Tools for Healthcare Leaders - Dr. Hanadi Hamadi and Dr. Shyam Paryani, University of North Florida Brooks College of Health

SHIV GAGLANI: Hi, I'm Shiv Gaglani. We've had the pleasure of welcoming many guests to Raise the Line who are working in the trenches to improve how healthcare is delivered and paid for, and to improve health outcomes. Today we're going to take a step back and get a broader look at what's happening in healthcare reform and health policy with experts from the University of North Florida Brooks College of Health. Dr. Shyam Paryani is Director of the Executive Master of Health Administration Program, and Dr. Hanadi Hamadi is an associate professor and health sciences researcher. They both bring a lot to the table and we'll be hearing about their backgrounds in their own words in a minute. I'm really looking forward to getting their insights on what's happening in these areas and why learning about it should matter to health professional students and practitioners. So, thank you both for taking the time to be with us today. 

 

DR. PARYANI: Our pleasure. 

DR. HAMADI: Thank you so much for having us. 

GAGLANI: I'd like to start with getting some career highlights from both of you and learn about what drew you into a career in healthcare and education. So, let's start with you, Dr. Hamadi, and then pass it on.

DR. HAMADI: I started really wanting to go into more of a medical route. I got into a nursing school and as I reflected back on whether I should pursue a nursing degree, it was a no for me. Then again, once I graduated from my biology degree, I applied for medical schools, kind of like the traditional route, and that wasn't really it for me either. So I decided again perhaps dental school is the right way for me. I realized I wasn't really interested in helping one individual at one time, but rather a group of people at once. That is really what made me look into a PhD program in Health Policy and Management and how I could really change the health system within, even within the federal government.

GAGLANI: That's great. That's very relatable actually in terms of going to the different programs. How about you Dr. Paryani? How about your background? 

DR. PARYANI: I'm a radiation oncologist, a physician. I grew up in a family that was doctors, so it was expected that you would become a doctor because my father was a doctor, my oldest sister was a physician. If you didn't become a physician, I think you were like a black sheep in our family. I went to medical school and have practiced oncology here in Florida for the last 30-plus years and also help run a large medical group around the country. 

I needed more expertise in health administration, so I came to UNF and I'm a UNF graduate. I have a Master's in Health Administration degree from UNF that I got about 20 years ago. When I graduated, I've been told that I never left UNF. It's often that students never leave campus. I was probably one of those. I was dragged back in, in a nice way because I was on multiple committees and helping with the Health Administration Ecology Health Program. Then I also started teaching part-time about 10 years ago at UNF. So I've been actively involved. In the last year or so, I've been the director of our new executive MHA program, which I'll tell you a little bit more about in a few minutes.

GAGLANI: That's great. Before the show started, I mentioned the fact that I grew up in Melbourne, Florida, just a couple hours south of where you both are in Jacksonville. I have a lot of friends who've gone to UNF and we're fortunate at Osmosis to be able to work with many students and some programs at UNF as well. So Dr. Hamadi, can you give us an overview of the Brooks College of Health and particularly what you all offer in the MHA program?

DR. HAMADI: Absolutely. Brooks College of Health is what we have in Jacksonville, Florida. One of the uniquenesses of Brooks College of Health is that it's not uniquely an allied health program. It has nursing, PT, exercise science, dietetic and nutrition, public health, and health administration, which, typically in other universities, you see it merged within the context of public health. The MHA program, which is a Master's in Health Administration, is a statewide recognized master's program. It is CAHME-accredited. We have a cutting-edge curriculum that is really focused on bringing in community partners into the classrooms. So students not only learn from researchers and what I do, but we really learn from those who are in the trenches learning from what is happening currently. That strengthened the program really over the past two years as we were developing and adapting to the new world of COVID.

GAGLANI: That's a very timely time to pursue the MHA degree. We haven't had too many people on the podcast who have gone through that program or through programs like that. It's great to have you both on to explain to our audience, many of whom could consider getting MHAs as well. So, Dr. Paryani, you do the Executive MHA program. Can you talk a bit about how that differs, the learner profile you get, and then what exactly the goals are of that program?

DR. PARYANI: As Dr. Hamadi said, we've had the MHA program for 30 years, and as I said I was a graduate myself. But one of the things we discovered, especially working professionals like myself, was it's hard to balance school while working full time in a healthcare environment in which the hours are unpredictable. Going to class is a real struggle. Most people have trouble going regularly to class and taking two or three courses per semester and completing the course in a timely fashion. It took me several years to finish this course, where most people, they were able to devote their full time to be completed in five semesters or so.

