The Health Care Blog posted the following “Population Health Isn’t Working Out Quite the Way They Said It Would. What’s Going On?” Authored by Hilary R. Hatch, Ph.D. from Vital Score, Inc.
I agree with all that Hatch presented especially the headline quote. It is all about collaboration. Her primary premiss is that we are putting patients into categories by conditions (i.e. diabetes, heart disease, etc.) when patients with the same conditions are different. She gives the example of depression and notes that for her depression is a billing condition and not relevant to treatment planning for a vast array of patients, those in mourning, postpartum moms, isolated geriatric patient, etc. Hatch further addressed how population health is failing in the physicians office.
“When the population health need gets attention, is it at the expense of the individual’s need? Care plans driven by population health diagnostic categories are more formulaic, symptom-focused and may ignore root causes. As such, they are less likely to be successful. Then, when patients fail in flawed care plans, we indulge in blaming and name-calling: “non-compliant” or “non-adherent.”
Hatch continues her logic with the thought that non-adherence is resistance by the patient to different forces such as cost, the patient sense the drug or therapy is not working, and other factors. Her solution and rightly so is to help patients ‘choose their own adventure’ to identify their pathways to health and success.
“…when people self-identify needs and self-refer to services, their participation rate increases up to 20x. People own their choices because their choices are personally driven for their own benefit. It’s not only better for workflow, it’s better for outcomes.”
In my opinion Hatch argues clearly and is spot on when it comes to motivating patients. It is all about self-identified goals and management from the bottom up (patient) not the top down (HCP). But I would add to this the work of Malcolm Knowles who studied how adults learn. If we understand and use adult learning we can improve patient motivation.
- Self-concept: As a person matures his self concept moves from one of being a dependent personality toward one of being a self-directed human being
- Experience: As a person matures he accumulates a growing reservoir of experience that becomes an increasing resource for learning.
- Readiness to learn. As a person matures his readiness to learn becomes oriented increasingly to the developmental tasks of his social roles.
- Orientation to learning. As a person matures his time perspective changes from one of postponed application of knowledge to immediacy of application, and accordingly his orientation toward learning shifts from one of subject-centeredness to one of problem centredness.
- Motivation to learn: As a person matures the motivation to learn is internal
This can be summed up in the simple idea, adults will only learn when they are seeking solutions to problems they have. I posted this a couple of years ago on Knowles.
New Web Site. New effort. Old news updated. The ACA then and now.
I was looking at my archives and found Notes & Links: October 21, 2013. I posted a piece that Dan Munro a healthcare contributor at Fobes had on Obamacare Numbers Success or Failure? Munro noted that there were 476,000 health insurance application were filled through ACA Federal and State exchanges. Since then we can say a few more Americans have applied with over 20 million people have health insurance either through public o private options. As of December 24, 2016 there were 11.5 million people who used the federal marketplace to buy health insurance. 8.9 million renewed their coverage or bought new plans to replace existing plans. 2.6 million new people enrolled. It was so cute that Munro ends that piece from 2013 noting that the ACA is the single biggest target on Obama’s back. You think.
Fast forward to Munro article in Forbes Trump Acknowledges That The ‘Replacement’ Of Obamacare Will Span Years. This was pulled from President Trumps interview with Bill O’Reilly. Besides the fact Trump is seeing that the ACA can’t be just turned off without doing great harm to millions of Americans. Ultimately in rich and ironic way the GOP is being forced think about outcomes that are not tied to punishing former President Obama. GOP oh my. Which brings me to my final thought here.
As the ACA is repealed, replaced, or repaired there will be reams of pages written about the harm these actions will have on the sick, the old, and the young. There will be competing projections of what these changes will produce. For now the little we know about what will be done or considered is not enough to get our outcomes arms around.
I would like to imagine that someone, some academic institution, some group of thinkers will set up a site to track key healthcare outcomes retrospectively from the beginning of the ACA to its ‘repair’ and then going forward. Surely there will be measures of those who have and don’t have health insurance and measures of cost of health insurance and more. I am hoping we can get into the granular data that may takes years to revel a trend.
Just to throw out some ideas: Measure standards of care treatments and their outcomes for specific conditions. Compare Repaired ACA to Pre-Repaired to Non-ACA health insurance. Will we see worse outcomes in one group vs. the other group?. Are treatments offered as first line differ between measured segments? Is the life expectancy for similar diseases and patients shorter or longer between segments?
