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Transcript from May 5 online chat on community care proposal

May 7, 2010

Following is a transcript of an online chat held May 5, 2010, about MIT Medical's proposed community care model. The transcript from the May 4 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 today. You can submit a question or comment at any time, starting right now. 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. We're still waiting for a couple panelists to join us; but I'll introduce the people we have with us at this point. First, we have David Diamond, M.D., our associate medical director; care manager Kim Carroll, B.S.N., R.N.; and Lucy Walsh, manager of the MIT Health Plans, who can respond to questions about insurance coverage. We're waiting for Medical Director William Kettyle, who is still seeing patients. We're working on a few answers now, but please submit any questions you have now.

acw: I'd like to ask Kim Carroll what specifically you do now as a nurse care manager -- is it hands-on patient care, or mostly phone calls and stuff? Is this going to be the same thing as what the staff in the future Community Care Center will be doing, or something different?

Kim Carroll: My role as care manager involves contact with patients, family members and outside resources in the form of phone calls, e-mails, and appointments -- both planned and walk-in -- as well as direct contact in regard to discharge planning while the patient is on the Inpatient Unit. I have continued to work per diem on the Inpatient Unit and delivered direct patient care in the form of assessments, IVs, wound care, and any other form of direct patient care as an RN. The new Care Manager role will incorporate all of these features and actually involve more community outreach especially as it relates to MIT student needs.

Kris Ruzycki [chief of nursing services and director of student health services]: Hello everyone.

[Pre-submitted question]: I have a question and concern as an MIT Medical subscriber who lives in a nearby community: I would like to have a better sense of the recommendations for what to do in case I'm at home and believe I need urgent care. As I live alone and am over 60, this is a concern I think about from time to time but really don't know the answer (besides dial 911!).

David Diamond: If it's a true medical emergency, dialing 911 is absolutely the right thing to do! Otherwise, you can call Urgent Care at 617-253-4481 for advice on what to do next. Under our proposal, patients who call that number when Urgent Care is closed during overnight hours would be given advice by on-call nurses on what to do next. If the phone triage nurse has questions or concerns about how best to manage the problem, MIT Medical physicians will be on call and will be contacted to further advise.

Kim Schive: Dr. Kettyle has arrived and is signing in now.

Bill Kettyle: Hello -- I have indeed arrived! Sorry for my tardiness!

Julia: Hi, my question is where students who need Urgent Care between 11 p.m. and 7 a.m. should go if MIT Medical is closed, especially those without cars.

Kris Ruzycki: Hello, Julia -- good question. The student should call the MIT Medical number as usual ( 617-253-4481) and they will be to prompted to press a number for help from a triage RN. The RN will ask them a few questions and then will instruct them what to do should they need to go to a hospital. We will have an agreement with a local taxi company that will be able to transport them to the hospital from the campus and take them back to the campus after they have been evaluated and treated at the hospital. If they are too ill for a taxi then an ambulance transport will be needed and the triage nurse will help facilitate that.

[Pre-submitted question]: I'm still a little confused how an emergency scenario would play out overnight. The proposal mentions that care is “available” 24/7, but does that mean the MIT Medical facility will have staff on site, or just available by telephone for advice and referral?

Kim Carroll: Some things would not change at all. Currently, if one of our patients experiences a true medical emergency during the overnight hours, we tell them to call 911, not 253-4481. And if a patient comes into MIT Medical during the overnight hours with a serious problem now, they are sent to a hospital emergency room. Under the new proposal, that’s the same advice these patients would receive if they called during the hours Urgent Care is closed. 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 the Urgent Care Service is closed would be offered advice and/or next-day appointments. MIT Medical clinicians in internal medicine and pediatrics will also be on call if the triage nurse has concerns about how serious a problem is.

student: First of all, I’d like to say that I'm irritated that this chat wasn't sent out to the student body.

Kim Schive: We publicized it through the MIT homepage; we also sent out postcards about 10 days ago to all campus addresses. Unfortunately, we don't have email addresses to do a mailing specifically to undergrads, but we did try to get the word out.

student: I'm sure that people would like to have known about it.