We came up with an alternate solution, which was an Executive Master of Health Administration program directed at working professionals. So working healthcare professionals who are already in the field have some experience. The knowledge base is a little further advanced, so we can start at a little more accelerated level and continue at an accelerated level. But all the instruction is done online. So you don't have to physically come to campus for any of the courses; that can all be done remotely. As I mentioned, all the instructions are done remotely, but the instructors of the faculty are exactly the same that teach our MHA program. So the coursework is very similar or parallel to what is done in the face-to-face program, but it's all done online. 

Again, it also requires about the same time, about five semesters, to complete the course of study. It's very suited and flexible for people who are working full time in the healthcare profession. We have physicians, nurses, pharmacists, physical therapists, radiologists, radiation technicians, nurse practitioners, really the gamut—healthcare administrators, even—that are looking to advance their career. We have a gamut and diversity of students in this program.

GAGLANI: That's amazing. It's good to know that there's so many interprofessional folks who pursue MHAs as well, because we clearly need not only coordinated care for patients, but probably interprofessional and coordinated health policy work. So moving into actual health policy, it's been about a decade since the Affordable Care Act started encouraging focus on population health here in the U.S. We're talking a couple weeks after the Supreme Court yet again upheld Obamacare or the ACA. Dr. Hamadi, can you comment a bit about the ripple effects of the ACA on our health system? That's obviously a large question, but anything top of mind for you given your studies there. 

DR. HAMADI: Absolutely. I'll focus a little bit on population health. Really, the ultimate goal of the Affordable Care Act was to do one thing, and they did it very well which is to provide the insurance card membership to as many people as possible. It didn't really do very well thinking about the capacity of the system, how will these people access the system, at what point do these people need access to the system, but rather that membership card saying, “You can enter the system.” The focus in the Affordable Care Act was specifically targeting that population health component, saying we will go to them in the community and we'll help them in the community. All non-for-profit hospitals, which is about 60–70% of that of the US, are now obligated to participate in population health metrics to maintain their not-for-profit status, which means they have to do a three-year needs assessment of the community, and they need to provide services and outreach and partnership to the community.

The downturn of a policy such as this is that its grandeur in size turns hospitals into a checkbox system where they say, “I provide population health because I do a tobacco cessation program— check!” So now what we're struggling with is the efficacy, the strength of these community population health programs and initiatives, how are they engaging in the community, and also creating an unforeseen issue and gap in that some programs or some communities are a lot better off than others simply by the strength of the health system that exists that are not only an acute system but a public health organization that provides population health efforts.

So really, that is one of the biggest ripple effects of the system is the system isn't intended to provide population health; it is intended for acute care treatment and discharge. Now we're asking it to be a chameleon and provide population health. We are seeing the unfairness that exists. The community health rankings by the Robert Wood Johnson Foundation show us that it's really important for hospitals and health systems to participate as a valid member of the system as a population health system, not just as their own entity of care delivery.

GAGLANI: That makes a lot of sense. Actually, let me pull on that thread a little further before we go back to Dr. Paryani for another question. We've had a lot of guests on our podcast talk about the importance of incorporating the social determinants of health, for example, Chris Chen, who runs ChenMed, also in Florida and all over, as well as Toyin Ajayi, who runs Cityblock MD. These are new primary care delivery models that are specifically focused on incorporating social determinants of health into diagnosis and treatment plans and removing obstacles to a person even getting into or accessing that healthcare—as you mentioned, things like providing transportation or even housing. Part of your research, Dr. Hamadi, focuses on evaluating these health outcome initiatives. Can you talk a bit about what your verdict has been on whether this emphasis is working to reduce costs and improve health outcomes? 

DR. HAMADI: It's a two-fold answer, and my apologies for doing it that way; it's the researcher in me. But for those who are doing it well and understand the scope of what social determinants are and how they can implicate it not only in delivery of care and treatment and diagnosis but follow-up and continuing care, we see significant improvement in patient outcomes and patient safety as they migrate through a system that talks to each other. But when we see it in big organizations—I will not name names—where the patient comes in and is recommended to fill in a social determinants questionnaire at point of entry, that doesn't really have an in-process root of how these multiple physicians, multiple admins, are going to view a six or seven page survey about a person's social determinants. At what point or what information becomes relevant? It really falls back onto the patient and consumer knowledge on how they can bring in their social determinants as well to the conversation.

A lot of initiatives that empower patients to understand how social determinants are impacting their health and their conversations with physicians in the room as they consciously apply it, is where we see more success. But when it's just running in the background as something that's important, we're just collecting data. There's a continuum where health organizations are at. Some are at the beginning, where they're just collecting the information, not really sure how they're going to use it; some are finding ways to utilize it and utilize it well.