I am not a statistician nor an epidemiologist (obviously). So I’m not sure any of this can be done. Should it be done? Yes, because this is the type of evidence (not alternative facts) that the fix and repair GOP made into law. We need to know if it’s keeping Americans alive and healthy. This GOP driven destruction of Americas health is similar to the Death Panels feared in 2012 by the GOP. Now they get to enact their dream, thinning the herd of poor, sick, and non-GOP voters.
Bonus link, One World In Data. Really great charts and graphs on healthcare.
“Now would be a good time to have end-of-life discussions with Donna,” the Hospice Rabbi said. “What does she want for her funeral? What are her regrets? Did she find joy in her life?”
Joy? I failed her. All I could do was think of that.
I hesitated for a day. Then next afternoon, alone in the room with Donna, I looked at her in the bed and said, “Donna, perhaps you want to talk about your funeral.”
She looked over at me and said, “Don’t be a maudlin pussy.” Then she rolled onto her side and fell asleep.
I smiled. That was the woman I married 28 years ago, life and death on her terms, her way, take no prisoners, with no doubt about what was needed. She was not dead yet.
This occurred about a week to ten days prior to Donna’s death. Yet my grief was an orchard in full bloom and thriving finding nourishment from the memories of our life together. It took seed when she was diagnosed with Stage IV cancer two plus years earlier. After she died it sunk it roots deep and remains part of me. Many may see my grief as a failure to launch away from the pain. You know that entire finding closure meme which is denial said pretty. I will not deny my grief nor Donna.
There is more to grief. Let me defend grief, specifically defend my grief and hopefully your grief. Grief is life’s artesian aquifer. It flows from within, bored out of the loss of a loved one.It is part love and light. It holds promise to satisfyingly quench our loss. To sustain us.
Grief should not be seen as a proper place or an improper place. It is the space between memories of the past and hope for the future. Those are distant points on a compass that intersects within us. At times where it overlaps may be a soft and subtle or hard and painful. No matter it creates a newness within us offering a fresh look that what was, what is, and what may be. If choose not shy from it or ignore it can open up new memories and new understanding.
I have written about grief and will continue to. Grief has its own narrative arc and begins as thumping numbing recognizing that what once is is now was. It moves with us and becomes dullness. We need to take grief and partner with it, in a sense embrace its strength and aching to create new.
Maine Public has a piece by Patty Wight. ‘If It’s All About You, There’s No Reward:’ Coping with Grief by Helping Others
She relates the story of Floyd Hastings and the death of his wife. How Hastings like many of us who face the loss of a loved one sought to give back to those who helped us care for our loved one. I remembered the chemo lab nurses and hospice staff for years following Donna’s death. I have posted about Donna and podcast on grief and how I’ve managed it well and not so well. I am volunteering. All of this as a way to pay forward what I’ve learned.
That is what we do but more to my premiss, our grief is a light within us to guide us to a better understanding of what was, is, and will be. Below are some links to my podcasts on the topic and posts. But stay tuned more to come.
Podcast 39: The Organic Nature of Grief. An Observer Effect
Podcast 37: The Insipid Nature of Grief, The Horse Latitudes
These past few years being carried by events surrounding me. Not powerless to changes as much as listless and supine. Donna became ill, passed away, my business and work became nonexistent. Meaning and purpose that were once part of life became abstract thoughts and longings for a time that was. This is aging. Many have written about aging especially the site Time Goes By. His thoughts and reflections on this and other aging topics are well considered and highly reflective. Yet there are moments or small events that buoy one to feel, all is not lost as we approach out expiration date.
Bronx Baking Company is one of these moments for me. I want to 1. Reflect on this company and its owner who I personally know and relate it to me then and now. 2. Give a shoutout to a fabulous company and product.
Alexis is the founder and owner of Bronx Baking. I met her through the space I was renting a desk at during Donna’s illness and death. When we first met she was mulling over the idea of a Bakery. I was struck by her drive and brains. And her Bronx attitude. She takes no shit. Kind of fits into my reference point for women.
