Neha Pathak, MD

This transcript has been edited for clarity.

Neha Pathak, MD: Hello. Today, we’re talking to Dr. Daniel Clauw, a professor at the University of Michigan in Ann Arbor, who is running a major trial on treatments for chronic back pain. We’re talking today about managing back pain in the post-opioid world. Thank you so much, Dr. Clauw, for taking the time to be our resident pain consultant today. Managing chronic pain can lead to a large amount of burnout and helplessness in the clinic setting. That’s the reality with some of the modalities that patients are requesting; there is still confusion about what is optimal for a particular type of patient, this feeling that we’re not really helping people get better, and whenever patients come in, that’s always still their chief complaint.

How would you advise providers to think about that and to settle into their role as communicators about better strategies without the burnout?

Daniel Clauw, MD: The first thing is to broaden the number of other providers that you get involved in these individuals’ care as the evidence base for all of these nonpharmacologic therapies being effective in chronic pain increases and increases. As third-party payers begin to reimburse for more and more of these therapies, it’s really difficult to manage chronic pain patients if you’re trying to do it alone on an island.

If you can, identify the good physical therapists in your community that are going to really work with people to give them an exercise program that they can use at home; find a pain psychologist that can offer some cognitive-behavioral therapy (CBT) for insomnia and some CBT for pain; and in the subset of patients with trauma, give them the emotional awareness of the neural reprocessing therapy for that specific subset.

As you start to identify more and more of these nonpharmacologic therapies that you want your patients to try, each of those has a set of providers and they can be incredibly helpful so that you, as the primary care provider (PCP), don’t really feel overwhelmed that you’re it, that you’re the only one.

Many of these individuals have more time to spend, and they have more one-on-one in-person time than you do as a primary care physician in the current healthcare system. Many of those providers have become really good at doing amateur CBT, goal-setting, and some of the other things that you need to do when you manage chronic pain patients. Try to find that other group of people that you can send your patients to that are going to be offering some of these nonpharmacologic therapies, and they’ll really help you manage these individuals.

Dr. Pathak: I think a couple of things come up for me. One is that we have to maybe broaden thinking about pain management, not only as multimodal strategies but also as multidisciplinary strategies. To your point, I think that’s really important. I also worry and wonder about health equity concerns, because just as overburdened as many PCPs are, we’re seeing it’s very difficult to get into physical therapy or to get into a setting where you’d be able to receive CBT for your pain. Any thoughts on those types of considerations?

Dr. Clauw: That’s a huge problem. Our group and many other groups in the pain space are developing websites, smartphone apps, and things like that to try to get some of these things directly to individuals with pain, not only for the reasons that you stated but also so that persons with pain don’t have to become patients. Our healthcare systems often make pain worse rather than better.

There were some great articles in The Lancet about 5 years ago talking about low back pain and that in different countries, the healthcare systems, for different reasons, have a tendency to actually make low back pain worse because they do too much surgery, immobilize people, or things like that rather than just not make them better. I think we’ve overmedicalized chronic pain in some settings, and much of what we’re trying to lead people to are things that are parts of wellness programs. The NIH National Center for Complementary and Integrative Health director talks about whole person health often.

I think that these interdisciplinary, integrative approaches are what we have to be using for chronic pain patients. I tell pain patients that, among acupuncture, acupressure, mindfulness, five different forms of CBT, yoga, and tai chi, I don’t know which of those is going to work, but I know that about 1 in 3 individuals that tries each of those therapies gets a benefit. What I really should be doing most is incentivizing people and motivating people to keep trying some of those nonpharmacologic approaches that they haven’t yet tried, because when they find one that works for them, then they will integrate it into their day-to-day life.

The other trick I would use for primary care physicians or anyone managing chronic pain patients is, don’t try to incentivize a pain patient to go try a new nonpharmacologic therapy or start an exercise program because you want their pain score to go from a 6 to a 3. Incentivize them by asking them, what are two or three things that you’re not able to do now because you have chronic pain that you’d really like to be able to do?

You’d like to play nine holes of golf; you’d like to be able to hug your grandchild; or you’d like to be able to do something else. Use those functional goals that are patient0driven to motivate your patients to do these things, because that will work much better. Again, any of us are inherently more likely to take the time and the effort to do some of these nonpharmacologic therapies if it’s for a reason that internally motivates us.

Dr. Pathak: I think that’s great. I’m very privileged to work within the Veterans Affairs (VA) healthcare system. I think that there’s been a huge shift within VA healthcare to provide these ancillary services, whether it’s yoga, tai chi, or acupuncture, as an adjunct to the pain management strategy.

Also, what comes up for me, as you’re saying, is grounding the point that instead of relying on a pain score — which can be objective and different from patient to patient and even within a patient — we should choose a smart goal that is almost more objective when it’s functional. Your goal is to walk two blocks to the mailbox. Can we achieve that as part of your pain control strategy?

I so appreciate your taking the time to be our pain consultant today. I really appreciate our discussion, and I’d like to hand it over to you for any final thoughts.

Dr. Clauw: I’d add that when you’re seeing chronic pain patients, many of them are going to have comorbid sleep problems. They’re going to have comorbid problems with fatigue and memory problems, especially the central nervous system–driven forms of pain that we now call nociplastic pain. Look at those as therapeutic targets.

If you’re befuddled because you’ve tried many different things for pain in this individual you’ve been seeing for a while, focus on their sleep and focus on getting them more active. Don’t use the word exercise — because that scares chronic pain patients — but focus on getting them more active.

There are many different tactics and strategies that you can use to motivate the patients to try some of these new nonpharmacologic approaches as the evidence base continues to increase.

Dr. Pathak: Thank you so much, again, to Dr. Clauw for joining us and being our pain consultant, really helping us to think about managing back pain in the postopioid world.
 

Dr. Pathak is Chief Physician Editor, Health and Lifestyle Medicine, WebMD. She has disclosed no relevant financial relationships. Dr. Clauw is Director, Chronic Pain and Fatigue Research Center, Department of Anesthesia, University of Michigan, Ann Arbor. He disclosed ties with Tonix and Viatris.

A version of this article appeared on Medscape.com.

This transcript has been edited for clarity.

Neha Pathak, MD: Hello. Today, we’re talking to Dr. Daniel Clauw, a professor at the University of Michigan in Ann Arbor, who is running a major trial on treatments for chronic back pain. We’re talking today about managing back pain in the post-opioid world. Thank you so much, Dr. Clauw, for taking the time to be our resident pain consultant today. Managing chronic pain can lead to a large amount of burnout and helplessness in the clinic setting. That’s the reality with some of the modalities that patients are requesting; there is still confusion about what is optimal for a particular type of patient, this feeling that we’re not really helping people get better, and whenever patients come in, that’s always still their chief complaint.

How would you advise providers to think about that and to settle into their role as communicators about better strategies without the burnout?

Daniel Clauw, MD: The first thing is to broaden the number of other providers that you get involved in these individuals’ care as the evidence base for all of these nonpharmacologic therapies being effective in chronic pain increases and increases. As third-party payers begin to reimburse for more and more of these therapies, it’s really difficult to manage chronic pain patients if you’re trying to do it alone on an island.

If you can, identify the good physical therapists in your community that are going to really work with people to give them an exercise program that they can use at home; find a pain psychologist that can offer some cognitive-behavioral therapy (CBT) for insomnia and some CBT for pain; and in the subset of patients with trauma, give them the emotional awareness of the neural reprocessing therapy for that specific subset.

As you start to identify more and more of these nonpharmacologic therapies that you want your patients to try, each of those has a set of providers and they can be incredibly helpful so that you, as the primary care provider (PCP), don’t really feel overwhelmed that you’re it, that you’re the only one.

Many of these individuals have more time to spend, and they have more one-on-one in-person time than you do as a primary care physician in the current healthcare system. Many of those providers have become really good at doing amateur CBT, goal-setting, and some of the other things that you need to do when you manage chronic pain patients. Try to find that other group of people that you can send your patients to that are going to be offering some of these nonpharmacologic therapies, and they’ll really help you manage these individuals.