GAGLANI: That's really important and good distinction. Just because you collect data, doesn't mean it's insightful and actionable. Certainly, that's something we're seeing across the board in healthcare. To you, Dr. Paryani, healthcare is enormously complex, ever-changing. There's so many different stakeholders. What tools do you feel are most essential for those in our audience who want to become healthcare leaders—and not only providers—to be able to manage effectively within this complex system?

DR. PARYANI: Well, I think Dr. Hamadi alluded to it. We need to not just recognize problems, but figure out how to deal with them. Just because you know there's an issue, if you don't do anything about it and don't know what to do about it, then you can't really solve the issues. So we create, or attempt to create, leaders. We're assuming most of our students are already managing in some capacity. There's a great difference between just managing and leading. We are trying to create healthcare leaders of the future with the correct vision and the correct thinking and skill set for the future. One of the things you mentioned is team care, and that's why we have such a diverse class of different specialties because we don't really aim for one specialty in healthcare. This is really across all specialties of healthcare. 

We have to work as a team. I think we saw it in COVID. If we don't work as teams, we have lots of fractured care. We've had fractured care all along, it just even brought it to surface with COVID. So we've got to figure out how to work as teams. These are skills we try to entrust to our students to become visionaries and figure out skill sets that allow for a team approach to healthcare. 

One of the major skills there is communicating properly. Doctors know how to communicate with doctors, and nurses know how to communicate with nurses, and technologists know how to communicate with technologists. But when you try to crosstalk, you get all this “I know better,” or "I think I know better." So, we've got to take that out and then create a level platform so everybody can communicate at the correct level. That's one of the skill sets we worked very consciously at, making sure that when our students graduate, they have that skill set. 

GAGLANI: Yes, that's definitely essential. One thing I enjoyed when I was a medical student at Johns Hopkins was they would actively try pairing us up with other providers in the ecosystem. So I shadowed a pharmacy tech within one of the outpatient centers and a neurosurgeon in the inpatient obviously. 

One thing that we did not learn though, as medical students, was much about health policy and practice management. That's a question that a lot of our audience, who are going to be practicing within a few years, or already are, are curious about. There are trends we've seen and heard from providers that their practices are being bought up by hospitals. We've had Kaiser and Geisinger on, which are huge integrated delivery networks. Dr. Paryani, can you talk a bit more about the way practice management is evolving and tools we can use to reduce burnout among our provider network?

DR. PARYANI: We actually have a specific course in practice management, and that's all we talk about is skill sets required to manage practices, not only from the physician end, but also from the administrative end, because you've got to have support. The problem with burnout is physicians feel that they're all by themselves, that they're loners out there. COVID has brought it to the surface. You're seeing all these patients, hundreds of patients that are sick, one after another, and you don't feel like you have the support that you need. Same thing goes for the nurses; same thing goes for the lab techs that are doing all the tests on the COVID patients. 

We've got to work as a team and say we are supporting each other. Support is very critical. If you look at surveys of physicians and nurses and all the frontline workers that were involved with COVID, the vast majority of them say they're burned out because they just could not handle the stress of patient after patient, of initially severely ill patients that required intensive care and lots of support. They really felt themselves they weren't getting enough support. Again, we've got to come up with a team approach to this so that we support all of our professionals—not just the physicians, but the nurses and all the other ancillary providers. A team approach is what it's going to take. It's very important.

The other thing is mental health. Mental health has been an ignored area for everyone, including the population. But guess what? It's also been ignored for our providers. Our providers need support, too. Fortunately, mental health, to a large degree, was able to rotate quickly to telehealth for patients. I think that's very good, but it also needs to help support our providers. 

GAGLANI: That echoes with a lot of our guests on the podcast have said, too. We were fortunate we had the Chief Medical Officer of Calm, which is one of the most popular meditation, mental health apps out there for consumers, Omar Dawood, as well as Arianna Huffington, who runs a group called Thrive Global. With her, we actually made a course on nursing resilience that you can get continuing education for, though obviously that puts the onus on the provider to become more resilient when the system itself is broken. But obviously, it's complex and so you'll need multiple solutions. 

The reason we launched this podcast in the first place during the heart of COVID—at least in the US—was, how do we not only flatten the curve, but raise the line and improve our healthcare system and make it stronger coming out of COVID than when we began? So, let's start with Dr. Hamadi and then go to you, Dr. Paryani. What do you think are the lasting changes that a COVID pandemic will yield for the healthcare system?

DR. HAMADI: One of the lasting changes is actually a thing that we've started to do, but have done in a fragmented way, which is telehealth. A lot of policies for telehealth have changed drastically during COVID, where prior it was so stringent, afraid of fraud and fraudulent claims. Now with Medicare and CMS and Centers for Medicare and Medicaid Services opening up that door for pretty much anything to be delivered through telehealth and to be reimbursable to a certain extent, it really changes the game where now providers can access not only specialty care that their hospitals need through telehealth, but also crossing the line of the invisible state line that currently exists. If you want to practice in Florida, you need to have a Florida license. The shortage of care is real with the state lines being there and telehealth crosses that line.