Alexis was born and raised in the Bronx on Arthur Ave. She has an enthusiasm verging on aggressive for the Bronx. So the location was set for her. Next came the product, real German style pretzels. Alexis set out to find recipes, talk to German Bakers, test, sample, and do it all over until they were perfect. And then she started baking. At first small. Then in a shared space. And now her own space. When she opened her own space she bought equipment, cleaned the space, set it up, and tested production. To her getting here feels like forever and feels like failure delayed. For me watching it is so fast and just another step to proving your meaning and purpose. All the while she was selling product to new customers. Improving the recipe. Solving delivery problems. Snaking a grease trap. Managing account receivable. Tweeting, Instagraming, Facebooking, and more. Metaphorically those pretzels are made with sweat and tears. Metaphorically, ok. A delicious pretzel.
I could go on. There is really nothing unique here for anyone that started and ran a small business. Big deal. Or not. Consider the fact that in the US about 3% to 4% of Americans start a business. Failure is part and parcel of owning a small business as is working your ass off, having debt, and loosing sleep every night. As I said, an average day nothing special for a business owner.
I watched Alexis. I helped her with some marketing. I tried to be a cheerleader. All the while in my mind I kept thinking I was there once. My friends were there once. This is so inspiring to see and know that what we did in old timey days still feels the same. The damn the torpedo and full fucking steam ahead let’s do this lives in the Bronx, in her pretzels, and in Alexis. It lives in those that create an app or drive for Lyft. It lives in those who want to find a way to thrive and not submit. And there my friends is the importance of this. My life’s meaning and purpose may be on the wane either from external issues or from my own being stuck in this emotional amber of life. Watching Alexis and Bronx Baking and in a small way being part of it and it is thrilling. I relieve what once was. I get motivated to do this and that. I am learning new things. Being in the presence of my past is keeping me centered on the present. Helping Alexis and Bronx Baking helps me. And she gives me a pretzel once in a while.
Why Bronx Baking?
It has been nearly a year since my last blog entry. I’d love to say I’ve been busy. Not so sure, at some point (age related) life becomes glacial in serving up burnt offerings. It becomes less of what is placed in front of you and more about, what you harvest, gather, uncover, and find. God helps those who help themselves and you got to help yourself prior to your expiration date. It’s been a year of sorting this out. Rest assured I am not all that self actualized. More on that later.
Here is the new site with all the old blog posts, podcasts, photos, etc. When Donna was going through chemotherapy and I was a part time gig worker and a full time caregiver. I moth balled my business. The web site I had was now in my responsibility to maintain and keep alive. Donna may be dying but I was not. At least not outwardly.
I went to Square Space and built (cobbled) a new site. That new site is now previous site. It was fine. It was mine. It was where I leaned to do new shit. Since it was on Square and my ISP is Pair.com I had to have someone create a DNS and MX set up so my email and etc. would work. I also needed a bunch of network work arounds. I was clueless how it worked. But it worked. It kept busy posting and podcasting. All the while I cared for Donna and then gave into grief.
Sometime mid 2016 my hero and all around amazing social media/SEO Baby Mozart (aka Shaun) kept telling me Square is okay but for SEO and all that a web site can do it is not readily available nor robust enough on Square. Baby Mozart said in no uncertain terms go WordPress. Host it on your ISP. So mid 2016 to 1st Q 2017 that is what Shaun did and I breathlessly watched as if I was a spectator at a BMX competition.
Shaun ported my old site to the new WP build. Got the DB built, added plugins, and so on. All magic to me. He found my podcast plugin blubrry, I ported over my podcasts. Just to note blubrry was so helpful and professional. Big recommend here.
Now it’s October. Ready to go. Not so fast. I was technologically bound up like an opioid users’ bowel. I feared if I did this switch from Square to WP at Pair I was going to break the Internet. Not a joke. I made about eight calls to Pair tech support, cried to Shaun, and lit a shit load of candles and sage sticks.
Well I did it. The Internet didn’t break. Shaun held my hand. Videos are teaching me about WP. Still learning.
February 14th 2016 is Valentines Day for all of us. For Donna it would have been her 64th trip around the Sun. This annual sojourn of circling the Sun ended in 2011. Yet her ashes and memories continue to race through my personal solar system. “All we are is what we leave behind.” I am left behind, your memory is not.
The memories (not just memory) of Donna, our time together, what we had, and what we didn’t have arebits of flesh and fur snagged on barbed wire. At other times these memories are the interstitial pastures between the fences containing peace and comfort.
