By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“No one has ever become poor by giving.”

-Anne Frank

Twenty years ago when I was the Medical Director of Community Health Clinic Ole in Napa, someone I still don’t know placed one hundred $50 gift cards to a grocery store in my home mailbox, with a note, saying that I should distribute them to needy patients of our Health Center. Our outreach team mobilized and distributed them to 50 particularly needy individual patients and families. The same thing happened the following year. The anonymous donor trusted me to make sure that their charity would go to a person who needed it; that person would never know who gave this gift, because even I did not know who it was. The charity was given without the desire or expectation of being recognized publicly, or even privately.

Eight years ago, a retired businessman –who came to the United States from India to build a business selling medical supplies—lent a 17 year old young man from his hometown in India the money to be able to attend UC Davis where he was accepted as an undergraduate aerospace engineering student. The young man’s family was of modest means; they could not afford to send him abroad to be educated. The retired businessman was not related to the family, but he made this high-risk personal loan to help him achieve his dream to be a high-tech engineer, and to support his family in the process. This young man met my daughter and is now my son-in-law.

Around this time of year, many people call local homeless shelters offering to help. Thanksgiving dinner at the Napa homeless shelter was purchased, cooked, and served by the local painters union. They called and volunteered to do this, without being asked.
All of these are examples of the highest level of charity. About 950 years ago, a physician-philosopher named Maimonides identified eight levels of charity. Paraphrasing them in order from highest to lowest:

1. The greatest level: Support a member of your community with a gift, a loan, or helping find employment to strengthen his hand so that he will not need to be dependent on others. This is the charity provided by the Indian businessman.
2. Give to the poor without knowing to whom one gives, and without the recipient knowing from whom he received it. It is given in secret to a trustworthy intermediary. This is the charity of my unknown neighbor, who provided the gift cards for my patients. Leaving a generous tip for the low-income housekeeping staff at a hotel could fit in this category, as well.
3. Give to someone that is known to the donor, but the recipient does not know who gave the gift.
4. Provide a donation when the donor does not know who they are helping, but the recipient does know.
5. Give directly to someone, with both the donor and recipient knowing each other, but the gift is given without being asked. The painters who prepared and served Thanksgiving dinner to the homeless of Napa would fit in one of these three levels (3, 4, or 5); although the donor and recipient could see each other, they did not know each other’s names.
6. Giving to a poor person after being asked.
7. Giving inadequately, but gladly and with a smile.
8. The lowest level of charity is to give unwillingly.

In the progressively lower levels of charity, much of the purpose of the charity is to be seen by others as being charitable (called virtue signaling by psychologists). This charity is still very important, as many U.S. charitable organizations rely on these lower levels to gather donations. In the higher levels, the charity is not intended to improve one’s social capital but rather aims to increase the opportunities of others and positively impact communities.

Here are three takeaways for each of us:

1. Contemplate these eight levels of charity; talk them over with your family and friends.
2. This holiday season think about ways you can give at one of the higher levels.
3. Let humility guide your giving practices. Celebrate those who quietly, give without expecting recognition.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“The only way you can stay on top is to remember to touch bottom and get back to basics.”

-Shane Black (Director, Screenwriter, Actor)

The COVID pandemic has had a number of ripple effects on the health of your patients, beyond the consequences of infection and stress-induced exacerbation of mental health status. Many clinical quality metrics saw plummeting performances in the past two years. For example, the proportion of those with a diagnosis of hypertension whose blood pressure is controlled dropped by over 10%. A major driver is decreased in-office visits where blood pressure is checked, with a relatively small proportion of patients using home BP monitors to follow their own blood pressure. Drops in well-child visits, breast, and cervical cancer screening are other examples.

The summer wave of the delta variant of COVID-19 led to increased infection rates, staffing disruptions, and new vaccination recommendations. It is becoming clear that COVID is so infectious and the level of protection from infection conferred by the initial vaccination series and prior infection is transient, so it will not be disappearing but rather become an endemic disease for the foreseeable future.