Florida just implemented a new policy that you can be in Georgia or any other state. All you have to do to practice in Florida is apply for licensure, and they will waive the fee. So it's pretty much a free licensure that you can get by just submitting the simple application, and now you can practice telehealth. That's a lasting effect and we've been trying to move in that direction for years, but now COVID has made it real. 

One of the other things that COVID has created is, typically when patients access the healthcare system, they access it at a point of fear. They're scared. Something is wrong. Something isn't ticking the way it's supposed to tick. COVID has showed us that people within these hospitals are now trying to deliver care at a point of fear as well. There are so many issues and so many trainings and programs that need to be developed to address that, to give them the tools to be able to reduce that risk of fear and stress, and enable them to treat their patients, because that is really the ultimate goal—but also to make sure they are taken care of as well. 

We've seen a lot of negative rumors happening around health administrators providing their nurses and their physicians with only one mask, or limiting it because of capacity, and that is not really reflective of all health administrators. This is reflective of the real dire situation where there are resource issues that now we should definitely account for and be ready, because according to Dr. Fauci, this is not the only pandemic; this is the first of many future pandemics that we need to prepare for. 

DR. PARYANI: I agree. I think one of the other things that we've been talking about already is siloed care. Basically, healthcare is siloed. We have our silos of areas that we take care of: hospitals, doctors, outpatient clinic surgery. We finally noticed that we can't all practice independently of each other. We all need to support each other. Telehealth needs to happen for all specialties, not just one specialty. All areas of care needed that access. As Dr. Hamadi eloquently pointed out, we need arrangements where we can institute this nationally. 

Although healthcare is local, there are things that we need to do, to allow to happen, nationally. Telehealth has showed us the obvious opportunity for us to be nationally aligned, because you need telehealth in Iowa just as much you need it in rural Florida or even urban Florida, right? We need it everywhere. We need to have consistent rules where physicians and health practitioners of all sorts—and that goes for mental health also, and other practitioners—can practice with telehealth no matter where they are located. 

GAGLANI: Absolutely. That echoes a lot of the lessons I think we're all taking away from this and hopefully its several silver linings are the change we'll see in the healthcare system as a result of COVID. 

My last question is, our audience obviously comprises a lot of current and future healthcare professionals. What advice would you give to them about meeting the challenges of the COVID pandemic and approaching their careers in healthcare? We can start with you, Dr. Paryani, and then end with you, Dr. Hamadi.

DR. PARYANI: Sure. I think the key is to take the initiative. Healthcare has finally showed us who's valuable in society. We have people who are very valuable in society in various ways. We regard healthcare as a necessary commodity, but really didn't realize how essential this really was. We finally found out that, of course, heroes are important and considered in athletics and politics and religious areas. Those are all important, but we finally realized that essential for everyday existence, healthcare personnel are very important. 

So I hope it lets everyone know who wants to consider healthcare as a future, that you're going to be very valued in society. This is a valued position. It's a very noble position. It's a noble calling. I encourage everyone who has that idea of serving society to go into healthcare. It's a very positive and rewarding time. There were challenges, but I think the positive that's going to come out is we realize how essential all healthcare personnel are.

DR. HAMADI: Just to kind of add to this and enhance what Dr. Paryani was saying, my only advice really for them is two-fold: Question everything. We say that the healthcare system is so complex, but question that. Is it really complex, or just simply so fragmented that not one single person can explain it? Be that agent of change in the way that you're disrupting the healthcare. 

A lot of the guests that you've had on this show are really agents for that change and destruction, and disruptive players in healthcare to really change it and simplify it in a way where now the patients are not clueless on what's happening. Even the providers who are providing the care a lot of times do not know what's happening within the walls of the hospital and behind the scenes of what's happening in administration.

On a more personal thing, as you engage in a healthcare system that requires you to be so much as part of a new patient's care and part of their lives as you take care of them, always remember your lines and your boundaries, your mental health. Reflect on where your line stands in administration as you connect with them. It's really important to learn how to say “no” at the right time and how to say “yes” for the right reasons.

GAGLANI: That's some really incredible advice to end on. I really want to thank both of you, not only for taking the time to be on the podcast, but also for the work that you're doing to train the current and next generation of healthcare leaders. 

DR. PARYANI: Thank you very much.

DR. HAMADI: Thank you so much for having us. 

GAGLANI: With that, I'm Shiv Gaglani. Thank you to our audience for checking out today's show, and remember to do your part to flatten the curve and raise the line. We are all in this together. Take care.