Kim Schive: We're also going out into the community to meet with groups in person, so if you'd like to have us set something like that up for a student group, just submit your request using the comment form on the right-hand side of this page (the purple box).

dherring: Follow-up Q: Both times we visited urgent care, it was after phone conversations were unable to resolve the issue. Experienced eyes were needed to look at the {burn, rash}. Since urgent care was “in house,” we felt comfortable visiting, but we may not have made the journey to the children's hospital or another facility if that had been the only option.

David Diamond: We will continue to have Urgent Care open 16 hours a day, seven days a week. It is true that eyes on the patient is often needed, and we will have clinicians here to do that most of the time. It is just between 11 p.m. and 7 a.m., when very few patients come our way, that referral to hospital ER may be needed to have such direct care. Most patients who call at night are sick enough that they are already being directed to nearest emergency rooms already. If it is clear that the problem is not an emergency and that waiting a few hours to be seen would not be a risk, we will make sure to accommodate such patients first thing in the morning.

dherring: Literature states that “not many” people will be affected by closing the overnight urgent care. My family has used it twice, and both times there were others being treated as well. Could you tell us how many visits Urgent Care gets per year?

Bill Kettyle: Hello -- the detailed statistics are at the URL below. Basically, in 2009 we saw about 17,000 visits in Urgent Care; about 460 occurred between midnight and 7 a.m. Most of the nocturnal visits were discharged to home and we think that many of these visits could have/might have been able to be seen later in the day when staffing and services are more robust. Some of these visits (see chart at URL below) were sent to the emergency room. During the H1N1 season this past fall, we had a significant uptick in Urgent Care visits, to about 80 a day up from about 40 per day, and we staffed for the rise and will plan to do the same in the future. Clearly, the numbers are only part of the story -- ensuring access to care both day and night is the key and our consistent goal.

[Pre-submitted question]: Just wondering why the census has decreased so dramatically? I would think the post-op care and hospice care would have remained the same, to say nothing about the traditional sick patients.

David Diamond: There are several reasons we think the census has drifted down over the last several years. More and more medical care has become technology-based, and [therefore] complicated, hospital-based resources beyond what we have in our infirmary is more appropriate. On the other hand, some conditions previously needing hospital care can be managed as outpatients with newer oral medications or less frequent IV infusions.

In addition, there are now more community-based resources such as visiting nurses, home based and residential hospice care, and out patient rehab centers available. The net effect is that demand for overnight care in our unit is down. At the same time, daytime use is up: for infusions, wound care, vaccination clinics, etc. So we feel redeploying our staffing resources towards our patient needs makes sense.

eob: I have a question as an MIT Medical subscriber. It is my understanding that care provided at MIT Medical is covered at no cost under my student insurance plan, but I must pay fees for care provided elsewhere. Does this mean if I get hurt and need care at 2 a.m., under this plan I would have to pay additional fees on top of my insurance fees?

Lucy Walsh: Any time you go to an outside provider, you most likely will have some out-of-pocket costs, if you are covered under the Student Extended Insurance Plan. An emergency room visit, for example, has a $100 copayment. So, yes, if you go to the emergency room -- at 2 a.m. or 2 in the afternoon -- you will have a $100 copay.

But if you call the Urgent Care number, 617-253-4481, at 2 a.m., they will help you decide if you need the emergency room or if your condition can wait until the morning. Many of the calls we get now at 2 a.m. are directed to the emergency room. But we are also working with Mt. Auburn Hospital for access to non-emergency services during the night at no additional cost to students. And the on-call nurses will advise you if that if the appropriate place for you to be seen.

[Pre-submitted question]: Why is it that during a time when we're supposedly expanding health care options in the U.S., MIT who prides itself on care is considering closing down the inpatient care unit, taking away options?

Kris Ruzycki: Closing the overnight stay in the Inpatient Unit will allow us to redeploy clinical resources during the hours when they are most needed and utilized. Our census in the Inpatient Unit over the last several years has steadily declined; on average we have only 1-2 patients in the unit, but we still need to maintain the same staffing 24 hours per day, seven days per week.

By redeploying those clinical resources, we are in fact able to offer more clinical support to more people between the hours of 7 a.m. and 11 p.m. Also, we are working with our hospital partners, such as Mt. Auburn Hospital, on ways of them helping us meet some of the less acute problems that students may develop over night when we are closed. More information on all of that will be shared as the plans become more developed and refined.

staffp1: Given that I live away from Cambridge, closer to Newton-Wellesley hospital, if I had an urgent care need, could I go directly to that hospital, or would I still have to come all the way in to Mt. Auburn?