Dr. Pathak: I think a couple of things come up for me. One is that we have to maybe broaden thinking about pain management, not only as multimodal strategies but also as multidisciplinary strategies. To your point, I think that’s really important. I also worry and wonder about health equity concerns, because just as overburdened as many PCPs are, we’re seeing it’s very difficult to get into physical therapy or to get into a setting where you’d be able to receive CBT for your pain. Any thoughts on those types of considerations?

Dr. Clauw: That’s a huge problem. Our group and many other groups in the pain space are developing websites, smartphone apps, and things like that to try to get some of these things directly to individuals with pain, not only for the reasons that you stated but also so that persons with pain don’t have to become patients. Our healthcare systems often make pain worse rather than better.

There were some great articles in The Lancet about 5 years ago talking about low back pain and that in different countries, the healthcare systems, for different reasons, have a tendency to actually make low back pain worse because they do too much surgery, immobilize people, or things like that rather than just not make them better. I think we’ve overmedicalized chronic pain in some settings, and much of what we’re trying to lead people to are things that are parts of wellness programs. The NIH National Center for Complementary and Integrative Health director talks about whole person health often.

I think that these interdisciplinary, integrative approaches are what we have to be using for chronic pain patients. I tell pain patients that, among acupuncture, acupressure, mindfulness, five different forms of CBT, yoga, and tai chi, I don’t know which of those is going to work, but I know that about 1 in 3 individuals that tries each of those therapies gets a benefit. What I really should be doing most is incentivizing people and motivating people to keep trying some of those nonpharmacologic approaches that they haven’t yet tried, because when they find one that works for them, then they will integrate it into their day-to-day life.

The other trick I would use for primary care physicians or anyone managing chronic pain patients is, don’t try to incentivize a pain patient to go try a new nonpharmacologic therapy or start an exercise program because you want their pain score to go from a 6 to a 3. Incentivize them by asking them, what are two or three things that you’re not able to do now because you have chronic pain that you’d really like to be able to do?

You’d like to play nine holes of golf; you’d like to be able to hug your grandchild; or you’d like to be able to do something else. Use those functional goals that are patient0driven to motivate your patients to do these things, because that will work much better. Again, any of us are inherently more likely to take the time and the effort to do some of these nonpharmacologic therapies if it’s for a reason that internally motivates us.

Dr. Pathak: I think that’s great. I’m very privileged to work within the Veterans Affairs (VA) healthcare system. I think that there’s been a huge shift within VA healthcare to provide these ancillary services, whether it’s yoga, tai chi, or acupuncture, as an adjunct to the pain management strategy.

Also, what comes up for me, as you’re saying, is grounding the point that instead of relying on a pain score — which can be objective and different from patient to patient and even within a patient — we should choose a smart goal that is almost more objective when it’s functional. Your goal is to walk two blocks to the mailbox. Can we achieve that as part of your pain control strategy?

I so appreciate your taking the time to be our pain consultant today. I really appreciate our discussion, and I’d like to hand it over to you for any final thoughts.

Dr. Clauw: I’d add that when you’re seeing chronic pain patients, many of them are going to have comorbid sleep problems. They’re going to have comorbid problems with fatigue and memory problems, especially the central nervous system–driven forms of pain that we now call nociplastic pain. Look at those as therapeutic targets.

If you’re befuddled because you’ve tried many different things for pain in this individual you’ve been seeing for a while, focus on their sleep and focus on getting them more active. Don’t use the word exercise — because that scares chronic pain patients — but focus on getting them more active.

There are many different tactics and strategies that you can use to motivate the patients to try some of these new nonpharmacologic approaches as the evidence base continues to increase.

Dr. Pathak: Thank you so much, again, to Dr. Clauw for joining us and being our pain consultant, really helping us to think about managing back pain in the postopioid world.
 

Dr. Pathak is Chief Physician Editor, Health and Lifestyle Medicine, WebMD. She has disclosed no relevant financial relationships. Dr. Clauw is Director, Chronic Pain and Fatigue Research Center, Department of Anesthesia, University of Michigan, Ann Arbor. He disclosed ties with Tonix and Viatris.

A version of this article appeared on Medscape.com.

This transcript has been edited for clarity.

Neha Pathak, MD: Hello. Today, we’re talking to Dr. Daniel Clauw, a professor at the University of Michigan in Ann Arbor, who is running a major trial on treatments for chronic back pain. We’re talking today about managing back pain in the post-opioid world. Thank you so much, Dr. Clauw, for taking the time to be our resident pain consultant today. Managing chronic pain can lead to a large amount of burnout and helplessness in the clinic setting. That’s the reality with some of the modalities that patients are requesting; there is still confusion about what is optimal for a particular type of patient, this feeling that we’re not really helping people get better, and whenever patients come in, that’s always still their chief complaint.

How would you advise providers to think about that and to settle into their role as communicators about better strategies without the burnout?

Daniel Clauw, MD: The first thing is to broaden the number of other providers that you get involved in these individuals’ care as the evidence base for all of these nonpharmacologic therapies being effective in chronic pain increases and increases. As third-party payers begin to reimburse for more and more of these therapies, it’s really difficult to manage chronic pain patients if you’re trying to do it alone on an island.

If you can, identify the good physical therapists in your community that are going to really work with people to give them an exercise program that they can use at home; find a pain psychologist that can offer some cognitive-behavioral therapy (CBT) for insomnia and some CBT for pain; and in the subset of patients with trauma, give them the emotional awareness of the neural reprocessing therapy for that specific subset.

As you start to identify more and more of these nonpharmacologic therapies that you want your patients to try, each of those has a set of providers and they can be incredibly helpful so that you, as the primary care provider (PCP), don’t really feel overwhelmed that you’re it, that you’re the only one.

Many of these individuals have more time to spend, and they have more one-on-one in-person time than you do as a primary care physician in the current healthcare system. Many of those providers have become really good at doing amateur CBT, goal-setting, and some of the other things that you need to do when you manage chronic pain patients. Try to find that other group of people that you can send your patients to that are going to be offering some of these nonpharmacologic therapies, and they’ll really help you manage these individuals.

Dr. Pathak: I think a couple of things come up for me. One is that we have to maybe broaden thinking about pain management, not only as multimodal strategies but also as multidisciplinary strategies. To your point, I think that’s really important. I also worry and wonder about health equity concerns, because just as overburdened as many PCPs are, we’re seeing it’s very difficult to get into physical therapy or to get into a setting where you’d be able to receive CBT for your pain. Any thoughts on those types of considerations?

Dr. Clauw: That’s a huge problem. Our group and many other groups in the pain space are developing websites, smartphone apps, and things like that to try to get some of these things directly to individuals with pain, not only for the reasons that you stated but also so that persons with pain don’t have to become patients. Our healthcare systems often make pain worse rather than better.

There were some great articles in The Lancet about 5 years ago talking about low back pain and that in different countries, the healthcare systems, for different reasons, have a tendency to actually make low back pain worse because they do too much surgery, immobilize people, or things like that rather than just not make them better. I think we’ve overmedicalized chronic pain in some settings, and much of what we’re trying to lead people to are things that are parts of wellness programs. The NIH National Center for Complementary and Integrative Health director talks about whole person health often.

I think that these interdisciplinary, integrative approaches are what we have to be using for chronic pain patients. I tell pain patients that, among acupuncture, acupressure, mindfulness, five different forms of CBT, yoga, and tai chi, I don’t know which of those is going to work, but I know that about 1 in 3 individuals that tries each of those therapies gets a benefit. What I really should be doing most is incentivizing people and motivating people to keep trying some of those nonpharmacologic approaches that they haven’t yet tried, because when they find one that works for them, then they will integrate it into their day-to-day life.

