(IAP ’16) Shahrin Islam, ’16
Shahrin Islam (’16, Chemical-Biological Engineering)
Shahrin will be working with Access to Healthcare Network in Reno, NV. AHN is a non-profit serving low-income Nevadans get access to the resources they need to live healthier lives. These resources include health insurance, care coordination, disease management programs and more. She will be working with AHN to help improve some of these programs, while simultaneously gaining experience in the non-profit healthcare fields.
Check back for her updates!
I’m back in Boston! I’m already missing Reno. The experience was incredible and I am extremely fortunate to have been able to work with AHN over IAP.
I went into AHN thinking that they will tell me about a problem they have and I will think of a solution to it. That’s not how things went at all. Over IAP, I developed training guides, health literacy assessment and surveys that the care coordinators can use to learn more about the conditions and the patients’ knowledge of their own condition. However, there are many challenges I wish I was able to address but I realized that addressing socioeconomic disparities in healthcare is extremely difficult in practice and cannot really be done in 4 weeks. Furthermore, specifically with readmissions, it requires a lot of individualized attention for the patients from the part of the care coordinators to help patients stay out of the hospital. There are changes that the hospital should also make but these changes will take a long time to happen. To truly address the aims of the HRRP program, non-profits, hospitals, primary care physicians, home health aides, nurses and the patients all need to work together to not only help the patient stay out of the hospital, but also reduce the healthcare costs in America. While the problem can be reduced to a sentence, the solution cannot.
I learned an immense amount over IAP. I have so much respect and admiration for the work that AHN and the care coordinators do to help these patients. Over a phone call, one patient came to tears while thanking Julia for everything she had done for him. It was amazing to hear the sincere gratitude in his voice and realize how important it is to the patient to know that someone is invested in their health for their sake.
I also learned that there is a long road ahead to changing the American healthcare system so that it is good for everyone-the patient, the doctors, the nurses, the administration and the government. With the upcoming election, I think it was a really good experience to learn about how the Affordable Care Act re-shaped healthcare and has forced me to really listen to what the current candidates are saying and think about how that will shift healthcare in the next few years.
I am extremely grateful to have been able to go back to my hometown and work with an organization that is so community-oriented and are working on addressing issues that my family has been impacted by. I hope to go back to Reno one day and have a part in addressing these issues, as well.
This week, I finished the guide for the care coordinators about hip and knee replacements. Like the guide on acute myocardial infarction, the guide included information about the conditions for which hip and knee replacements are an appropriate intervention, the components of prostheses, post-surgical complications and red flags and some information about readmissions associated with hip and knee replacements. This guide took me a bit longer to make than the other guide because there isn’t as much literature relative to heart conditions or COPD and readmissions associated with those two conditions. Along with finishing up the guides, I edited the health literacy assessment and surveys I had created based on feedback by Trevor. I was also able to visit one more patient this week, which again was an interesting experience. No two patients are ever the same- this is what makes care coordination challenging. There is no perfectly standardized way of approaching a patient and assisting them through the 45-day period following discharge from the hospital.
Because of this, I have wondered and discussed with Trevor about whether the program that AHN has designed can work anywhere else in the country. While elements of the program are fairly standard, the factors that cause readmissions vary significantly and to manage each of these factors takes a lot of time and dedication and individualized attention for the patient on the care coordinator’s part. In literature, it seems like the strategy that has been shown best to prevent readmissions is a follow-up appointment with the patient’s primary care physician (PCP) within the first week after discharge. This may not seem that difficult, but in speaking with Trevor and Julia and even from personal observation of patient interactions, I realize that there are many barriers that prevent a patient from following up with their PCP. These barriers include lack of transportation, lack of communication between the patient and PCP, scheduling issues, etc.
My project was aimed at improving the program that AHN has designed but it has been proving difficult to do so. The program is still very much in flux and a lot of it is shaped by the experiences of the care coordinators. Since I have never done care coordination, it’s hard for me to go to the care coordinators and suggest new things for them to try or do based on what I read in literature. Often, Julia will tell me that certain things I propose just won’t work (either she has already tried or she just knows they won’t based on her 15+ years of experience).