With this in mind, it is a good time to remind ourselves of other health issues facing the patients we serve, issues that were often deferred by patients and clinicians in the midst of the waves of pandemic cases. They include core preventive activities, like screening for breast and cervical cancer, use of nicotine products, and misuse of alcohol and other drugs. They include control of chronic conditions like hypertension, diabetes, asthma, and COPD.

In the next couple of months, we encourage you to pause, take a breath, and start to think about how you will re-engage your organization with these important core preventive and chronic disease activities!

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“If you have knowledge, let others light their candles in it.”

-Margaret Fuller,
American Journalist and Women’s Right Advocate

Most organizations that implemented Electronic Medical Record (EMR) systems in the last two decades found that this implementation led to increased clerical workload of clinicians, leading to increased burnout and job dissatisfaction. Additionally, overuse and misuse of templates led to longer but less accurate and less useful clinical notes.

Several primary care organizations in our region added a new position to address these issues like medical scribes, who perform real-time electronic health record documentation, in the exam room (or video call) with the clinician.

A survey of the published literature on medical scribes have shown increased efficiency, clinician productivity and provider experience, while patient experience with scribes is mixed.

Shasta Community Health Center (SCHC) reports that the increased efficiency of scribes leads clinicians to finish their work earlier at the end of the day, with administrative tasks completed which allows them to go home to their families on time. Since first implementing a scribe program over a decade ago, SCHC has refined their model to increase the quality of documentation in the medical record and to drive quality performance in the Primary Care Providers Quality Incentive Program (PCP QIP) measures.

1. Training: SCHC has developed a training curriculum to train promising candidates in medical language, standards of documentation, etc., which is now being adapted to be offered in community college courses.
2. Continuity: a clinician-scribe diad often develops short cuts and non-verbal communication methods to work rapidly as a team to support the patient. This may include sending instant messages to the clinician during the visit, such as ordering preventive screenings.
3. Quality focus: Assigning the scribe responsibility for measures amenable to their intervention, like ordering labs that are due or scheduling well child visits.
4. Incentives: A pilot showed that a small incentive for scribes linked to a single measure worked well, but Shasta CHC is cautious about unintended negative consequences, such as removing intrinsic motivation for improving quality.

This “tip from the field,” was collected by Partnership HealthPlan of California’s (PHC’s) Medical Directors, Dr. Robert Moore and Dr. Jeff Ribordy, at our first trip to Redding in many months. We will be working our way out to visit other counties and providers in the months to come.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Ancient medicine had once had a name for this something present in the living body but missing from the corpse. Spiritus was the breath, the regular, rhythmic breathing of the live body that is so shockingly absent from the dead.”

-Dr. Victoria Sweet, Author and Medical Historian

October is National Lung Health Month, sponsored by the American Lung Association. Why October? Possibly to coincide with the prime season for influenza vaccination.
Here are few ways (besides flu vaccination) primary care clinicians can support our patient’s lungs.

1. Asthma Treatment: Use combination formoterol-corticosteroid inhalers (such as Symbicort or Dulera) instead of albuterol or levalbuterol for short-acting relief of mild to moderate asthma. International and national guidelines and a strong evidence base support this approach.
2. Asthma Misdiagnosis: Be on the lookout for the 10% of patients with a diagnosis of asthma who have other conditions. Order spirometry or pulmonary function tests if the diagnosis is unclear, especially if not responding as expected to usual asthma treatment.
3. COVID: About 20% of patients hospitalized with COVID develop long-term lung damage, causing dyspnea and decreased exercise tolerance. Prevent permanent lung damage caused by COVID by encouraging all eligible patients to be vaccinated, especially pregnant women and teens. Consider use of monoclonal antibodies to treat early COVID infection to prevent it from becoming severe.
4. COPD: Ensure that patients discharged from emergency departments and hospitals for COPD exacerbations receive prescriptions for tapering oral corticosteroids and combination bronchodilators (long acting beta agonists and long acting muscarinic agonists).
5. Action Plans: Ensure that patients with COPD and Asthma have action plans to allow them to self-manage exacerbations.
6. Pneumococcal Vaccination: When giving annual influenza vaccine, co-administer pneumococcal vaccine for those who have not been previously vaccinated. Who are eligible? Adults over age 65, those with immuno-compromising conditions, chronic CSF leak, and those with cochlear implants.
7. Smoking cessation: ask about smoking status, provide counselling to those using tobacco products, and prescribe smoking cessation medications when appropriate.