The other trick I would use for primary care physicians or anyone managing chronic pain patients is, don’t try to incentivize a pain patient to go try a new nonpharmacologic therapy or start an exercise program because you want their pain score to go from a 6 to a 3. Incentivize them by asking them, what are two or three things that you’re not able to do now because you have chronic pain that you’d really like to be able to do?

You’d like to play nine holes of golf; you’d like to be able to hug your grandchild; or you’d like to be able to do something else. Use those functional goals that are patient0driven to motivate your patients to do these things, because that will work much better. Again, any of us are inherently more likely to take the time and the effort to do some of these nonpharmacologic therapies if it’s for a reason that internally motivates us.

Dr. Pathak: I think that’s great. I’m very privileged to work within the Veterans Affairs (VA) healthcare system. I think that there’s been a huge shift within VA healthcare to provide these ancillary services, whether it’s yoga, tai chi, or acupuncture, as an adjunct to the pain management strategy.

Also, what comes up for me, as you’re saying, is grounding the point that instead of relying on a pain score — which can be objective and different from patient to patient and even within a patient — we should choose a smart goal that is almost more objective when it’s functional. Your goal is to walk two blocks to the mailbox. Can we achieve that as part of your pain control strategy?

I so appreciate your taking the time to be our pain consultant today. I really appreciate our discussion, and I’d like to hand it over to you for any final thoughts.

Dr. Clauw: I’d add that when you’re seeing chronic pain patients, many of them are going to have comorbid sleep problems. They’re going to have comorbid problems with fatigue and memory problems, especially the central nervous system–driven forms of pain that we now call nociplastic pain. Look at those as therapeutic targets.

If you’re befuddled because you’ve tried many different things for pain in this individual you’ve been seeing for a while, focus on their sleep and focus on getting them more active. Don’t use the word exercise — because that scares chronic pain patients — but focus on getting them more active.

There are many different tactics and strategies that you can use to motivate the patients to try some of these new nonpharmacologic approaches as the evidence base continues to increase.

Dr. Pathak: Thank you so much, again, to Dr. Clauw for joining us and being our pain consultant, really helping us to think about managing back pain in the postopioid world.
 

Dr. Pathak is Chief Physician Editor, Health and Lifestyle Medicine, WebMD. She has disclosed no relevant financial relationships. Dr. Clauw is Director, Chronic Pain and Fatigue Research Center, Department of Anesthesia, University of Michigan, Ann Arbor. He disclosed ties with Tonix and Viatris.

A version of this article appeared on Medscape.com.

Heart disease. Cancer. Diabetes. Dementia.

Researchers spend billions of dollars every year trying to eradicate these medical scourges.

Yet even if we discover cures to these and all other chronic conditions, it won’t change our ultimate prognosis: death.

“That’s because you haven’t stopped aging,” says Jay Olshansky, PhD, a professor of epidemiology and biostatistics at the University of Illinois at Chicago School of Public Health.

But what if we could? What if we are trying to extend longevity in the wrong way? Instead of focusing on diseases, should we take aim at aging itself?

Some scientists think so. Fueled in part by a billion dollars of investor money, they are attempting to reverse-engineer your molecular biological clock. Their goal? To eliminate not merely diseases that kill people, but to prevent death itself. 
 

Hacking the code for immortality

Aubrey de Grey, PhD, a biomedical gerontologist, has drawn wide attention for his belief that the first person who will live to be 1,000 years old is already among us. 

He believes there’s no cap on how long we can live, depending on what medicines we develop in the future.

“The whole idea is that there would not be a limit on how long we can keep people healthy,” Dr. de Grey says. He’s the chief science officer and co-founder of the SENS Research Foundation, which funds research on how to put the brakes on aging.

Dr. De Grey’s view, in theory, isn’t so far-fetched.

Scientists have studied the immortal jellyfish, Turritopsis dohrnii. It’s the only animal that can cheat death by reverting from adulthood back to its polyp stage when threatened with danger or starvation.

Other clues to possible eternal life also may exist underwater. Certain marine clams can live more than 500 years. And lobsters stock a seemingly limitless supply of a youthful enzyme that has some scientists wondering if the crustacean, under the best conditions, just might live forever.

Among humans, researchers have been studying “super-agers” – people who not only live exceptionally long, but also do so without many of the chronic diseases that plague their peers. That’s even though they share some of the same bad habits as everyone else.

“They are making it past the age of 80 with their minds completely intact. That’s what’s so unusual,” Dr. Olshansky says. The rest of their bodies are doing better than those of average 80-year-olds, too.

People who reached ages 95 to 112 got cancer, heart disease, diabetes, osteoporosis, and stroke up to 24 years later than those with average lifespans, data show. Figuring out why might pave the way for targeted gene therapy to mimic the DNA of these nonagenarians and centenarians.

“There’s likely to be secrets contained within their genome that are eventually discovered that will help us develop therapeutic interventions to mimic the effects of decelerated aging,” Dr. Olshansky says.

Treating aging this way may offer a bigger payoff than targeting individual diseases. That’s because even if you manage to dodge any illnesses, there’s ultimately no escaping old age.

“Longevity is a side effect of health,” Dr. de Grey says. “If we can keep people healthy, then their likelihood of dying is reduced.”
 

Aging as a preventable condition

In 2015, Michael Cantor was prescribed metformin for prediabetes. Once that was under control, his doctor said Mr. Cantor could quit the drug. But Mr. Cantor had heard about studies testing it as an anti-aging drug. The 62-year-old Connecticut-based attorney asked if he could stay on it. A year ago Cantor’s wife, Shari, who is mayor of West Hartford, Conn., started to take metformin, too.

“I read the articles, they made a lot of sense to me, and with the number of people that have been taking this drug worldwide for decades, I felt like there was nothing to lose,” he says.

The couple can’t say if their daily doses have led to any changes in how they look or feel. After all, they’re taking the pills not to treat current ailments but to prevent ones in the future.

They may have answers soon. Nir Barzilai, MD, director of the National Institutes of Health’s Nathan Shock Centers of Excellence in the Basic Biology of Aging, is leading a study that hopes to prove aging is a preventable health condition. The TAME (Targeting Aging with Metformin) study is designed to do this by demonstrating that metformin, a cheap and widely prescribed pill for diabetes, may also be an anti-aging elixir.

The TAME trial is currently in phase III – typically the final step of research into any treatment before drugmakers can apply for FDA approval.

Earlier studies found that people with type 2 diabetes who take metformin have lower death rates from any cause, compared to peers who don’t take the drug. Metformin also seems to help curb the incidence of age-related diseases, including heart disease, dementia, and Alzheimer›s. It also may lower the risk of many types of cancer as well as raise the chances of survival. Observations made since the beginning of the COVID-19 pandemic suggest that people who get the virus while taking metformin are less likely to land in the hospital or die from it.

It’s not clear exactly how metformin works to do all that. The compound was originally derived from Galega officinalis, also known as goat’s rue, a perennial plant used as medicine since medieval times.

Dr. Barzilai says he hopes to prove that aging is a preventable condition.

“If the results are what they think they will be, the whole world could go on metformin and extend life for everybody – extend your good quality of life,” Dr. Barzilai says. “That’s what we all want. Every extra year that we could get where we’re still vigorous and vital would be amazing.”

Long life versus healthy life

Some researchers argue that only the “healthspan” – the period of life free of illness – is worth extending. Of course, a healthy lifestyle can add years to most people’s lives and actually improve cellular aging. Some of the biggest payoffs come from quitting or never smoking, logging more than 5½ hours of physical activity per week, and keeping a normal weight.

Drugs may be able to do that as well by interrupting common markers of aging, including telomere length, inflammation, oxidative stress, and slower cell metabolism.

“You don’t have to target all of these hallmarks to get improvement” in healthspans, says Dr. Barzilai, who also is director of the Institute for Aging Research at the Albert Einstein College of Medicine in the Bronx and scientific director of the American Federation for Aging Research.

“If you target one, you show benefit in the others.”

The medical term for growing old is senescence. Buffeted by DNA damage and stresses, your cells deteriorate and eventually stop multiplying, but don’t die.