Lucy Walsh: You do not have to come in to Mt. Auburn Hospital, as long as you go to a hospital that is part of your insurance plan. If you have one of our MIT Plans, you can go to Newton-Wellesley Hospital for emergency care. Keep in mind that you will have an emergency room copay. If you are not sure if you need to go to the emergency room, you should call our Urgent Care Department to speak to one of the on-call nurses. If your condition is less urgent you may want to wait until the morning and come into MIT Medical, but the on-call nurses can help assess your needs.

student: Second, what about if people don't have the time outside of class or work to go to MIT Medical during its regular hours?

Bill Kettyle: Hello -- under the proposed changes, our hours of operation for Urgent Care will cover approximately 16 hours per day, from 7 a.m. until 11 p.m., seven days a week. Hopefully, that span of care availability will provide an opportunity for any and all needing care. Labs and class are not supposed to be happening between 5 p.m. and 7 p.m. I realize that life and the flow of work and play activities in our community may not conform to the “traditional” 9-to-5 school/work world, but 16 hours a day should, we think, provide the needed availability.

Jim_Kirtley: This may have been answered last evening, in which case I apologize for repeating. I am wondering what will be done with patients who would ordinarily be treated in the infirmary, such as my case when I was put on “high test” (IV) antibiotics to clear up an infection. Will they be sent to the hospital? Or are there other treatment means that can be used?

Kris Ruzycki: Jim, You will still be able to come into the medical department during the day to receive the antibiotics. If you need doses given during hours that we are not open, then the nurse care manager will work with you on arrangements to get those doses at another facility or at home. Of course, if your physician feels that you can be switched to another IV antibiotic that you could receive either once or twice per day and still get the same therapeutic effect, that would be an option and you could continue to receive all doses at medical or when medically appropriate be switched to an oral antibiotic. Hope that answers your question and concerns.

nothappy: I think that this new plan is a terrible idea. Having an overnight on-campus facility lowers the bar for people to come to get something that doesn't seem that serious to get checked out. MIT students are bound to put emergency care off due to exams and other activities, and some things just don't happen in business hours.

Last January I went to Urgent Care at 3 a.m. because I felt too sick to sleep after throwing up. I felt bad enough to not sleep but didn't think I needed an ER. The phone advice I had gotten before coming in was totally wrong! What MIT Medical did that made the difference for me was they took some blood. I didn't have a fever and didn't really seem or feel sick except for a weird pain. In the morning I was let go and told to come back if the location of the pain changed. It did, but it also got a lot weaker. Had I not gotten the advice to come back, I would have just ignored it. I had appendicitis!

David Diamond: We are very aware of the importance of have a low barrier to care and the importance of close follow-up. Under the proposed model, we will have nurse care managers closely following up on all phone calls and visits. In your example of appendicitis, you would be advised as to what symptoms to look out for, and if in doubt you would be advised to go to the emergency room (in a dispatched MIT ambulance if appropriate) where blood work, surgical evaluation, and, if needed, a CT scan to confirm the diagnosis would all be available at 3 a.m. We feel that we maybe actually less likely to miss an appendicitis case by having the resources of the hospital available than in our current mode of limited on-site services in the middle of the night.

nothappy: Also, I'd never been to a hospital before, and wouldn't have thought I needed one. I felt like a fraud in the ER when I eventually was sent there 12 hours later because my symptoms lessened drastically during the day (and my white blood count was lower the second time it was measured).

David Diamond: If we advise you to go to a hospital, we will also call the hospital so that they know you are on the way and what we are worried about. Hopefully, you will not get a feeling that you are a “fraud.” We will monitor carefully how our patients are treated and we have close working relationships with our hospital colleagues so that we can feedback any issues in this regard.

staffp1: re. what the person asked about paying add'l insurance fees for hospital (or emergency room) visits -- you responded $100 for students. What about staff on the MIT Traditional plan?

Lucy Walsh: Students and Traditional/Flexible Health Plan members have a $100 emergency room copayment.

dherring: Umm... Is this chat or email? This is terribly slow.

Kim Schive: It's very slow chat. We're looking into other options for the future, but this is what we have for now. The other issue is that some of these questions are quite complex, and don't lend themselves to quick answers.

dherring: I didn't mean the server (which isn't impressive -- I can suggest better for free) but rather the conversation.