Although these are core primary care activities, we sometimes are distracted by other clinical issues that come up in our visits. Please pass this along to your clinicians to remind them to think about more than just flu vaccine, this month.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Work is hard. Distractions are plentiful. And time is short.”

-Adam Hochschild (Writer, historian)

The approval of COVID boosters this week, and the expected expansion of vaccination to school aged children in the next 2 months, will lead to a surge in demand for vaccination. Counties, pharmacies, hospitals, and medical providers are planning on how to respond to this demand, which could distract us from something all public health experts agree on: most hospitalizations and deaths are occurring in the unvaccinated. The unvaccinated deserve continued focus and attention.

Additionally, the energy and resources to provide boosters and pediatric vaccinations this fall will distract from other important healthcare needs of the populations we serve: increased levels of depression, substance use and obesity are combined with worsening control of hypertension and diabetes. Children are falling behind on well-child visits and routine childhood vaccinations.

What should be the role of Primary Care Providers (PCPs) in providing boosters and pediatric vaccines, during the fall of 2021? Planning with county stakeholders is key, with each stakeholder asking themselves, “What are YOU best equipped to do, what is MY responsibility, what do we need to do TOGETHER to be successful? What is yours, what is mine, what is ours?”

Yours. Consider directing motivated patients to register for vaccinations at community pharmacies, which are currently providing about 2/3 of vaccinations in the state.

Mine. How can we integrate COVID vaccination in our practices as efficiently as possible to avoid negatively impacting other preventive activities, including efforts to vaccinate those without prior doses of vaccine? Can we vaccinate our patients during regular hours and use the leftover doses at the end of the day to provide non-urgent boosters to those previously vaccinated?

Ours. Work with counties to develop a plan to vaccinate school-aged children rapidly, ideally in the school setting. How can we mobilize volunteers to take the pressure off practicing clinicians?

The work remains hard. The new vaccine policy distractions are plentiful. Although the fall Delta wave is subsiding, time is short before a winter wave begins. Nonetheless, it is worth the time to plan now.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Difficulties mastered are opportunities won.“

-Winston Churchill

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“I have no idea what’s awaiting me, or what will happen when this all ends. For the moment I know this: there are sick people and they need curing.”

-Dr. Bernard Rieux in The Plague, by Albert Camus

August has not been a good month in our PHC counties.

Another summer of massive wildfires and poor air quality.  Another surge of COVID, this time hitting the rural northern counties with particular severity.  For several hospitals, their ICUs and Emergency Departments are full.  Patients are being transferred hundreds of miles south, to hospitals that still have capacity.  Many hospitals report they have no open mammogram or colonoscopy appointments for the rest of the year.

PCP offices are short staffed, as the sheer number of COVID cases leads to illness, but also to quarantines affecting a larger proportion of staff.  Telephone and video visits are on the rise again.  A state requirement that all health care providers require their staff to be vaccinated will lead to additional staffing stress for many of you.  The staff that are able to work are exhausted; you are working so hard to keep them from burning out.

In the midst of all this, we at PHC are impressed with your dedication to take care of your populations, with testing and vaccination efforts both in your offices and in your larger communities.  You are partnering with our public health colleagues, your local hospitals, and with trusted community-based-organizations to respond in an organized, professional and compassionate way to the many simultaneous stresses you are facing.

