Kavita Bhavan, MD, MHS is associate professor of infectious diseases at the University of Texas Southwestern Medical Center and chief innovation officer at Parkland Health & Hospital System in Dallas, TX.
This interview was conducted by Vikas Chowdhry, MS, MBA, chief analytics and information officer of Parkland Center for Clinical Innovations in Dallas, TX.
Describe how your career led you to become a chief innovation officer.
I started out as a graduate student in public health at Johns Hopkins and then pursued my MD at Penn State. After completing my residency training in Internal Medicine at Ochsner, I chose infectious diseases, at Washington University, as a subspecialty because it is an area where public health and medicine naturally interface. I joined the faculty at UTSW in 2009, working in an HIV clinic at Parkland.
Shortly after joining the faculty here, I was asked to work in a smaller capacity with a great team of pharmacists on ways in which we could improve delivery of care for uninsured patients that require long courses of IV antibiotics in the outpatient setting. The existing disparity between this group of patients and those with adequate insurance was that they could not access standard forms of outpatient therapy, such as infusion centers, home health services, or skilled nursing facilities.
Prolonged inpatient care is difficult for an individual patient since it limits their ability to return to work or care for family at home. It also impacts the safety net system, where many patients may be waiting to be admitted in the ER. We innovate in this kind of an environment out of necessity and can only succeed when we are given space to rethink care delivery with support from leadership and key input from frontline providers.
What does innovation in healthcare space mean to you?
Innovation in healthcare can present itself in a various forms. While many people associate technology with innovation, I’ve been increasingly interested in thinking about another aspect — low-tech, low-cost approaches to patient-centered innovation to address disparities and improve health equity. The most natural place to start seems to be effectively engaging patients in care processes to reconfigure existing resources to improve high-value care.
What does that mean? In healthcare, we often talk about empowering nurses, social workers, and physicians to practice at the top of their license. What does top of the license for patients look like? Innovation in healthcare includes co-designing care with patients to improve access and address other existing problems. Better clinical outcomes can be achieved with such co-production of care.
There is a shift that occurs when a patient is providing care for themselves at home, as in our home IV antibiotic program. They move from being a passive recipient of care in the hospital to being an active participant in their care at home. We have observed better clinical outcomes over the years while also seeing enhanced engagement and management of one’s health, including other chronic diseases such as diabetes.
Innovation is usually thought of as synonymous with technology. While technology is important, we need to make room for another model of innovation that is even cheaper and easier – recognizing human potential.
How does engagement that goes deeper than “use this app to check your lab results” or “use this device to report your steps” work in practice?
Our self-administered outpatient antimicrobial program at Parkland has become a new standard of care for our patient population and is an example of effective patient engagement. Typically, patients with infections that require long-term antibiotics receive intensive diagnostic and therapeutic services in the first several hospital days. Afterward, they remain in the hospital only to receive antimicrobial infusions.
Insured patients may be discharged early to complete their antimicrobial courses at home with contracted nursing assistance or in lower-cost nursing facilities, but uninsured patients usually remain in the hospital because they cannot afford a healthcare-administered outpatient parenteral antimicrobial therapy (H-OPAT, overseen by the healthcare system).
Those uninsured patients have limited options and may be confined to the hospital, which prevents them from resuming work or other activities of daily living or caring for family members at home. In the safety net hospital setting, this can be a challenge in terms of capacity and the ability to care for other patients, in the ER for example, as a sub-optimal use of resources such as beds.
We approached this problem by piloting our program with a few patients in 2009 with the goal to teach and train the method of self-administrated IV antibiotic therapy by gravity at home. We started the program with minimal resources as patients did not have a home visit or access to home health nurse, infusion center, or devices such as pumps / elastomeric balls (S-OPAT, overseen by the patient themselves).
We began with four patients as a proof of concept and have now cared for more than 4,000 patients through this program. Along the way, our multidisciplinary team listened and learned from our patients what works and what doesn’t work to further refine the process.
We translated education material to appropriate levels of health literacy for our population, achieving a fourth-grade literacy level in English and Spanish and including pictures. After a few years, we moved to an audiovisual process where patients can scan a QR code on the back of an IV bag and be sent to a teaching video on their smart phone where they can watch the process and review all of the steps for infusion at their own pace. This has been effective not only for patients who speak other languages, but also for those who prefer visual learning.
We developed a competency checklist, and using the teach-back method, had patients demonstrate all of the steps of infusion and PICC line care needed to ensure safe discharge from hospital to home.
After the first four years of operation, we tracked clinical outcomes for our S-OPAT patients compared to patients with insurance who left our hospital for healthcare-associated OPAT such as home health or skilled nursing facilities. We were surprised to find that our S-OPAT patients had a 47% lower 30-day readmission rate along with higher patient satisfaction.
How is that possible? When we talked to our patients on return visits, we found they mastered all of the steps and took ownership of the process. It was clear they were more invested with effective engagement. One patient actually said she thought she did better because “it is my own body” versus a nurse coming out to the home to perform a job. We began to appreciate the positive impact of patient engagement with meaningful results.
How do you scale the program?
One of the interesting aspects of this program was that after learning about the success of self-administration, other patients who were insured with access to healthcare-administered therapy wanted to participate in our self-administration process. I have since learned from others that this may fit a model of disruptive innovation. You create something that is useful for a small section, usually a bottom tier of your consumers, that eventually becomes attractive to the broader market. However, unlike a consumer market, adoption by the broader market is determined by a lot of other factors, including existing health policy, reimbursements, etc.
There has been other interest in promoting patient engagement as seen by the recent CMS position on encouraging at-home dialysis. The proposed ESRD Treatment Choices model will give patients an ability to choose at-home dialysis, which may potentially improve satisfaction, lower costs, and improve outcomes.
Could your work have been done at other institutions?
UTSW and Parkland’s partnership is unique because we are committed to caring for a large population of uninsured or underinsured patients with health disparities. Innovation centers attached to larger health systems may have greater investment in technology-based innovation. Our approach has been more patient centered. Our CEO, Fred Cerise, MD, MPH, described another way of looking at innovation that does not need to be driven by profit in his Harvard Business Review article a few years ago
We are likely in the minority coming from a safety net hospital in the larger healthcare innovation space, but there is a need to grow across the country since safety net settings innovate out of necessity.
What’s the most impactful book you have read in the last 12 months?
“The Moment of Lift” by Melinda Gates. She articulates the value of inclusiveness and educating and empowering women to fully recognize our collective potential as a society. There are examples of how impactful this can be around the world and here in the United States.
How do you remain optimistic as a physician when working with a population whose inequities and social disparities are root causes that you can’t address?
The problems are far reaching and there is no simple solution. We are increasingly aware that social determinants affect health and outcomes. Just because we cannot do everything to solve these problems does not mean we cannot do something, to do some small part to help address a given problem to improve the status quo.
I’m lucky to work in an environment where I and many others have the opportunity to make some small difference as we strive to improve patient care.