Latest / Becker’s Healthcare - Clinical Leadership Podcast / Andrew B. Wallach, Ambulatory Care Chief at NYC Health + Hospitals/Bellevue and Ambulatory Care Chief Medical Officer for NYC Health + Hospitals

Transcript

Andrew B. Wallach, Ambulatory Care Chief at NYC Health + Hospitals/Bellevue and Ambulatory Care Chief Medical Officer for NYC Health + Hospitals · Becker’s Healthcare - Clinical Leadership Podcast

• 0:00
  Hi. This is Paige Twenner, assistant editor with
• 0:03
  Becker's Health Care. I'm so, so excited to
• 0:06
  be joined by Andrew Wallach,
• 0:09
  an ambulatory care leader at NYC Health and
• 0:12
  Hospitals.
• 0:13
  I don't wanna take your thunder. So,
• 0:16
  doctor Wallach, if you can just, you know,
• 0:18
  briefly introduce yourself, tell us a bit about
• 0:20
  your organization, and then we'll dive right in.
• 0:22
  Wonderful. Well, thank you, Paige, for having me,
• 0:25
  today.
• 0:26
  Indeed, my name is Andrew Wallach, and I'm
• 0:28
  a board certified,
• 0:29
  internist. I like to describe myself as a
• 0:32
  recovering hospitalist,
• 0:33
  who's now working clinically,
• 0:35
  solely in the outpatient arena.
• 0:37
  And at my institution, which is New York
• 0:39
  City Health and Hospitals, I currently
• 0:42
  serve as the system's ambulatory
• 0:44
  chief medical officer.
• 0:46
  You may or may not know, but New
• 0:47
  York City Health and Hospitals,
• 0:49
  often known as H and H, is the
• 0:51
  largest municipal health care system here in The
• 0:53
  US.
• 0:54
  We operate as a public benefit corporation,
• 0:57
  and essentially serve as a safety net for
• 0:59
  New York City,
• 1:01
  and provide care for over 1,000,000,
• 1:03
  New Yorkers regardless of their ability to pay
• 1:06
  or their immigration status.
• 1:08
  And interestingly, we provide over 60% of all
• 1:11
  behavioral health care,
• 1:13
  here in New York City, so really, are
• 1:16
  at the the the forefront, of that. We
• 1:18
  have 11,
• 1:20
  acute care hospitals. We have five post acute
• 1:22
  or long term care centers. We have a
• 1:24
  federally qualified health center.
• 1:26
  We run a correctional health service,
• 1:28
  operation, and we also have our own,
• 1:32
  high quality, low to no cost health insurance
• 1:34
  plan called MetroPlus. So all that to say,
• 1:37
  we are big, and we reach all, all
• 1:39
  parts of New York.
• 1:41
  Big and mighty. And, I'm excited to hear
• 1:44
  about, Jarls' strategy
• 1:46
  through,
• 1:47
  this particularly
• 1:49
  severe,
• 1:50
  flu season currently.
• 1:52
  We were talking before the for listeners, we're
• 1:55
  doctor Wallach and I were talking before the
• 1:57
  podcast, and it sounds like New York's data,
• 2:00
  latest kinda shows that,
• 2:02
  the state has just passed its peak in
• 2:04
  flu hospitalizations.
• 2:06
  That's correct.
• 2:07
  I would love to hear, and I'm sure
• 2:09
  listeners would love to hear,
• 2:12
  what you all saw on the grounds. Like,
• 2:14
  what did you see in your
• 2:16
  in, H and H in terms of capacity
• 2:19
  and,
• 2:20
  flu acuity?
• 2:22
  Yeah. No. That's exactly right, Paige. Thankfully, at
• 2:24
  least, here in New York state, not only
• 2:27
  are total number of flu cases that are
• 2:29
  reported weekly,
• 2:30
  down, but so are hospitalizations,
• 2:32
  which, as we know, oftentimes lags,
• 2:35
  the number of cases.
• 2:36
  But as you alluded to, New York City
• 2:38
  was hit really hard,
• 2:39
  and early this year, by the flu outbreak,
• 2:42
  perhaps earlier than other jurisdictions,
• 2:44
  across the country. And in fact, on December
• 2:46
  2,
• 2:48
  of last year, our health commissioner declared influenza
• 2:50
  prevalent throughout the state,
• 2:52
  which is really kind of the activation, if
• 2:54
  you will, of our flu season.