I smile remembering our Honeymoon in Greece. A warm Mediterranean afternoon napping in a cheap room on a beach listening to the buzz of Vespa’s outside, except there was no doppler effect. With a start we realized no Vespa. It was a huge bee in the room racing around. Simultaneously we made the same shocked oh my face, latter named Bee Face. It was similar to Edvard Munch painting The Scream.
The bit of skin hanging on the barbed wire is knowing that is forever gone and never to be repeated. The pastoral moment is knowing it happened and smiling.
Lobsters, oh how you loved to have a lobster while we vacationed or for your birthday at the Palm. I would crack the claws for you. The smile and the yum on face was pure joy to see and hold in my memories.
Did I offer you enough lobsters during your 59 trips around the Sun?
Naming pets was your speciality. The key in your mind was looking at the face and naming the pet accordingly. Nina was the perfect name for this face. I wonder if we had children how long you would wait to name them because all newborns are ugly.
[i carry your heart with me(i carry it in]
i carry your heart with me(i carry it in
my heart)i am never without it(anywhere
i go you go,my dear;and whatever is done
by only me is your doing,my darling)
no fate(for you are my fate,my sweet)i want
no world(for beautiful you are my world,my true)
and it’s you are whatever a moon has always meant
and whatever a sun will always sing is you
here is the deepest secret nobody knows
(here is the root of the root and the bud of the bud
and the sky of the sky of a tree called life;which grows
higher than soul can hope or mind can hide)
and this is the wonder that’s keeping the stars apart
i carry your heart(i carry it in my heart)
Last night, late for an old guy, I listened to an online video/Twitter chat hosted by #spsm (Suicide Prevention Social Media). The kind @docforeman invites me to these which flatters me to no end considering my mollusk like IQ. The topic was a new platform offering ‘anonymous and confidential online text chat with trained listeners, online therapists and counselors’. It’s called 7cups. @GlenMoriarty1 the founder of 7cups was the presenter.
The #spsm weekly chats are smart and address important topics outside my professional wheelhouse but I join and find them interesting and thoughtful. They are tres funny too if that counts. Last night with Glen Moriarty of 7cups was pure genius and riveting. So much so I had to get my ass out of bed and plug the laptop into the 27” screen so I could watch the chat, the video, and use Safari.
Everyone on the chat are Ph.D, MD’s or social workers who are passionate about #spsm and helping others. And they are a critical bunch questioning how the mental healthcare system works. They know the emperor some days is naked. First go to the 7cups site and check it out. I won’t get into my TL:DR mode. You back?
The chat and what 7cups is doing is brilliant on a human level and that is my point here. The talk last night focused on the technology and how amazingly this was funded and now has 800k people a month participating. Totally amazing platform story. There is more. This platform meets a basic human need we all try and find via social media. Humans need to talk to share to help especially when we are struggling. Just go back and read my posts on grief and loss and mourning. Not many read themor listen which I do to help others and to plumb the depths of my grief. All six of you who read my blog 20% got something from them. In a very small way I met the above conditions of human need via social media. 7cups is this on steroids and it is not the technology in my mind driving it. Reverse that, lede with the human need to help, talk, share, and listen 7cups has greased that need like a strippers pole to make it work better through technology. And I will add that Dr. Google, social media, etc. patient engagement is a robust extension of our lives. Here is short piece on that.
I’ve written and hocked about adult learning being at the core of both business and human needs. Bioc.net “Learning is the process of reflecting on experiences that produces insights useful in solving future problems (Slotnick, 1999)” And I will add, solving current problems.
Adults learn when they seek solutions to problems. New information discovered during problem solving creates experiences that upon reflection fosters new knowledge for that adult. That knowledge is incorporated in their consciousness. Learning changes consciousness. The most powerful effect we can have on patients (and each other) is to aid in learning.
Learning opens our minds to accept new information. When we incorporate new information through reflection we expand our compendium of knowledge. Our consciousness changes with new knowledge/experience and we apply it to create new experiences, change behavior, or make decisions. This is a problem-centric solution. It’s the bedrock of communications and marketing.
This effect is greater in a social situation. When we learn with someone else or in a group we learn better. Each learner comes to the same problem with different solutions and understanding. Each learner adds something to the solution of the problem at hand for other learners. Social media is a learning. It is a tactic NOT a strategy. The strategy is about identifying problems and helping adults solve them make them learners. Social media is a tactic to drive learning and knowledge not create it.