PHC is here to support you with advocacy and resources to support these efforts.  In the coming weeks we will be offering incentive opportunities for primary care providers to increase the vaccination rate in the PHC population, and to capture vaccination information missing from state registry databases.  In the coming week, PHC will also be offering grants to community organizations in every one of our counties to increase vaccinations among the most vulnerable populations.  We will be making calls, handing out gift cards to members as they get vaccinated, funding local media campaigns, and asking pharmacies to remind their customers of the option of getting vaccinated while picking up their prescriptions.  The September monthly newsletter will have more details.

Balancing Boosters
As the federal government has signaled an intention to approve a booster dose of COVID vaccination for those at least eight months post-vaccination, many of you are worried about this overwhelming your capacity.  Remember, those vaccinated early, especially health care workers, have more agency than more vulnerable patients. Community pharmacies have a large amount of untapped vaccination capacity: where possible, you may want to steer those who know how to make on-line reservations and keep appointments to pharmacies for their boosters, and save your in-office capacity for those who are actually in your offices at the moment, or for specific outreach events.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Don’t accept the world as it is. Dream of what the world could be – and then help make it happen.”

-Peter Tatchell

For the past year, for some reason I have enjoyed playing some Pandemic-related games with my sequestered family. The best is Pandemic Legacy: Season 1, a cooperative game where players work together to save the world from dangerous pathogens, including some that turn people into virtual zombies. It is a long game, taking many days to complete. I’m happy to say that my family saved the world twice, although many people died and some cities were destroyed in the process.

An older computer game (from 2008) called Pandemic 2 takes a different perspective, where you are the microbe and you are trying to kill as many people as possible. Not surprisingly, perhaps, the best way to do well in this game is to know how COVID-19 unfolded, with asymptomatic respiratory spread, followed by mutations that increase infectiousness and subvert the effectiveness of vaccines. This really helps hit home what is currently happening with the Delta variant.

Recent estimates put the R₀ more infectious Delta variant of COVID-19 at six to eight, compared to the R₀ of the original Wuhan strain, which was estimated at 2.7. (Reminder: the R₀ represents the average number of contacts infected by a single infected person.) This translates to 80-90% of the entire population (including children) would need to have good immunity to this strain to prevent a wave.

While the vaccination rate among California adults is 61.4%, only 51.8% of California’s entire population has been fully vaccinated against COVID-19. Of the 12% of the partially vaccinated, some may have had prior COVID infection before vaccination, in which case the single dose is probably about as effective as two doses in a person who never had COVID; the remaining individuals with a single dose have about 34% protection. Overall an additional 8% protection rate is reasonable. From seroprevalence studies, around 15% of the remaining 36% have been previously infected against COVID, but not vaccinated. Unfortunately, prior infection with non-Delta strains confers only about 30% protection against Delta, so the effective rate of protective immunity is only about 65% in our state, far from the now-needed 80-90%, hence the current exponential growth of infection against the Delta variant.

As of last week, the California Department of Public Health (CDPH) projected that the 2021 summer delta wave will be a little less severe than last summer’s COVID-19 wave. Based on the experience in the similarly-vaccinated United Kingdom, which is about 1 month ahead of us in the Delta wave, the hospitalization rate will be about 1/3 of what we experienced in prior waves. This means the risk of overwhelming the hospitals and ICU capacity of the state is low, so dramatic stay at home orders or restaurant closures are less likely to be needed or considered.

The upshot: this will likely be a quicker, steeper wave, with hospitalizations and deaths concentrated in the smaller, unvaccinated population. The rates of infection in the unvaccinated population will likely equal the overall infection rates we saw this past winter.