However, by creating the guides, the health literacy assessment and the surveys, I am aiming to help the care coordinators learn more about the conditions that afflict the patients that they work with and help them get a better sense of the patient’s understanding of their disease so that they can address these gaps in knowledge and help the patient stay out of the hospital. My guides will be used to train care coordinators and the care coordinators can also use the health literacy assessment when they first contact the patient to help them decide how much assistance the patient will need. The surveys are retroactive and are aimed at helping AHN understand what truly helps the patients from the patients’ perspectives.
Care coordination is tricky. I like how Trevor puts it: “People are messy.” He means that every person is different and their lives are complex and their health is impacted by multiple factors, not just the disease itself. Addressing all of this is not simple or easy and there is no “exact solution” to the problem of readmissions. However, I believe that AHN is doing a great job so far-the data shows it! In the cohort that they have worked with, readmissions are lower than the overall hospital readmission rates and even lower amongst a cohort that either refused assistance with AHN or did not go through a care coordination program. It will be interested to see how they make this program more formal and standard(ish) in the future.
I’m halfway through this internship, which is crazy! Time has flown by and as each day passes, I get more sad that IAP isn’t longer. There’s so much to be done but so little time.
In the past two weeks, I have developed a guide for the care coordinators on acute myocardial infarction (AMI), which is commonly known as heart attack. This was a fairly basic Powerpoint about the disease (causes, signs and symptoms, risk factors, treatment, etc.) that Trevor can use to train his staff, most of whom do not have a clinical background. This will help the care coordinators get a sense of the disease so they can better assist the patients.
I have also developed a sort of health literacy assessment that the care coordinators can use to determine how much the patient knows about their disease. I have visited a few patients and through my visits, I have come to learn that even if a patient has had a chronic condition for years, they have very little knowledge about their condition. The less you know about your condition, the harder it is to know how to best take care of yourself and manage your condition. Not only that, they don’t really know who to reach out to if they need help. The American healthcare system is extremely complex and difficult to navigate, regardless of your socioeconomic status, age, gender, etc. While this is something I have heard often (especially from my sister, who is in medical school), I didn’t realize the extent of the complexity till this internship. AHN works hard to help patients from various demographic groups in navigating the healthcare system here in Nevada and it’s great that their resources are available to many people here.
Another thing I have realized is that it is extremely hard to change how things work. That sounds really simplistic but there’s no better way to put it. Saint Mary’s has contracted AHN to help them work with patients at risk for readmission. However, the referral process isn’t the best at the moment. For this program to really be beneficial to both the hospital and the patients, it would be really great if the Saint Mary’s did a risk-assessment at intake and then referred a patient as soon as possible so that AHN can contact the patient before discharge. However, a risk-assessment is not part of normal hospital protocol for inpatient services and Trevor and I have talked about sort of the administrative hurdles that make it harder for the care coordinators to do their job. This is on Saint Mary’s end and with time, I’m sure they will make adjustments to this process but it will take awhile from what I gather.
Last week, I also developed a survey that the care coordinators can give to patients to help get some perspective on how the patient benefited from the program and what they think could be improved. This information will be useful to know as AHN continues to develop their programs for reducing readmissions.
This week, I am going to work on developing guides for hip/knee replacements, similar to the one I did for heart attacks. Hopefully I will get to do some more patient visits, as well. I think the patient visits are really interesting; at the end of the day, it is the patient who is the most important so it’s really great to see how Julia, one of the care coordinators, interacts with the patient and determines how much help the patient will need.
I work at a desk everyday so I don’t have any exciting pictures from field work. Apart from working, I have been hanging out with my middle school best friend, Katrina, and it’s been really awesome catching up with her. We’ve been exploring restaurants in Reno and have attended various events so it’s been fun. My older sister came into town last weekend because she’s been wanting to visit Reno for awhile too but we haven’t found a reason to come back. The entire weekend, we visited all the places we lived, the schools we attended, ate at restaurants we used to eat at and visited family friends who have known us since we were babies. I still can’t believe I’m here; I never thought I’d come back to Reno but this has been a great way to learn about a field I otherwise would not get to learn about and also get in touch with my roots, so to speak.
