coming from.

Maryanne Kirkbride: We know there are people in our community who feel as you do. Unfortunately, we are living at the intersection of a profound and sustained decrease in the numbers of people who need inpatient care and a profound and sustained increase in the numbers of people who use our day services for newly developed IV medications and other outpatient treatments. We feel will be able to provide much more “special” care by assisting every hospitalized patient as they transition home than we would be by providing hospital level care to the 1+ person per day we have been seeing as inpatients.

Adam: In my opinion, if the community and staff feel that Urgent Care is not available during certain times of the day, the psychological harm will cost MIT Medical and the community further damage. Knowing that after 11p.m. I can just go to Mt. Auburn or MGH, and that MIT Medical is not available to me, why bother using Urgent Care during the day either? The beauty of Urgent Care has been the knowledge that in any situation aside from truly 911 type emergencies, I can be seen face-to-face with a nurse or doctor at any time of the day at MIT Medical. With a late-night case of food poisoning, I know I can go and get medication and an IV to help me feel better.

But knowing I will have to rely on a telephone triage would make myself, and many of my colleagues, more likely to stop using the Urgent Care service all together. In my opinion, this aspect of the proposal will ultimately do more harm than good. Essentially, the fact of knowing that Urgent Care is always available makes me feel more comfortable using the service. If this proposal goes through, I will sincerely miss the ability to get personalized care by the wonderful staff at MIT Medical. It is something that MIT should be proud to support, not marginalize.

David Diamond: We are happy you appreciate the care we provide at MIT Medical. Between midnight and 7 a.m. very few patients are being seen here [1-2% of Urgent Care visits], and some who do come during those hours could easily have come or called a bit earlier or later for appropriate on-site care. We are working hard to provide personalized and seamless clinical services for those needing to be cared for overnight. To this end, we’re working closely with our hospital colleagues and are hiring three MIT Medical nurse care managers to help provide high-quality and integrated care.

Adam: My previous question, as requested, which has partly been addressed thus far, has not calmed my concerns about how it will harm the opinion of the community regarding how MIT Medical cares about the community as a whole. In my opinion, closing Urgent care between 11 p.m. and 7 a.m. will be a terrible mistake for the health of the MIT community.

My wife, a healthy, active 25-year-old graduate student, has had a series of unfortunate, unrelated health emergencies over the past six months (gallstones and gallbladder removal, an emergency appendectomy, retinopathy, painful ovarian cysts, digestive issues resulting from aforementioned surgeries) -- ALL of which were swiftly and well taken care of because of the amazing, swift, and wonderful care given to her by Urgent Care at MIT Medical. ALL of her emergency visits started there, ALL after 11 p.m. The pre-emptive care given to her before transferring her to MGH emergency (where surgeries and CT scans took place), we believe, helped reduce her pain, increase her comfort, and promote her healing, much faster and better than if we had gone directly to the busy and crowded ER at MGH or Mt. Auburn, where she would have waited, likely for HOURS, to be seen and to receive any initial treatment.

Just because the majority of Urgent Care visits do not occur after 11 p.m. does not mean it is not extremely important and worth the extra cost to keep it available. My wife and I are not the only ones with this experience or sentiment. To quote Dr. Kettyle, “these closings do not appear to have had a large impact on the community” based on the summer 2009 term, is a GRAVE mistake -- many of my colleagues wound up directly in the MGH ER without the availability of the MIT Urgent Care system after 11 p.m. -- and furthermore, most students are off-campus during the summer months, poorly reflecting the necessity of the MIT Urgent Care to be open 24 hrs during the normal school term. Closing Urgent Care between these hours would be a tragedy, especially regarding the safety and well-being of the MIT student/staff community as a whole, and if it is closed, where will the students be able to turn in case of these emergencies? Will they now need to rely on 911 and the packed ER at MGH after 11 p.m.?

Urgent Care was able to administer pain relief, antinausea medicine, and the simple care of a calm concerned nurse to my wife. This is not something available at most ERs and MIT should pride itself on its ability to provide such care to its community. Does the current proposal really believe that a telephone triage system will be the most effective way to address serious medical concerns?

Bill Kettyle: While I’m glad to hear we have been of service to you and your wife, I also want to be absolutely sure that we are providing the best care we can for our community with the resources available. Your comments about the summer of 2009 experience are of concern to me. We carefully looked at our claims data for that period of time -- all the bills should be in and I think virtually all the visits would have been billed to insurance -- we did not see any appreciable change in hospital billings or emergency room charges.

ER waits are long and uncomfortable. Mount Auburn Hospital ER is less busy and we are working on a modified "fast-lane" for MIT folks -- the devil is in the details. The enhancement of care management and outpatient services will, we feel, enhance the care package we offer. I can understand your concerns and appreciate your presentation of these important points.

patientwb: My opinion of this chat: People seem to be saying “but ... but... but...” and the MIT Medical people are saying “not to worry.” Same old sorry excuses for cutting back from MIT Medical! Sounds like their minds are made up. At least that’s how it seems from this end.

Maryanne Kirkbride: You are right that we are enthusiastic about our proposal. We are moving forward to explore the concerns that have been raised. This isn't a blanket “cutback!” We are, in fact, increasing the services that have risen in demand, as the need for inpatient services has dropped off. We will be running the new system in parallel for a while and will be able to make sure everything is working well.

Kim Schive: I think that's it for tonight. Thanks so much coming, and thanks for your patience with this technology. We'll post a transcript in the next few days -- both for this chat and the one tomorrow at noon. Good night!

*This news story has not been updated since the date shown. Information contained in this story may be outdated. For current information about MIT Medical’s services, please see relevant areas of the MIT Medical website.