The vaccinated population is considering the recommendations of local public health officers to encourage wearing masks in indoor settings when among strangers, to slow down their lower-morbidity spread of the Delta variant. By itself, this will have a small impact on the overall epidemic curve. It may protect them and their families in the month ahead.

Vaccination is our best hope for fighting this particular virus, with its combination of high infectiousness, high level of asymptomatic spread, and relatively rapid development of mutations that help it evade our immunological and public health defenses—a lesson confirmed by two games written before COVID-19 struck.

You play a key role in this real-life game. Thanks for dedicating yourself to this vision of a better world.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“Most of us forget the basics and wonder why the specifics don’t work.“

-Garrison Wynn

In 2019, about 40% of PHC members with diabetes were not being prescribed recommended cholesterol-lowering medications. For patients with diagnosed cardiovascular disease, about 20% had not received statin therapy.

Statin therapy prescriptions and patient adherence to prescribed statin treatment are NCQA HEDIS measures that we will be focusing on in the years ahead. We urge clinician leaders to look at the rates of prescriptions in your practice and remind clinicians of the importance of prescribing statins in these two groups. If you can, set alerts in your Electronic Health Record system (EHRs) to remind clinicians to consider this therapy.

Clinical Background:
Cardiovascular disease is the leading cause of death in the United States. Patients with clinical Atherosclerotic Cardiovascular Disease (ASCVD) are at high risk for future cardiovascular events, including myocardial infarction, stroke, and death from Cardiovascular Disease (CVD). Lipid abnormalities are also common in patients with diabetes, and contribute to an increased risk for developing ASCVD. The American College of Cardiology and American Heart Association (ACC/AHA) as well as the American Diabetes Association (ADA) recommend statin therapy to prevent cardiovascular disease and reduce ASCVD risk.

Summary of Recommendations:
Therapy to reduce the risk of subsequent cardiovascular events includes addressing modifiable risk factors such as smoking, hypertension, diabetes, and elevated levels of low-density lipoprotein cholesterol (LDL-C). The ACC/AHA guidelines state that statins of high intensity or maximally tolerated statin doses are recommended for adults age 75 or under with established clinical ASCVD regardless of the baseline LDL-C. A maximally tolerated statin dose should be used to reduce LDL-C levels by 50% or more.

In patients with diabetes (but without clinical ASCVD), the ADA and the 2019 ACC/AHA guidelines recommend statins for primary prevention of cardiovascular disease, based on age and other risk factors. Moderate-intensity statin therapy can be initiated without calculating a 10-year ASCVD risk. For patients with diabetes who are at higher risk, especially those with multiple ASCVD risk factors or aged 50 to 70 years, high-intensity statin therapy should be considered to reduce the LDL-C level by 50% or more. Consideration may be given for addition of a SGLT-2 inhibitor or GLP-1 receptor agonist with proven CVD benefit to improve glycemic control and reduce CVD risk in patients at higher risk.

The HEDIS Measures
The HEDIS measure Statin Therapy for Patients with Cardiovascular Disease assesses the percentage of males 21–75 years of age and females 40–75 years of age with clinical ASCVD who have received and adhered to statin therapy.
The HEDIS measure Statin Therapy for Patients with Diabetes assesses the percentage of adults 40-75 years of age who do not have diagnosed ASCVD.

Best Practices
Here is a summary of best practices for adding appropriate statin therapy and improving adherence for patients with diabetes and/or cardiovascular disease:

1. Review medication list to confirm a statin has been prescribed when indicated.
2. Provide patient education: explaining goals of statin therapy and need for adherence.
3. Prescribe statins as 90 day supplies, once therapy is stable.
4. Ask your patients open-ended questions to monitor for adverse drug reactions, drug-drug interactions, and other obstacles that may hinder medication adherence.
5. Collaborate with dispensing pharmacies to identify and address medication adherence gaps.
6. Specific medication recommendations:
   1. For high intensity statin therapy (lowers LDL-C by >50%), consider atorvastatin 40-80 mg or rosuvastatin 20-40 mg.
   2. For moderate intensity statin therapy (lowers LDL-C by 30% to <50%), consider atorvastatin 10-20 mg, rosuvastatin 5-10 mg, or simvastatin 20-40 mg.