• 2:57
  If you look at the data, the number
• 2:59
  of reported
• 3:00
  cases here in New York
• 3:02
  peaked at over seventy thousand affected individuals in
• 3:05
  a week.
• 3:06
  And, again, just to give you some comparison,
• 3:10
  last year's flu season in New York state,
• 3:13
  at its peak only had fifty five thousand
• 3:15
  cases reported per week. So pretty significant,
• 3:18
  you know, increase compared to to previous years.
• 3:22
  And in fact,
• 3:23
  not only these case counts, but the hospitalizations
• 3:26
  are the highest ever recorded in our region,
• 3:30
  dating back to 2004 when we started tracking
• 3:32
  this information. So it hit early,
• 3:35
  and it hit hard. Now interestingly,
• 3:37
  as of the week of January 3,
• 3:40
  as I mentioned a moment ago, a little
• 3:41
  bit of a lag in hospitalizations, but those
• 3:43
  started to come down. And then today's data
• 3:45
  actually showed,
• 3:47
  continuing decrease in hospitalizations
• 3:49
  related to flu. So what did we see
• 3:51
  here, at New York City Health and Hospitals?
• 3:53
  Well, our experience really mimicked
• 3:56
  very closely,
• 3:57
  you know, what we were seeing in the
• 3:59
  reported numbers. Our emergency departments,
• 4:02
  really, started seeing large numbers of folks presenting
• 4:05
  with respiratory symptoms.
• 4:07
  Our virtual express care, which is something that
• 4:09
  we have really grown out,
• 4:11
  since the pandemic,
• 4:13
  was also very busy in taking calls and
• 4:15
  patients who weren't feeling well,
• 4:18
  many from the flu.
• 4:20
  And then lastly, our outpatient practices also saw
• 4:23
  large influx
• 4:25
  of individuals, you know, presenting with these symptoms.
• 4:27
  Now interestingly,
• 4:28
  the the piece that we don't always talk
• 4:30
  about is not just the patients,
• 4:32
  but certainly kinda wearing my,
• 4:35
  health care system cap, if you will, is
• 4:38
  we wanna make sure that our staff also
• 4:40
  are protected. Right? Because they're people too. They
• 4:42
  get sick. We're, you know, we're not immune
• 4:44
  to all things.
• 4:46
  And so we really wanted to protect our
• 4:47
  workforce to make sure they were able to
• 4:49
  show up to work, to be able to
• 4:50
  take care of folks, who weren't doing well.
• 4:53
  Were you all expecting
• 4:55
  the early, like,
• 4:57
  season of flu or expecting,
• 5:00
  you know, that weekly caseload to exceed last
• 5:03
  year's record? Yeah. It's a really great question.
• 5:06
  So the short answer is yes. You know,
• 5:08
  based on experience that we saw in the
• 5:09
  Southern Hemisphere earlier this year and then certainly
• 5:13
  reports coming out of Japan and The United
• 5:15
  Kingdom. We knew about,
• 5:18
  you know, kind of the variant that was,
• 5:20
  you know, circulating the subclade,
• 5:22
  subclade k,
• 5:24
  variant, which we knew was causing, you know,
• 5:27
  havoc, if you will, overseas and down under.
• 5:29
  So we had the anticipation that it would
• 5:31
  be a rough flu season this year, but
• 5:34
  I don't think we appreciated just how quickly,
• 5:38
  it would fall upon us here in New
• 5:39
  York.
• 5:42
  You mentioned both the,
• 5:44
  virtual express care and,
• 5:46
  investment in protecting
• 5:48
  staff,
• 5:49
  to be able to care for this influx
• 5:51
  of patients. Can you kind of
• 5:54
  dive further,
• 5:55
  into those kinda care coordination strategies?