That slowdown may have big consequences for your health. Your genes become more likely to get mutations, which can pave the way for cancer. Mitochondria, which produce energy in the cell, struggle to fuel your body. That can damage cells and cause chronic inflammation, which plays a part in diabetes, arthritis, ulcerative colitis, and many other diseases.

One major hallmark of aging is the growing stockpile of these senescent cells. Damaged cells become deactivated as a way to protect your body from harmful or uncontrolled cell division. But like the rotten apple that spoils the whole bunch, senescent cells encourage their neighbors to turn dysfunctional, too. They also emit proteins that trigger inflammation. Your body naturally removes these dormant cells. But older immune systems have a harder time cleaning up, so the senescent cells are more likely to hang around.

Flushing out this accumulated debris may be one way to avert aging, some experts say.

Dr. De Grey also believes that could be done with drugs.

“These therapies would actually repair [cellular] damage,” he says. “They’ll eliminate damage from the body by resetting or turning back the clock.”

James Kirkland, MD, PhD, of the Mayo Clinic, is one researcher exploring this theory. He gave a mixture of the cancer drug dasatinib and a plant pigment called quercetin to people with diabetic kidney disease. Quercetin is an antioxidant that gives grapes, tomatoes, and other fruits and vegetables their flavor.

A small phase I clinical trial showed that the dasatinib-quercetin combination got rid of senescent cells in the tissues of people with the disease.

The researchers don’t know yet if the results will translate into prolonged youth. They also don’t know how high a dosage is needed and what long-term problems the treatment might cause. People with chronic leukemia take dasatinib for years with few serious ill effects.

In another recent study, scientists used oxygen therapy to tackle senescent cells. Thirty-five adults ages 64 and older received oxygen therapy in a pressurized chamber. After 60 daily sessions, they showed a decrease in senescent cells and improvement in the length of DNA segments called telomeres. Shortened segments of telomeres are thought to be another marker of aging.

Researchers are also looking to the gene-editing technology CRISPR for anti-aging treatments, but the testing is only in mice so far.

Dr. Barzilai hopes that if the metformin trial succeeds, it will open the floodgates to a wave of new drugs that can stop or reverse human aging. Some of the major players in this field include Juvenescence, AgeX Therapeutics, LyGenesis, and Life Biosciences, which Dr. Barzilai founded.

“Until aging is seen as preventable, health plans won’t have to pay for this type of treatment,” he says. And if health plans won’t cover aging, pharmaceutical companies have little incentive to invest in drug development.

That may be the only thing standing between humans and unprecedented lifespans. The Census Bureau projects that Americans born in 2060 should live an average of 85.6 years, up from 78.7 years in 2018. Dr. De Grey’s prediction tops that mark by a factor of about 50. He believes that the life expectancy for someone born in 2100 may well be 5,000 years.

Dr. Barzilai, for his part, has a prediction that’s seemingly more modest.

“We die at 80. Getting an additional 35 years is relatively low-hanging fruit,” he says. “But I don’t believe that is a fixed limit.”

A version of this article first appeared on WebMD.com.

Heart disease. Cancer. Diabetes. Dementia.

Researchers spend billions of dollars every year trying to eradicate these medical scourges.

Yet even if we discover cures to these and all other chronic conditions, it won’t change our ultimate prognosis: death.

“That’s because you haven’t stopped aging,” says Jay Olshansky, PhD, a professor of epidemiology and biostatistics at the University of Illinois at Chicago School of Public Health.

But what if we could? What if we are trying to extend longevity in the wrong way? Instead of focusing on diseases, should we take aim at aging itself?

Some scientists think so. Fueled in part by a billion dollars of investor money, they are attempting to reverse-engineer your molecular biological clock. Their goal? To eliminate not merely diseases that kill people, but to prevent death itself. 
 

Hacking the code for immortality

Aubrey de Grey, PhD, a biomedical gerontologist, has drawn wide attention for his belief that the first person who will live to be 1,000 years old is already among us. 

He believes there’s no cap on how long we can live, depending on what medicines we develop in the future.

“The whole idea is that there would not be a limit on how long we can keep people healthy,” Dr. de Grey says. He’s the chief science officer and co-founder of the SENS Research Foundation, which funds research on how to put the brakes on aging.

Dr. De Grey’s view, in theory, isn’t so far-fetched.

Scientists have studied the immortal jellyfish, Turritopsis dohrnii. It’s the only animal that can cheat death by reverting from adulthood back to its polyp stage when threatened with danger or starvation.

Other clues to possible eternal life also may exist underwater. Certain marine clams can live more than 500 years. And lobsters stock a seemingly limitless supply of a youthful enzyme that has some scientists wondering if the crustacean, under the best conditions, just might live forever.

Among humans, researchers have been studying “super-agers” – people who not only live exceptionally long, but also do so without many of the chronic diseases that plague their peers. That’s even though they share some of the same bad habits as everyone else.

“They are making it past the age of 80 with their minds completely intact. That’s what’s so unusual,” Dr. Olshansky says. The rest of their bodies are doing better than those of average 80-year-olds, too.

People who reached ages 95 to 112 got cancer, heart disease, diabetes, osteoporosis, and stroke up to 24 years later than those with average lifespans, data show. Figuring out why might pave the way for targeted gene therapy to mimic the DNA of these nonagenarians and centenarians.

“There’s likely to be secrets contained within their genome that are eventually discovered that will help us develop therapeutic interventions to mimic the effects of decelerated aging,” Dr. Olshansky says.

Treating aging this way may offer a bigger payoff than targeting individual diseases. That’s because even if you manage to dodge any illnesses, there’s ultimately no escaping old age.

“Longevity is a side effect of health,” Dr. de Grey says. “If we can keep people healthy, then their likelihood of dying is reduced.”
 

Aging as a preventable condition

In 2015, Michael Cantor was prescribed metformin for prediabetes. Once that was under control, his doctor said Mr. Cantor could quit the drug. But Mr. Cantor had heard about studies testing it as an anti-aging drug. The 62-year-old Connecticut-based attorney asked if he could stay on it. A year ago Cantor’s wife, Shari, who is mayor of West Hartford, Conn., started to take metformin, too.

“I read the articles, they made a lot of sense to me, and with the number of people that have been taking this drug worldwide for decades, I felt like there was nothing to lose,” he says.

The couple can’t say if their daily doses have led to any changes in how they look or feel. After all, they’re taking the pills not to treat current ailments but to prevent ones in the future.

They may have answers soon. Nir Barzilai, MD, director of the National Institutes of Health’s Nathan Shock Centers of Excellence in the Basic Biology of Aging, is leading a study that hopes to prove aging is a preventable health condition. The TAME (Targeting Aging with Metformin) study is designed to do this by demonstrating that metformin, a cheap and widely prescribed pill for diabetes, may also be an anti-aging elixir.

The TAME trial is currently in phase III – typically the final step of research into any treatment before drugmakers can apply for FDA approval.

Earlier studies found that people with type 2 diabetes who take metformin have lower death rates from any cause, compared to peers who don’t take the drug. Metformin also seems to help curb the incidence of age-related diseases, including heart disease, dementia, and Alzheimer›s. It also may lower the risk of many types of cancer as well as raise the chances of survival. Observations made since the beginning of the COVID-19 pandemic suggest that people who get the virus while taking metformin are less likely to land in the hospital or die from it.

It’s not clear exactly how metformin works to do all that. The compound was originally derived from Galega officinalis, also known as goat’s rue, a perennial plant used as medicine since medieval times.

Dr. Barzilai says he hopes to prove that aging is a preventable condition.

“If the results are what they think they will be, the whole world could go on metformin and extend life for everybody – extend your good quality of life,” Dr. Barzilai says. “That’s what we all want. Every extra year that we could get where we’re still vigorous and vital would be amazing.”

Long life versus healthy life

Some researchers argue that only the “healthspan” – the period of life free of illness – is worth extending. Of course, a healthy lifestyle can add years to most people’s lives and actually improve cellular aging. Some of the biggest payoffs come from quitting or never smoking, logging more than 5½ hours of physical activity per week, and keeping a normal weight.