I’m Rin and I am a senior in course 10 (chemical engineering) at MIT. This IAP, I am on a Paul and Priscilla Gray Internship administered through MIT’s Public Service Center. I am interning with Access to Healthcare Network (AHN), a non-profit organization in Reno, Nevada that is helping people gain access to the resources they need in order to better manage their health. What is unique about AHN is that they not only focus on the clinical aspects of managing health but the socioeconomic factors that also influence how people manage their health, as well. For example, can a patient afford the medication that they need to take in order to manage their disease? Do they have food and housing security? Do they have transportation to visit their primary care physician? These factors are just as important as the clinical aspects and AHN has implemented multiple programs that address a variety of these challenges.
The office where I am working at. It’s inside a mall, which is kind of interesting.
So why Reno? When I told my friends or other people I was coming to Reno, confusion was a common reaction because no one really hears about Reno that much. I was actually born in Reno and I lived here till December 2007. We moved away from Reno to a suburb outside Philadelphia for better healthcare options for my dad, who suffers from a variety of health problems. I have been wanting to come back to Reno for awhile and the issues associated with healthcare here are something I have personal experience with. Through some heavy Googling, I came across a NPR article that discussed the work AHN was doing. I decided to give them a call and was super lucky to have them be interested in letting me intern with them for IAP.
My interests extend beyond engineering. The social determinants, as well as the biological complexities, of medicine interest me, especially due to my personal background. As a MIT student, I have gained a ton of experience and exposure to the engineering and science aspect through my classes and research but I have not had as much exposure to the social determinants aspect. I thought this internship would be a great way to learn about how non-profit organizations address complex issues in healthcare.
I arrived on December 16 and I finally recently decided on a project. There were a ton of options so it was really difficult to decide but I will be working with AHN in their efforts to reduce hospital readmissions through a partnership with a local hospital, Saint Mary’s Regional Medical Center (which is the hospital where I was born!).
The issue at hand is that hospital readmissions are a heavy burden to healthcare costs in America; it is estimated that one in five Medicare beneficiaries is readmitted within 30 days at a cost of more than $26 billion per year (1). In 2012, after the Affordable Care Act (ACA) was passed, the government decided to penalize hospitals with higher-than-expected 30-day readmissions rates for conditions that are most commonly associated with hospital readmissions: heart attack, heart failure, pneumonia, hip/knee replacement, and chronic obstructive pulmonary disease (COPD). This program, known as the Hospital Readmissions Reduction Program (HRRP), penalizes hospitals with higher-than-expected readmission rates up to 3% of their total Medicare payments (2). Therefore, it is of increased interest to hospitals to reduce their 30-day readmission rates. Saint Mary’s has partnered with AHN to help them manage patients at risk for readmission. AHN has developed a variety of strategies to help these patients and preliminary data has shown promise that their strategies are working. However, the program is still in development so I will be working on figuring out what’s working and develop other strategies to help improve the program.
So far, I have had many meetings with the Chief Operating Officer of AHN, Trevor Rice. He’s super cool and knowledgable and hearing about the history behind the organization, the programs and just talking about healthcare issues, I have learned a ton about things I had no idea about and stuff I don’t really learn about in classes I’ve taken. Today, I got to shadow one of the care coordinators who helps manage the cases referred by Saint Mary’s to AHN. I was able to visit a patient and while I can’t delve too much into what happened due to privacy concerns, I got to see how a case starts. I will continue to shadow her and learn more about the case management process. The rest of my time has been dedicated to research on hospital readmissions and strategies to reduce readmissions to help direct my work.
Saint Mary’s Hospital from my visit today.
I have enjoyed just being back in Reno and it’s really been a huge rush of nostalgia. I joined a gym and the other day, I saw my middle school PE teacher there. I caught up with one of my friends who I’ve known since our diaper days and haven’t seen since 2007. Reno has changed a ton! It’s crazy being back, but it’s really great and I’m super grateful for the opportunity to be able to intern with an organization who is doing really great work in my hometown and contribute to their work. I am super excited for the rest of this month!
Fun Fact: The name Nevada comes from the Spanish Sierra Nevada, meaning snow-covered mountain range (“Nevada” is the Spanish feminine form of “covered in snow”).
(1) Jencks, Stephen F., Mark V. Williams, and Eric A. Coleman. “Rehospitalizations among patients in the Medicare fee-for-service program.”New England Journal of Medicine 360.14 (2009): 1418-1428.