• 5:58
  Yeah. No. Sure. You know, I think one
• 6:00
  of the you know, I'm I'm definitely a
• 6:02
  glass half full kinda guy. And if you
• 6:05
  look back, over the COVID pandemic, which was
• 6:08
  so traumatic
• 6:09
  on so many levels for all of us,
• 6:10
  you know, in healthcare,
• 6:12
  one of the good things, or one of
• 6:14
  the several good things, that we learned and
• 6:17
  were able to develop was the role of
• 6:19
  virtual care. You know, we really weren't doing
• 6:21
  very much of it,
• 6:23
  before the pandemic. And quite honestly, we turned
• 6:25
  it on essentially overnight. And, you know, in
• 6:27
  the years since, we've been able to fine
• 6:29
  tune and grow it. And it has really
• 6:31
  become such an important
• 6:34
  aspect,
• 6:35
  of our care delivery model to
• 6:38
  allow patients
• 6:39
  to seek healthcare,
• 6:41
  without having to physically come in, to a
• 6:44
  facility. So it's something that we've continued to
• 6:46
  grow over time.
• 6:47
  And in a situation like this, really lends
• 6:49
  itself very nicely, especially in conjunction with the
• 6:52
  fact
• 6:53
  that there is so readily available, you know,
• 6:56
  in 2025
• 6:57
  and 2026,
• 6:58
  the ability for one to go to a
• 7:00
  retail pharmacy and purchase an over the counter,
• 7:03
  you know, flu test, if you will. So
• 7:05
  somebody can test, themselves if they have symptoms
• 7:07
  in the comfort of their home and then
• 7:09
  can pick up the phone,
• 7:11
  you know, and speak to a to a
• 7:13
  clinician,
• 7:14
  to get treatment if appropriate, and if nothing
• 7:16
  else, to get guidance.
• 7:18
  Now, with regard to our staff, again, to
• 7:20
  your point that we knew that it was
• 7:22
  going to be,
• 7:24
  a rough flu season,
• 7:26
  we really, this year,
• 7:28
  earlier than ever, really pushed with our staff,
• 7:31
  the importance of getting vaccinated. We really, you
• 7:34
  know,
• 7:36
  did full court,
• 7:37
  press, to let people know how important it
• 7:40
  was to get the vaccine. And although we
• 7:43
  know that the vaccine is not a perfect
• 7:45
  match this year, to the circulating strains, we
• 7:47
  do know that it still offers protection,
• 7:50
  certainly in decreasing severity of disease and certainly
• 7:53
  hospitalization and death. So those are some of
• 7:55
  the strategies that we kind of use this
• 7:57
  year in anticipation.
• 8:03
  Speaking on a broader lens outside of, New
• 8:05
  York,
• 8:06
  the day we're recording
• 8:08
  this podcast,
• 8:09
  you know, we're talking of, New York's kinda
• 8:11
  dip, but other, regions in the in The
• 8:14
  US are expecting,
• 8:16
  or have not yet hit their peak likely,
• 8:20
  in flu cases and hospitalizations.
• 8:23
  For hospital leaders out there that, you know,
• 8:25
  are reading the research, like, you know, we're
• 8:27
  watching the Southern Hemisphere data. We're, you know,
• 8:30
  watching what's happening in,
• 8:32
  New York and a a few other states.
• 8:34
  What
• 8:35
  top recommendations would you give them?
• 8:37
  Yeah. It's it's a really great question. And
• 8:40
  so, you know, from my perspective, again, I
• 8:42
  can't overemphasize. And I know I'm speaking, you
• 8:44
  know, to the to the converted,
• 8:46
  but making sure that staff and patients are
• 8:48
  vaccinated is just so critical. So I just
• 8:50
  wanna say that again and again and again
• 8:51
  because I think, you know,
• 8:53
  getting the word out is just so critical.
• 8:56
  So I can't under or overestimate, rather,
• 8:59
  the importance of that. Now that said,
• 9:02
  you know, when hospitals face a sudden surge,
• 9:05
  in in things like flu, for example,
• 9:08
  you really need to shift your strategy from
• 9:10
  what I call routine care to surge capacity
• 9:13
  management. And oftentimes, when we talk about surge
• 9:15
  capacity,
• 9:16
  I think of it in the four s
• 9:18
  framework, and that's really staffing,
• 9:21
  space,
• 9:22
  supplies, and systems. And so I'll go into
• 9:24
  a little bit more of what I mean
• 9:25
  by that. So space, again, lessons learned from
• 9:28
  the COVID pandemic is the ability to repurpose
• 9:31
  nonclinical areas, right, in order to maintain patient
• 9:34
  flow and safety. So there are areas and
• 9:37
  and parts of our facilities where we can
• 9:39
  readily flex back to active clinical care,
• 9:42
  to be able to take care of patients
• 9:44
  as needed.