Drugs may be able to do that as well by interrupting common markers of aging, including telomere length, inflammation, oxidative stress, and slower cell metabolism.

“You don’t have to target all of these hallmarks to get improvement” in healthspans, says Dr. Barzilai, who also is director of the Institute for Aging Research at the Albert Einstein College of Medicine in the Bronx and scientific director of the American Federation for Aging Research.

“If you target one, you show benefit in the others.”

The medical term for growing old is senescence. Buffeted by DNA damage and stresses, your cells deteriorate and eventually stop multiplying, but don’t die.

That slowdown may have big consequences for your health. Your genes become more likely to get mutations, which can pave the way for cancer. Mitochondria, which produce energy in the cell, struggle to fuel your body. That can damage cells and cause chronic inflammation, which plays a part in diabetes, arthritis, ulcerative colitis, and many other diseases.

One major hallmark of aging is the growing stockpile of these senescent cells. Damaged cells become deactivated as a way to protect your body from harmful or uncontrolled cell division. But like the rotten apple that spoils the whole bunch, senescent cells encourage their neighbors to turn dysfunctional, too. They also emit proteins that trigger inflammation. Your body naturally removes these dormant cells. But older immune systems have a harder time cleaning up, so the senescent cells are more likely to hang around.

Flushing out this accumulated debris may be one way to avert aging, some experts say.

Dr. De Grey also believes that could be done with drugs.

“These therapies would actually repair [cellular] damage,” he says. “They’ll eliminate damage from the body by resetting or turning back the clock.”

James Kirkland, MD, PhD, of the Mayo Clinic, is one researcher exploring this theory. He gave a mixture of the cancer drug dasatinib and a plant pigment called quercetin to people with diabetic kidney disease. Quercetin is an antioxidant that gives grapes, tomatoes, and other fruits and vegetables their flavor.

A small phase I clinical trial showed that the dasatinib-quercetin combination got rid of senescent cells in the tissues of people with the disease.

The researchers don’t know yet if the results will translate into prolonged youth. They also don’t know how high a dosage is needed and what long-term problems the treatment might cause. People with chronic leukemia take dasatinib for years with few serious ill effects.

In another recent study, scientists used oxygen therapy to tackle senescent cells. Thirty-five adults ages 64 and older received oxygen therapy in a pressurized chamber. After 60 daily sessions, they showed a decrease in senescent cells and improvement in the length of DNA segments called telomeres. Shortened segments of telomeres are thought to be another marker of aging.

Researchers are also looking to the gene-editing technology CRISPR for anti-aging treatments, but the testing is only in mice so far.

Dr. Barzilai hopes that if the metformin trial succeeds, it will open the floodgates to a wave of new drugs that can stop or reverse human aging. Some of the major players in this field include Juvenescence, AgeX Therapeutics, LyGenesis, and Life Biosciences, which Dr. Barzilai founded.

“Until aging is seen as preventable, health plans won’t have to pay for this type of treatment,” he says. And if health plans won’t cover aging, pharmaceutical companies have little incentive to invest in drug development.

That may be the only thing standing between humans and unprecedented lifespans. The Census Bureau projects that Americans born in 2060 should live an average of 85.6 years, up from 78.7 years in 2018. Dr. De Grey’s prediction tops that mark by a factor of about 50. He believes that the life expectancy for someone born in 2100 may well be 5,000 years.

Dr. Barzilai, for his part, has a prediction that’s seemingly more modest.

“We die at 80. Getting an additional 35 years is relatively low-hanging fruit,” he says. “But I don’t believe that is a fixed limit.”

A version of this article first appeared on WebMD.com.

Heart disease. Cancer. Diabetes. Dementia.

Researchers spend billions of dollars every year trying to eradicate these medical scourges.

Yet even if we discover cures to these and all other chronic conditions, it won’t change our ultimate prognosis: death.

“That’s because you haven’t stopped aging,” says Jay Olshansky, PhD, a professor of epidemiology and biostatistics at the University of Illinois at Chicago School of Public Health.

But what if we could? What if we are trying to extend longevity in the wrong way? Instead of focusing on diseases, should we take aim at aging itself?

Some scientists think so. Fueled in part by a billion dollars of investor money, they are attempting to reverse-engineer your molecular biological clock. Their goal? To eliminate not merely diseases that kill people, but to prevent death itself. 
 

Hacking the code for immortality

Aubrey de Grey, PhD, a biomedical gerontologist, has drawn wide attention for his belief that the first person who will live to be 1,000 years old is already among us. 

He believes there’s no cap on how long we can live, depending on what medicines we develop in the future.

“The whole idea is that there would not be a limit on how long we can keep people healthy,” Dr. de Grey says. He’s the chief science officer and co-founder of the SENS Research Foundation, which funds research on how to put the brakes on aging.

Dr. De Grey’s view, in theory, isn’t so far-fetched.

Scientists have studied the immortal jellyfish, Turritopsis dohrnii. It’s the only animal that can cheat death by reverting from adulthood back to its polyp stage when threatened with danger or starvation.

Other clues to possible eternal life also may exist underwater. Certain marine clams can live more than 500 years. And lobsters stock a seemingly limitless supply of a youthful enzyme that has some scientists wondering if the crustacean, under the best conditions, just might live forever.

Among humans, researchers have been studying “super-agers” – people who not only live exceptionally long, but also do so without many of the chronic diseases that plague their peers. That’s even though they share some of the same bad habits as everyone else.

“They are making it past the age of 80 with their minds completely intact. That’s what’s so unusual,” Dr. Olshansky says. The rest of their bodies are doing better than those of average 80-year-olds, too.

People who reached ages 95 to 112 got cancer, heart disease, diabetes, osteoporosis, and stroke up to 24 years later than those with average lifespans, data show. Figuring out why might pave the way for targeted gene therapy to mimic the DNA of these nonagenarians and centenarians.

“There’s likely to be secrets contained within their genome that are eventually discovered that will help us develop therapeutic interventions to mimic the effects of decelerated aging,” Dr. Olshansky says.

Treating aging this way may offer a bigger payoff than targeting individual diseases. That’s because even if you manage to dodge any illnesses, there’s ultimately no escaping old age.

“Longevity is a side effect of health,” Dr. de Grey says. “If we can keep people healthy, then their likelihood of dying is reduced.”
 

Aging as a preventable condition

In 2015, Michael Cantor was prescribed metformin for prediabetes. Once that was under control, his doctor said Mr. Cantor could quit the drug. But Mr. Cantor had heard about studies testing it as an anti-aging drug. The 62-year-old Connecticut-based attorney asked if he could stay on it. A year ago Cantor’s wife, Shari, who is mayor of West Hartford, Conn., started to take metformin, too.

“I read the articles, they made a lot of sense to me, and with the number of people that have been taking this drug worldwide for decades, I felt like there was nothing to lose,” he says.

The couple can’t say if their daily doses have led to any changes in how they look or feel. After all, they’re taking the pills not to treat current ailments but to prevent ones in the future.

They may have answers soon. Nir Barzilai, MD, director of the National Institutes of Health’s Nathan Shock Centers of Excellence in the Basic Biology of Aging, is leading a study that hopes to prove aging is a preventable health condition. The TAME (Targeting Aging with Metformin) study is designed to do this by demonstrating that metformin, a cheap and widely prescribed pill for diabetes, may also be an anti-aging elixir.

The TAME trial is currently in phase III – typically the final step of research into any treatment before drugmakers can apply for FDA approval.

Earlier studies found that people with type 2 diabetes who take metformin have lower death rates from any cause, compared to peers who don’t take the drug. Metformin also seems to help curb the incidence of age-related diseases, including heart disease, dementia, and Alzheimer›s. It also may lower the risk of many types of cancer as well as raise the chances of survival. Observations made since the beginning of the COVID-19 pandemic suggest that people who get the virus while taking metformin are less likely to land in the hospital or die from it.