Thanks for passing this along to your front line clinicians.

By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer

“What are the necessary and sufficient conditions for improvement in large systems? Will, ideas and execution!” —Tom Nolan, one of the creators of the Model for Improvement.

In a tribute to Tom Nolan, who died on March 19, 2019, pediatrician and founder of the Institute for Healthcare Improvement (IHI) Donald Berwick describes what will, ideas, and execution means:

“Providing will refers to the tasks of fostering discomfort with the status quo and attractiveness for the as-yet-unrealized future. Providing ideas means assuring access to alternative designs and ideas worth testing, as opposed to continuing legacy systems. And execution was his term for embedding learning activities and change in the day-to-day work of everyone, beginning with leaders.” —Milbank Quarterly, August, 2019

Nolan’s three conditions, flow roughly in the following order:

• Execution cannot lead to improvement without testing
• Ideas will not be sought out and tested unless organizational leaders make this a personal and organizational priority, an act of will.

It starts with will to improve.

For leaders to decide to make major improvements, fundamentally, we need to challenge the status quo. We must insist on change and provide a vision for a better state that the organization must strive to achieve.

Creating an atmosphere where new ideas can be explored and where strong, independent teams can test these ideas is a central duty of clinical leaders of health care institutions. Yet, it all starts with leadership’s willingness to take risks, communicate a vision of excellence that is achievable, and communicate that the problems of the status quo are unacceptable.

Challenging the status quo is uncomfortable, can be mentally and emotionally draining, and potentially socially isolating.

An alternative leadership style –cherishing tradition and stability– has a certain appeal in the short term. All those staff and stakeholders with an interest in the status quo are happier. There is no need to risk testing new ideas that might fail and make the leader look bad.

When a leader succeeds in upsetting the status quo, particularly in a larger organization, there is significant risk of backlash, which could torpedo the success of the changes. Unless the underlying organizational culture also changes, there is also a probability that improvements will not be sustained and that quality will regress when there is staff turnover.

How do transformational leaders address these challenges? One key tactic is drawing energy from colleagues who are doing the same work in sister organizations. This can help sustain willpower in the face of negative pushback. Another tactic is to develop a group of “true believers” in the quest for quality within different levels of their organization.

Both of these activities require intentionality. They will not naturally happen in the course of our everyday workweek activities. We need to take some time and mental space to build relationships with colleagues outside our organization and with staff within our organization. These relationships must be based on mutual trust, respect, and a shared dedication to lifetime learning. In short, they require some time for reflection, a critical activity that transformational leaders must ensure they do not neglect.

This suggests a causal chain of activities for transformational leaders to be successful at mobilizing the will to improve:

Clinical leaders overwhelmed with patient care and administrative responsibilities lack the time needed to be transformational leaders. The irony is that an improved/transformed health system can use clinician time more efficiently, ultimately giving more potential time for reflection and cultivating relationships. But how can a clinical leader reach this state of improved efficiency if they don’t have time to reflect on the system they are working in?

If the health care system has capacity to add clinical capacity, this can alleviate time pressures for the clinical leaders. This is certainly ideal, if at all possible. Focus first and foremost on recruiting excellent clinicians with a similar dedication to improving quality.

The other options are to work longer hours (which can lead to family stress), or to disappear from everyday work periodically to attend conferences, read books or listen to podcasts, or even complete formal leadership training. This time away can impact patient care in the short term.

Of course, a combination of these three factors –more staffing, longer hours, and disappearing from everyday work– may also give sufficient time for reflective time and building relationships.  Indeed, most transformational leaders have used this combination tactic for their finding time to work on their initial transformational activities.