• 9:45
  Some, facilities, depending on how severe, things may
• 9:48
  be, you want might wanna put up, temporary
• 9:51
  structures like tents, heated tents, outside your emergency
• 9:54
  departments, but really think creatively,
• 9:57
  of how you can add,
• 9:59
  clinical space, to be able to, adjust and
• 10:02
  flex,
• 10:03
  for the incoming.
• 10:04
  The other thing that we did, and, again,
• 10:06
  I would highly recommend to other health systems
• 10:08
  out there, is the idea of cohorting patients.
• 10:11
  Right? So historically, we always think of one
• 10:13
  patient
• 10:14
  to one room, especially when you're talking about
• 10:16
  isolation.
• 10:17
  But that's not always possible.
• 10:19
  We don't have enough isolation rooms for each
• 10:22
  individual person. So you can move towards cohorting
• 10:25
  together
• 10:26
  flu patients
• 10:27
  in a multi bedded room,
• 10:29
  to kind of help,
• 10:31
  get with space and flow.
• 10:33
  Oftentimes, they're called respiratory pods or dedicated wards.
• 10:36
  It also helps streamline
• 10:38
  your nursing care, right, because your nurses can
• 10:40
  really be dedicated to these folks. They know
• 10:42
  what they're doing, and can, be very attentive,
• 10:45
  to the needs of those, folks all with
• 10:47
  the same same diagnosis.
• 10:49
  From a staffing perspective, you know, that's always
• 10:51
  the crux, of all of our facilities. Right?
• 10:54
  And we rely so heavily
• 10:56
  on our amazing nursing staff. They really are
• 10:59
  the ones that keep us moving forward,
• 11:01
  and making sure patients are well cared for.
• 11:04
  And so developing things like internal float pools,
• 11:07
  have been very effective,
• 11:08
  in being able to kind of, again, flex,
• 11:10
  and manage, when you have these surges,
• 11:13
  and be able to focus on those areas
• 11:15
  of the hospital that that need it.
• 11:17
  Other things from a systems perspective, I like
• 11:19
  to really, you know, tend to think about
• 11:21
  kind of, performance from a system perspective
• 11:24
  is what can we do,
• 11:27
  to kind of implement,
• 11:29
  you know, kind of triage to treatment orders,
• 11:31
  if you will, like non patient specific orders.
• 11:34
  That includes things like having nurses when patients
• 11:37
  come in with respiratory symptoms, you know, go
• 11:39
  ahead and do swabs and test folks, start
• 11:42
  hydration protocols,
• 11:44
  even before the provider starts to see the
• 11:45
  physician. You don't wanna lose any time. So
• 11:47
  whatever you can do upfront,
• 11:49
  to kind of work as a team, I
• 11:51
  think really goes a long way.
• 11:53
  And then similarly,
• 11:54
  again, what's really important,
• 11:57
  is the use of our antivirals. Right? So
• 11:59
  we wanna get the message out to staff
• 12:01
  and to patients that if you're not feeling
• 12:03
  well, get tested early
• 12:05
  so that we know what we're dealing with.
• 12:07
  And if you're eligible, there are antivirals,
• 12:09
  that, that we can give you to shorten
• 12:12
  your
• 12:13
  course and certainly decrease the severity. So again,
• 12:16
  getting that message out and working,
• 12:18
  with, our clinicians,
• 12:20
  to make sure folks are getting treatment, as
• 12:22
  appropriate.
• 12:23
  And then, of course, lastly, you know, everything,
• 12:25
  you know, boils down to supplies and infection
• 12:27
  control. So maintaining,
• 12:29
  a system and monitoring your PPE supply so
• 12:32
  you don't get to the point where, oh
• 12:33
  my goodness, we only have a day's worth
• 12:35
  of, you know, N95 masks available, but really
• 12:37
  to make sure that you've got hard
• 12:39
  triggers,
• 12:40
  that let you know in advance so that
• 12:42
  you can order, and make sure that you
• 12:44
  always have a good supply, of these needed
• 12:46
  items.