It’s not clear exactly how metformin works to do all that. The compound was originally derived from Galega officinalis, also known as goat’s rue, a perennial plant used as medicine since medieval times.

Dr. Barzilai says he hopes to prove that aging is a preventable condition.

“If the results are what they think they will be, the whole world could go on metformin and extend life for everybody – extend your good quality of life,” Dr. Barzilai says. “That’s what we all want. Every extra year that we could get where we’re still vigorous and vital would be amazing.”

Long life versus healthy life

Some researchers argue that only the “healthspan” – the period of life free of illness – is worth extending. Of course, a healthy lifestyle can add years to most people’s lives and actually improve cellular aging. Some of the biggest payoffs come from quitting or never smoking, logging more than 5½ hours of physical activity per week, and keeping a normal weight.

Drugs may be able to do that as well by interrupting common markers of aging, including telomere length, inflammation, oxidative stress, and slower cell metabolism.

“You don’t have to target all of these hallmarks to get improvement” in healthspans, says Dr. Barzilai, who also is director of the Institute for Aging Research at the Albert Einstein College of Medicine in the Bronx and scientific director of the American Federation for Aging Research.

“If you target one, you show benefit in the others.”

The medical term for growing old is senescence. Buffeted by DNA damage and stresses, your cells deteriorate and eventually stop multiplying, but don’t die.

That slowdown may have big consequences for your health. Your genes become more likely to get mutations, which can pave the way for cancer. Mitochondria, which produce energy in the cell, struggle to fuel your body. That can damage cells and cause chronic inflammation, which plays a part in diabetes, arthritis, ulcerative colitis, and many other diseases.

One major hallmark of aging is the growing stockpile of these senescent cells. Damaged cells become deactivated as a way to protect your body from harmful or uncontrolled cell division. But like the rotten apple that spoils the whole bunch, senescent cells encourage their neighbors to turn dysfunctional, too. They also emit proteins that trigger inflammation. Your body naturally removes these dormant cells. But older immune systems have a harder time cleaning up, so the senescent cells are more likely to hang around.

Flushing out this accumulated debris may be one way to avert aging, some experts say.

Dr. De Grey also believes that could be done with drugs.

“These therapies would actually repair [cellular] damage,” he says. “They’ll eliminate damage from the body by resetting or turning back the clock.”

James Kirkland, MD, PhD, of the Mayo Clinic, is one researcher exploring this theory. He gave a mixture of the cancer drug dasatinib and a plant pigment called quercetin to people with diabetic kidney disease. Quercetin is an antioxidant that gives grapes, tomatoes, and other fruits and vegetables their flavor.

A small phase I clinical trial showed that the dasatinib-quercetin combination got rid of senescent cells in the tissues of people with the disease.

The researchers don’t know yet if the results will translate into prolonged youth. They also don’t know how high a dosage is needed and what long-term problems the treatment might cause. People with chronic leukemia take dasatinib for years with few serious ill effects.

In another recent study, scientists used oxygen therapy to tackle senescent cells. Thirty-five adults ages 64 and older received oxygen therapy in a pressurized chamber. After 60 daily sessions, they showed a decrease in senescent cells and improvement in the length of DNA segments called telomeres. Shortened segments of telomeres are thought to be another marker of aging.

Researchers are also looking to the gene-editing technology CRISPR for anti-aging treatments, but the testing is only in mice so far.

Dr. Barzilai hopes that if the metformin trial succeeds, it will open the floodgates to a wave of new drugs that can stop or reverse human aging. Some of the major players in this field include Juvenescence, AgeX Therapeutics, LyGenesis, and Life Biosciences, which Dr. Barzilai founded.

“Until aging is seen as preventable, health plans won’t have to pay for this type of treatment,” he says. And if health plans won’t cover aging, pharmaceutical companies have little incentive to invest in drug development.

That may be the only thing standing between humans and unprecedented lifespans. The Census Bureau projects that Americans born in 2060 should live an average of 85.6 years, up from 78.7 years in 2018. Dr. De Grey’s prediction tops that mark by a factor of about 50. He believes that the life expectancy for someone born in 2100 may well be 5,000 years.

Dr. Barzilai, for his part, has a prediction that’s seemingly more modest.

“We die at 80. Getting an additional 35 years is relatively low-hanging fruit,” he says. “But I don’t believe that is a fixed limit.”

A version of this article first appeared on WebMD.com.

Millions of Americans have been languishing for weeks in the oppressive heat and humidity of a merciless summer. Deadly heat has already taken the lives of hundreds in the Pacific Northwest alone, with numbers likely to grow as the full impact of heat-related deaths eventually comes to light.

In the final week of July, the National Weather Service issued excessive heat warnings for 17 states, stretching from the West Coast, across the Midwest, down south into Louisiana and Georgia. Temperatures 10° to 15° F above average threaten the lives and livelihoods of people all across the country.

After a scorching heat wave in late June, residents of the Pacific Northwest are once again likely to see triple-digit temperatures in the coming days. With the heat, hospitals may face another surge of people with heat-related illnesses.

Erika Moseson, MD, a lung and intensive care specialist, witnessed firsthand the life-threatening impacts of soaring temperatures. She happened to be running her 10-bed intensive care unit in a suburban hospital in Gresham, Ore., about 15 miles east of Portland, the weekend of June 26. Within 12 hours, almost half her ICU beds were filled with people found unconscious on the street, in the bushes, or in their own beds, all because their body’s defenses had become overwhelmed by heat.

“It was unidentified person after unidentified person, coming in, same story, temperatures through the roof, comatose,” Dr. Moseson recalled. Young people in their 20s with muscle breakdown markers through the roof, a sign of rhabdomyolysis; people with no other medical problems that would have put them in a high-risk category.

As a lifelong Oregonian, she’d never seen anything like this before. “We’re all trained for it. I know what happens to you if you have heatstroke, I know how to treat it,” she trailed off, still finding it hard to believe. Still reeling from the number of cases in just a few hours. Still shocked that this happened on what’s supposed to be the cooler, rainforest side of Oregon.

Among those she treated and resuscitated, the memory of a patient that she lost continues to gnaw at her.

“I’ve gone back to it day after day since it happened,” she reflected.

Adults, in their 50s, living at home with their children. Just 1 hour prior, they’d all said goodnight. Then 1 hour later, when a child came to check in, both parents were unconscious.

Dr. Moseson shared how her team tried everything in their power for 18 hours to save the parent that was brought to her ICU. But like hundreds of others who went through the heat wave that weekend, her patient didn’t survive.

It was too late. From Dr. Moseson’s experience, it’s what happens “if you’re cooking a human.”
 

How heat kills

Regardless of where we live on the planet, humans maintain a consistent internal temperature around 98° F for our systems to function properly. 

Our bodies have an entire temperature-regulating system to balance heat gain with heat loss so we don’t stray too far from our ideal range. The hypothalamus functions as the thermostat, communicating with heat sensors in our skin, muscles, and spinal cord. Based on signals about our core body temperature, our nervous system makes many decisions for us – opening up blood vessels in the peripheral parts of our body, pushing more blood toward the skin, and activating sweat glands to produce more sweat.  

Sweat is one of the most powerful tools we have to maintain a safe internal temperature. Of course, there are some things under our control, such as removing clothing, drinking more water, and finding shade (or preferably air conditioning). But beyond that, it’s our ability to sweat that keeps us cool. When sweat evaporates into the air, heat from our skin goes with it, cooling us off.

Over time, our sweat response can work better as we get used to warmer environments, a process that’s known as acclimatization. Over the period of a few days to weeks, the sweat glands of acclimated people can start making sweat at lower temperatures, produce more sweat, and absorb more salt back into our system, all to make us more efficient “sweaters.”

While someone who’s not used to the heat may only produce 1 liter of sweat per hour, people who have become acclimated can produce 2-3 liters every hour, allowing evaporation to eliminate more than two times the amount of heat.   