Kim Schive: Yes, the complexity of the questions is an issue, and the panelists are trying to give thoughtful answers. It is slow, I agree, but we appreciate your patience.

dherring: Rather than implement a “Community Care” center (which still sounds like a medical concierge service diverting resources to the older population), why are we not increasing funds to hire more pediatricians and general practitioners? It seems they are always too full.

Bill Kettyle: The Community Care Center (CCC) will serve the entire community. Indeed, we will be providing services for our “older population,” but many of the Community Care Center activities will enhance care for students and members of our health plans. Intravenous fluids, antibiotic administration and wound care are required by folks of all ages.

We will continue our current pediatric services and the proposed changes will provide support for our primary care clinical activities and will, because of related changes in coverage requirements, increase the availability with our current clinical staffing. The CCC will enhance the flow of care for our patients and our clinicians. Good question.

Jim_Kirtley: Have you given any thought to the impact of closing the Inpatient Unit on faculty recruitment and retention?

David Diamond: We have heard that having comprehensive and excellent health care services right on campus is a big plus for faculty. In fact about 70% of current faculty do choose the MIT Health Plan for their medical care. We do provide many services in E23, but we also refer out a lot of specialized care to the most expert clinical resources in our area. Middle-of-the-night emergency evaluations and hospital based care for acute illnesses are parts of medical care that can be done more expertly at facilities designed for such care.

That leaves us with the resources and focus to integrate that care into a longitudinal plan that is convenient and effective. The net result: our patients will continue to get the most convenient and most expert care as appropriate to their needs, and that will be appreciated by current and prospective faculty.

staffp1: re your answer to going to Newton-Wellesley at night, what if it's something like a bladder infection that just needs an antibiotic (IMMEDIATELY) but is not an emergency room type of thing? This has happened to me, and believe me it required IMMEDIATE attention! i.e. can't wait till morning!

Kris Ruzycki: Hi staffp1. Most often something like a urinary tract infection, although can be painful, is not an emergency and waiting a couple of hours to see a clinician is not going to make much difference. But if you are in that much discomfort and the triage nurse recommends you seek care then and not wait, then yes you would have to go to an emergency room. Another option would be for the triage nurse to consult with the physician on call to see if prescribing an antibiotic over the phone would be appropriate

Jim_Kirtley While speaking of physician skills, are you likely to hire another endocrinologist?

David Diamond: No plans to do that presently We now have three endocrinologists on staff and our wait for new appointments is much less than in years past when access had been a problem -- and we always make accommodations for urgent consults as needed.

Jim_Kirtley: Indeed, you guys at the Medical Department are a big plus for those of us who work here. I don't want to give the wrong impression. But I am of the impression that the presence of an overnight care facility is also a big plus. I won't share in the forum the couple of stories I have about the difference between Mt. Auburn and your facility, but yours is a LOT more pleasant. (No answer required to this comment.)

student: Wouldn't having to go to the emergency room defeat the whole purpose of the free basic health care that MIT offers? 100 dollars is a lot of money for a student, especially a student who is from an extremely low-income background. Say the student sprained his/her ankle. It's not quite an emergency room injury (esp. not with $100 copay) and if this happened in the middle of the night, what would the student do?

Lucy Walsh: As we have discussed many of the visits to Urgent Care overnight now are not true emergencies and can safely wait until the next morning. For those situations that are true emergencies, even if the student came to our Urgent Care now, they would likely be referred to the emergency room. Going forward we are working with Mt. Auburn to handle non-emergent but urgent visits overnight, at no additional costs to the students. You should call the Urgent Care line to get advice from the on-call nurses.

staffp1: I second Jim's comment about how special the overnight unit is! I'm really bummed that you're doing this!

Alice: So what precisely will become of the Inpatient Unit?

Kim Carroll: The Inpatient Unit will be utilized in the same manner it is now for IV administration, wound care, and other nursing care that is needed. We will continue transient care of patients who are ill and may need a stay up to 12 hours. The care managers will be staffing the unit and providing this direct care and also continuing follow care of patients via phone contact and possible student visits.