• 12:47
  The last thing that I will mention from
• 12:49
  an infection prevention,
• 12:50
  and control process and something we actually did,
• 12:54
  at my hospital
• 12:55
  is when we saw this large surge,
• 12:58
  we actually moved to universal masking policies,
• 13:01
  meaning that, during the surge when we saw
• 13:04
  so many cases,
• 13:06
  we moved to the fact that you needed
• 13:07
  to wear a mask,
• 13:09
  regardless of whether you've had a flu vaccine
• 13:11
  during every direct patient, encounter. Again, the goal
• 13:14
  is to mitigate further transmission,
• 13:16
  keep our, patients and our staff, healthy, and
• 13:19
  and and not have others get infected.
• 13:21
  Yeah.
• 13:22
  And also on that note of supply, I
• 13:24
  would imagine, like, the antiviral, just supply of,
• 13:27
  you know, Tamiflu and other,
• 13:30
  common flu medications.
• 13:34
  I shortages are, popping up in different regions
• 13:38
  of different areas of The US, so I
• 13:39
  know also just something to keep track of.
• 13:41
  I'm not sure if that's a big concern
• 13:43
  for that. Yeah. It's a it's a really
• 13:45
  great point. Right? And and again, you know,
• 13:47
  looking back, not to to,
• 13:50
  beat a dead horse, but to look back
• 13:51
  to the pandemic,
• 13:53
  you know, again, another lesson learned from us
• 13:55
  is don't put all of your eggs in
• 13:56
  one basket. So historically, like, we would have
• 13:59
  one supplier, right, for antivirals. Right? And so
• 14:02
  our supply chain now has gotten very adept,
• 14:05
  at making sure that if our main supplier
• 14:08
  is out of a particular medication, do they
• 14:09
  have a backup? Do they have a second
• 14:11
  and a third tier,
• 14:12
  to make sure that we're always, well stocked,
• 14:15
  with the needed medications?
• 14:18
  We have about one minute left for our
• 14:20
  podcast recording. Is there anything
• 14:22
  we haven't talked about yet that you'd love
• 14:24
  to, you know, share with other hospital execs?
• 14:27
  Yeah. I mean, I think from my perspective,
• 14:29
  you know, here at New York City Health
• 14:30
  and Hospitals, my recommendation to my colleagues out
• 14:33
  there, and again, I hope that you guys
• 14:35
  quickly follow us, in coming down, you know,
• 14:37
  from your peak. But, you know, there there
• 14:39
  are four main essentials that I think of,
• 14:41
  kind of wearing, you know, my health care
• 14:43
  executive cap, and that is to make sure
• 14:45
  that there's tight communications. Right? And so one
• 14:47
  of the things we did is we conducted,
• 14:49
  bed huddles on a regular basis just to
• 14:51
  understand our census and our discharges to be
• 14:54
  able to plan,
• 14:55
  how to run our house.
• 14:57
  Again, from a safety perspective,
• 14:59
  making sure that you get the message out
• 15:01
  to folks that if you don't feel well,
• 15:03
  if you're sick, stay at home. We don't
• 15:05
  want you coming to work,
• 15:07
  infecting other individuals.
• 15:09
  Again, we talked about efficiencies, using standing orders
• 15:12
  where appropriate and allowed, you know, by your
• 15:14
  state legislatures. But that really goes a long
• 15:17
  way in helping, with those efficiencies.
• 15:19
  And then lastly, I would just remind all
• 15:22
  of us that it's hard, to being a
• 15:24
  healthcare provider in 2025 and 2026.
• 15:27
  And so, you know, be aware of what
• 15:29
  the toll that has taken upon our staff,
• 15:32
  and, you know, make sure that you recognize
• 15:34
  them, that you rotate people out. You don't
• 15:37
  want the same people working
• 15:39
  in the flu wards, if you will, day
• 15:40
  after day. Give folks a break,
• 15:43
  and consider
• 15:44
  that, to be able to have sustainable positions
• 15:47
  and keep your workforce healthy.
• 15:50
  To keep patients healthy in the end of
• 15:52
  the day. Yes. Exactly.
• 15:54
  Right. Well, thank you so much, doctor Wallach,
• 15:56
  for joining us on the Becker's podcast.
• 15:59
  It was my pleasure. Thank you for having
• 16:01
  me.