Lev Vygotsky identified “zone of proximal development.” If a person is engaged in self-directed learning, they’ll get a certain amount out of what they do. If, however, they learn with another person of the same level of sophistication, they’ll learn more. Hank Slotnick, Ph.D. says, “the pooled ignorance is less than the sum of the individual ignorance’s.”
Most decisions we make as adults especially in healthcare revolve around solving problems for a family member or ourselves. Buying decisions and products we use or want to learn more about are based on our need to learn. Adult learning is a way to improve those decisions. And it is powerful in helping each other if we identify the problems others need to solve. AND a place to do it (i.e. 7cups)
And as I noted, 7cups is doing the above in spades. I immediately jumped on the idea of this as a place for those of us who recently lost a loved one to go and find a place to share your grief or help others share there grief to in fact achieve a zone of proximal development. Yes there are platforms like Widowed Village where you can chat and meet others in the same place. I have been there and used it but it never really grabbed me or me them it was more like joining a party already in progress. 7cups strikes me as a place/platform where you step into your own personalize party ether to help or find help which is key to us bipeds we love interaction.
Already TL:DR. Peace Out
A strange set of circumstances happened last month. I received a box of photos and documents that were passed from Donna’s estranged brother to his girlfriend following his death in 2006. (Her brothers lawyer wrote to Donna and said in his will Jack noted that you are my sister but I am not giving you anything.) True story.
The girl friend passed away this year and her friend was cleaning the house and found a box of photos and documents. There were photos of Donna, her mother, and various family members including her uncle Oscar Leibowitz. Donna’s mothers brother. Surprisingly the box even contained her grandparents naturalization papers and documents.
Oscar from what I recall was the favorite son of the family and the apple of Donna’s mothers eye. You know the oldest son of an immigrant Jewish family. Most of the photos of Oscar were from his days in the service and his time at Army Air Corp training and in England during WWII. September 1946 Donna’s mom received a letter from the Army Air Force in response to a letter she wrote, which I don’t have a copy of. The letter from the Army Air Force gave details of his death. “Lietuenant Leibowitz was killed in action March 22,1944 while flying his B-17 over Pfahlhausen from antiaircraft fire. He was interred in a cemetery at Oldenburg.”
Notification of Death during combat mission.
He was awarded Purple Heart.
The Purple Heart was not his only medal. In September of 1943 he was awarded for “exceptionally meritorious achievement and participating in five separate bomber combat missions over enemy occupied Europe.
In October of 1942 the family received a letter from the Army Air Forces Training Center announcing that Oscar has been selected for training as a Pilot in the Army Air Forced.
Those are some of the military files and government letters regarding this airman’s serving in the Army Air Corp and his death. There are also communications regarding returning his remains from Germany to the US for burial. That process took until 1949 before his remains were returned to the US and buried in Long Island. Yet there is much more here that offers a rich mosaic of this one airman, a son, a brother, and uncle. There were letters he wrote home and many photos. Below are some of the examples of his life while in service to the US.
These letters are fascinating insight into what it is like to be a soldier and keeping the family up to date. He requests his birth certificate so he can apply to pilot training. Another is about not getting furlough. There is one where he describes his first cross country flight of 300 miles. Just letters home but a window into the man and the moment. CLICK ON THE LETTER BELOW TO SCROLL THROUGH THEM.
Here is a gallery of photos that show training in the US and being stationed in England and Europe. CLICK ON THE PHOTO BELOW TO SCROLL THROUGH THEM.
Originally when I received these items I just wanted to grab the photos of Donna and any documents that were specific to her and toss the rest. As I looked through them I found a family history all but forgotten in a box stuck in a basement in Berkeley. This deserved more.
The kindness of a stranger to find Donna’s address and write at first set me back. Donna and her brother had a history that was fraught with pain and anger. I was angry. Going through this box and seeing not what is lost and forgotten but what is found deserved to be remembered in some small measure. The immediacy of our digital world today and the movement to what is next, new, hot, and liked somehow belittles the rich tapestry of small narrative moments in time.
This is a memory that lives for now, as it has in a time past. There are moments when memories sting. Today these memories sing.