Alice: Thank you, Kim.

yves: I will also agree that I am NOT in favor of closing the Inpatient Unit. I have had to use it in the past (bad fall off my bike, 2 broken elbows), and I cannot emphasize enough how beneficial it was to have the Inpatient Unit available; I was able to have people help me with mundane tasks like eating and getting dressed up, all the while being on campus and therefore capable of going to class and/or have meetings in the inpatient room.

Bill Kettyle: I’m glad we could be of help and indeed the situation you describe has traditionally been one of our most important roles. Utilization has declined significantly and we are at minimum staffing levels. We would like to rebalance our resource deployment-- hence our proposal. We are working on solidifying a relationship with Mount Auburn Hospital and another possible venue that would provide the type of sub-acute care you needed and from which you benefited.

I know that Mount Auburn is not on campus, but it is not far and is served by the T-- two Red Line stops and a short bus ride. In addition, our Community Care Center would be able to play a role in providing the type of care you required. The details, which are hugely important, are being worked out. Good issues... thanks.

staffp1: So I would have to pay $100 to go to the emergency room just to be given an antibiotic for my UTI? That's crazy! And no, when this happens, one cannot wait even 2 hours!! You literally have to sit on the toilet all night -- how would one get any sleep?? Have any of you ever had a UTI (which should not be considered an emergency room sort of thing, let alone pay $100 for)?

Kris Ruzycki: staffp 1, Unfortunately if you go to an ER you would have to pay whatever your copay was, unless you are admitted into the hospital. There maybe other options for people who may have recurrent infections, such as a urinary tract infection, that they could discuss with their physician. Or as I said in my other response, the physician on call may elect to prescribe medication over the phone.

Kim Schive: We're finishing up the questions in the queue, and then we'll be shutting down the room. A transcript will be available in the next few days. If you have questions that we didn't answer here, please use the comment/question form on the right-hand side of this page (the purple box).

Alice: I hope that the nurse care managers that you choose will be as diligent and caring as Kim. Also, teamwork will be essential.

rs: Will there be any reimbursement program for off-hour emergency room care until Mt. Auburn Hospital (or others) will handle the “less acute” problems that should still be treated in a timely fashion after hours? It sounds like such care options are still in the formative stages.

Lucy Walsh: Under the current proposal, our Urgent Care service will remain open during the night until the end of the year. This time allows us to finalize these plans to make sure all services are in place.

staffp1: what about STAFF?? You keep referring to the students' needs. What about working with Mt. Auburn (or other closer hospitals nearer to where staff people live (usually away from Cambridge) -- are you also arranging for middle-of-night urgent care (rather than emergency room $100 visit) visits that won't cost STAFF people as well (esp. since some staff don't make a whole lot of money, or are working less than full time)?

Lucy Walsh: We are focusing on students because they have fewer options, and they are the ones who come in to Urgent Care now with subacute conditions. The vast majority of staff who call or come into Urgent Care during the night truly need to go to the emergency room.

Andy: I'm a visitor/guest speaker here and was impressed by how many clinicians you have on staff. I'm curious, do you have any allied health clinicians such as acupuncturists/herbalists? If not, could this ever be likely?

David Diamond: Thank you for your comment. We do not have those particular clinicians on staff presently. Our Center for Health Promotion and Wellness is a clearinghouse for information on complementary care approaches and helps direct patients who want to add these modalities to their care plan. Most of our clinician are open to helping patients integrate allied health care into a comprehensive and effective approach to their problems.

nothappy: I know that the people who come in to Urgent Care each night is very small, but how is the severity of the condition, the eventual outcome of each individual case and the importance of seeing the person at that time (between 11 and 7) weighted with respect to that small number?

Bill Kettyle: We have worked with a very efficient and clinically excellent triage service. Experienced, trained nurses will field phone calls and provide advice based on protocols and telephonic medicine standards. The advice may be to arrange a visit later in the AM, go to the emergency room or talk with the physician on call. The calls will be logged and care needs will be followed up by our Community Care Center staff.

About 10% of our nocturnal visits require emergency room care -- a decision that can often be made on the basis of a phone conversation. Advice and care will be available around the clock. The proposed changes will augment care in several important areas and we think we can meet our community's needs with the proposed changes. Good question -- thanks.

Kim Schive: Thanks for coming to this chat. We've finished drafting answers to all the questions in the queue, so we'll be shutting down the room now. Again, feel free to use the comment/question form for additional questions. Thanks again.



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