Because the process of acclimatization can take some time, typically it’s the first throes of summer, or heat waves in places where people don’t typically see high temperatures, that are the most deadly. And of course, the right infrastructure, like access to air conditioning, also plays a large role in limiting heat-related death and hospitalization.

A 2019 study showed that heat-related hospitalizations peak at different temperatures in different places. For example, hospitalizations typically peak in Texas when the temperature hits 105° F. But they might be highest in the Pacific Northwest at just 81° F.

Even with acclimatization, there are limits to how much our bodies can adapt to heat. When the humidity goes up past 75%, there’s already so much moisture in the air that heat loss through evaporation no longer occurs.

It’s this connection between heat and humidity that can be deadly. This is why the heat index (a measure that takes into account temperature and relative humidity) and wet bulb globe temperature (a measure commonly used by the military and competitive athletes that takes into account temperature, humidity, wind speed, sun angle, and cloud cover) are both better at showing how dangerous the heat may be for our health, compared to temperature alone.

Kristie L. Ebi, PhD, a professor in the Center for Health and the Global Environment at the University of Washington, Seattle, has been studying the effects of heat and other climate-sensitive conditions on health for over 20 years. She stresses that it’s not just the recorded temperatures, but the prolonged exposure that kills.

If you never get a chance to bring down that core body temperature, if your internal temperatures stay above the range where your cells and your organs can work well for a long time, that’s when you can have the most dangerous effects of heat.

“It depends then on your age, your fitness, your individual physiology, underlying medical conditions, to how quickly that could affect the functioning of those organs. There’s lots of variability in there,” Dr. Ebi said.

Our hearts take on the brunt of the early response, working harder to pump blood toward the skin. Water and salt loss through our skin can start to cause electrolyte changes that can cause heat cramps and heat exhaustion. We feel tired, nauseated, dizzy. With enough water loss, we may become dehydrated, limiting the blood flow to our brains, causing us to pass out.

These early signs are like a car’s check engine light – systems are already being damaged, but resting, refueling, and, most importantly, turning off the heat are critical steps to prevent fatal injury.

If hazardous heat exposure continues and our internal temperatures continue to rise, nerves stop talking to each other, the proteins in our body unfold and lose their shape, and the cells of our organs disintegrate. This in turn sets off a fire alarm in our blood vessels, where a variety of chemical messengers, including “heat-shock proteins,” are released. The release of these inflammatory proteins, coupled with the loss of blood flow, eventually leads to the death of cells throughout the body, from the brain, to the heart, the muscles, and the kidneys.

This process is referred to as heatstroke. In essence, we melt from the inside.

At a certain point, this cascade can’t be reversed. Just like when you cool a melting block of ice, the parts that have melted will not go back to their original shape. It’s a similar process in our bodies, so delays in cooling and treatment can lead to death rates as high as 80%.

On the outside, we see people who look confused and disoriented, with hot skin and rapid breathing, and they may eventually become unconscious. Core body temperatures over 105° F clinch the diagnosis, but at the first sign of feeling unwell, cooling should be started.

There is no fancier or more effective treatment than that: Cool right away. In emergency rooms in Washington State, doctors used body bags filled with ice and water to cool victims of the heat wave in late June.

“It was all from heat ... that’s the thing, you feel so idiotic ... you’re like, ‘I’ve given you ice’ ... you bring their temperature down. But it’s already set off this cascade that you can’t stop,” Dr. Moseson said.

By the time Dr. Moseson’s patient made it to her, cooling with ice was just the beginning of the attempts to resuscitate and revive. The patient was already showing evidence of a process causing widespread bleeding and clotting, known as disseminated intravascular coagulation, along with damage to the heart and failing kidneys. Over 18 hours, her team cooled the patient, flooded the blood vessels with fluids and blood products, attempted to start dialysis, and inserted a breathing tube – all of the technology that is used to save people from serious cardiovascular collapse from other conditions. But nothing could reverse the melting that had already occurred.

Deaths from heat are 100% preventable. Until they’re not.
 

No respite

As Dr. Ebi says, the key to preventing heat-related death is to cool down enough to stabilize our internal cells and proteins before the irreversible cascade begins.

But for close to 80% of Americans who live in urban areas, temperatures can be even higher and more intolerable compared to surrounding areas because of the way we’ve designed our cities. In effect, we have unintentionally created hot zones called “urban heat islands.”

Jeremy Hoffman, PhD, chief scientist for the Science Museum of Virginia, explains that things like bricks, asphalt, and parking lots absorb more of the sun’s energy throughout the day and then emit that back into the air as heat throughout the afternoon and into the evening. This raises the air and surface temperatures in cities, relative to rural areas. When temperatures don’t cool enough at night, there’s no way to recover from the day’s heat. You start the next day still depleted, with less reserve to face the heat of a new day.

When you dig even deeper, it turns out that even within the same city, there are huge “thermal inequities,” as Dr. Hoffman calls them. In a 2019 study, he found that wealthier parts of cities had more natural spaces such as parks and tree-lined streets, compared to areas that had been intentionally “redlined,” or systematically deprived of investment. This pattern repeats itself in over 100 urban areas across the country and translates to huge temperature differences on the order of 10-20 degrees Fahrenheit within the same city, at the exact same time during a heat wave.

“In some ways, the way that we’ve decided to plan and build our cities physically turns up the thermostat by several tens of degrees during heat waves in particular neighborhoods,” Dr. Hoffman said.

Dr. Hoffman’s work showed that the city of Portland (where the death toll from the heat wave in late June was the highest) had some of the most intense differences between formerly redlined vs. tree-lined areas out of the more than 100 cities that he studied.  

“Watching it play out, I was really concerned, not only as a climate scientist, but as a human. Understanding the urban heat island effect and the extreme nature of the inequity in our cities, thermally and otherwise, once you start to really recognize it, you can’t forget it.”
 

The most vulnerable

When it comes to identifying and protecting the people most vulnerable to heat stress and heat-related death, there is an ever-growing list of those most at risk. Unfortunately, very few recognize when they themselves are at risk, often until it’s too late.

According to Linda McCauley, PhD, dean of the Emory University School of Nursing in Atlanta, “the scope of who is vulnerable is quickly increasing.”

For example, we’re used to recognizing that pregnant women and young children are at risk. Public health campaigns have long advised us not to leave young children and pets in hot cars. We know that adolescents who play sports during hot summer months are at high risk for heat-related events and even death.

In Georgia, a 15-year-old boy collapsed and died after his first day back at football practice when the heat index was 105° F on July 26, even as it appears that all protocols for heat safety were being followed.

We recognize that outdoor workers face devastating consequences from prolonged exertion in the heat and must have safer working conditions.

The elderly and those with long-term medical and mental health conditions are also more vulnerable to heat. The elderly may not have the same warning signs and may not recognize that they are dehydrated until it is too late. In addition, their sweating mechanism weakens, and they may be taking medicines that interfere with their ability to regulate their temperature.

Poverty and inadequate housing are risk factors, especially for those in urban heat islands. For many people, their housing does not have enough cooling to protect them, and they can’t safely get themselves to cooling shelters.

These patterns for the most vulnerable fit for the majority of deaths in Oregon during the late June heat wave. Most victims were older, lived alone, and didn’t have air conditioning. But with climate change, the predictions are that temperatures will go higher and heat waves will last longer.

“There’s probably very few people today that are ‘immune’ to the effects of heat-related stress with climate change. All of us can be put in situations where we are susceptible,” Dr. McCauley said.

Dr. Moseson agreed. Many of her patients fit none of these risk categories – she treated people with no health problems in their 20s in her ICU, and the patient she lost would not traditionally have been thought of as high risk. That 50-something patient had no long-standing medical problems, and lived with family in a newly renovated suburban home that had air conditioning. The only problem was that the air conditioner had broken and there had been no rush to fix it based on past experience with Oregon summers.
 

Preventing heat deaths

Protecting ourselves and our families means monitoring the “simple things.” The first three rules are to make sure we’re drinking plenty of water – this means drinking whether we feel thirsty or not. If we’re not in an air-conditioned place, we’ve got to look for shade. And we need to take regular rest breaks.

Inside a home without air conditioning, placing ice in front of a fan to cool the air can work, but realistically, if you are in a place without air conditioning and the temperatures are approaching 90° F, it’s safest to find another place to stay, if possible.

For those playing sports, there are usually 1-week to 2-week protocols that allow for acclimatization when the season begins – this means starting slowly, without gear, and ramping up activity. Still, parents and coaches should watch advanced weather reports to make sure it’s safe to practice outside.

How we dress can also help us, so light clothing is key. And if we’re able to schedule activities for times when it is cooler, that can also protect us from overheating.

If anyone shows early signs of heat stress, removing clothing, cooling their bodies with cold water, and getting them out of the heat is critical. Any evidence of heatstroke is an emergency, and 911 should be called without delay. The faster the core temperature can be dropped, the better the chances for recovery.

On the level of communities, access to natural air conditioning in the form of healthy tree canopies, and trees at bus stops to provide shade can help a lot. According to Dr. Hoffman, these investments help almost right away. Reimagining our cities to remove the “hot zones” that we have created is another key to protecting ourselves as our climate changes.
 

Reaching our limits in a changing climate

Already, we are seeing more intense, more frequent, and longer-lasting heat waves throughout the country and across the globe.

Dr. Ebi, a coauthor of a recently released scientific analysis that found that the late June Pacific Northwest heat wave would have been virtually impossible without climate change, herself lived through the scorching temperatures in Seattle. Her work shows that the changing climate is killing us right now.

We are approaching a time where extreme temperatures and humidity will make it almost impossible for people to be outside in many parts of the world. Researchers have found that periods of extreme humid heat have more than doubled since 1979, and some places have already had wet-bulb temperatures at the limits of what scientists think humans can tolerate under ideal conditions, meaning for people in perfect health, completely unclothed, in gale-force winds, performing no activity. Obviously that’s less than ideal for most of us and helps explain why thousands of people die at temperatures much lower than our upper limit.

Dr. Ebi pointed out that the good news is that many local communities with a long history of managing high temperatures have a lot of knowledge to share with regions that are newly dealing with these conditions. This includes how local areas develop early warning and response systems with specific action plans.

But, she cautions, it’s going to take a lot of coordination and a lot of behavior change to stabilize the earth’s climate, understand our weak points, and protect our health.

For Dr. Moseson, this reality has hit home.

“I already spent the year being terrified that I as an ICU doctor was going to be the one who gave my mom COVID. Finally I’m vaccinated, she’s vaccinated. Now I’ve watched someone die because they don’t have AC. And my parents, they’re old-school Oregonians, they don’t have AC.”

A version of this article originally appeared on WebMD.com.

Millions of Americans have been languishing for weeks in the oppressive heat and humidity of a merciless summer. Deadly heat has already taken the lives of hundreds in the Pacific Northwest alone, with numbers likely to grow as the full impact of heat-related deaths eventually comes to light.

In the final week of July, the National Weather Service issued excessive heat warnings for 17 states, stretching from the West Coast, across the Midwest, down south into Louisiana and Georgia. Temperatures 10° to 15° F above average threaten the lives and livelihoods of people all across the country.

After a scorching heat wave in late June, residents of the Pacific Northwest are once again likely to see triple-digit temperatures in the coming days. With the heat, hospitals may face another surge of people with heat-related illnesses.

Erika Moseson, MD, a lung and intensive care specialist, witnessed firsthand the life-threatening impacts of soaring temperatures. She happened to be running her 10-bed intensive care unit in a suburban hospital in Gresham, Ore., about 15 miles east of Portland, the weekend of June 26. Within 12 hours, almost half her ICU beds were filled with people found unconscious on the street, in the bushes, or in their own beds, all because their body’s defenses had become overwhelmed by heat.

“It was unidentified person after unidentified person, coming in, same story, temperatures through the roof, comatose,” Dr. Moseson recalled. Young people in their 20s with muscle breakdown markers through the roof, a sign of rhabdomyolysis; people with no other medical problems that would have put them in a high-risk category.

As a lifelong Oregonian, she’d never seen anything like this before. “We’re all trained for it. I know what happens to you if you have heatstroke, I know how to treat it,” she trailed off, still finding it hard to believe. Still reeling from the number of cases in just a few hours. Still shocked that this happened on what’s supposed to be the cooler, rainforest side of Oregon.

Among those she treated and resuscitated, the memory of a patient that she lost continues to gnaw at her.

“I’ve gone back to it day after day since it happened,” she reflected.

Adults, in their 50s, living at home with their children. Just 1 hour prior, they’d all said goodnight. Then 1 hour later, when a child came to check in, both parents were unconscious.

Dr. Moseson shared how her team tried everything in their power for 18 hours to save the parent that was brought to her ICU. But like hundreds of others who went through the heat wave that weekend, her patient didn’t survive.

It was too late. From Dr. Moseson’s experience, it’s what happens “if you’re cooking a human.”
 

How heat kills

Regardless of where we live on the planet, humans maintain a consistent internal temperature around 98° F for our systems to function properly. 

Our bodies have an entire temperature-regulating system to balance heat gain with heat loss so we don’t stray too far from our ideal range. The hypothalamus functions as the thermostat, communicating with heat sensors in our skin, muscles, and spinal cord. Based on signals about our core body temperature, our nervous system makes many decisions for us – opening up blood vessels in the peripheral parts of our body, pushing more blood toward the skin, and activating sweat glands to produce more sweat.  

Sweat is one of the most powerful tools we have to maintain a safe internal temperature. Of course, there are some things under our control, such as removing clothing, drinking more water, and finding shade (or preferably air conditioning). But beyond that, it’s our ability to sweat that keeps us cool. When sweat evaporates into the air, heat from our skin goes with it, cooling us off.

Over time, our sweat response can work better as we get used to warmer environments, a process that’s known as acclimatization. Over the period of a few days to weeks, the sweat glands of acclimated people can start making sweat at lower temperatures, produce more sweat, and absorb more salt back into our system, all to make us more efficient “sweaters.”

While someone who’s not used to the heat may only produce 1 liter of sweat per hour, people who have become acclimated can produce 2-3 liters every hour, allowing evaporation to eliminate more than two times the amount of heat.   

Because the process of acclimatization can take some time, typically it’s the first throes of summer, or heat waves in places where people don’t typically see high temperatures, that are the most deadly. And of course, the right infrastructure, like access to air conditioning, also plays a large role in limiting heat-related death and hospitalization.

A 2019 study showed that heat-related hospitalizations peak at different temperatures in different places. For example, hospitalizations typically peak in Texas when the temperature hits 105° F. But they might be highest in the Pacific Northwest at just 81° F.

Even with acclimatization, there are limits to how much our bodies can adapt to heat. When the humidity goes up past 75%, there’s already so much moisture in the air that heat loss through evaporation no longer occurs.

It’s this connection between heat and humidity that can be deadly. This is why the heat index (a measure that takes into account temperature and relative humidity) and wet bulb globe temperature (a measure commonly used by the military and competitive athletes that takes into account temperature, humidity, wind speed, sun angle, and cloud cover) are both better at showing how dangerous the heat may be for our health, compared to temperature alone.

Kristie L. Ebi, PhD, a professor in the Center for Health and the Global Environment at the University of Washington, Seattle, has been studying the effects of heat and other climate-sensitive conditions on health for over 20 years. She stresses that it’s not just the recorded temperatures, but the prolonged exposure that kills.

If you never get a chance to bring down that core body temperature, if your internal temperatures stay above the range where your cells and your organs can work well for a long time, that’s when you can have the most dangerous effects of heat.

“It depends then on your age, your fitness, your individual physiology, underlying medical conditions, to how quickly that could affect the functioning of those organs. There’s lots of variability in there,” Dr. Ebi said.

Our hearts take on the brunt of the early response, working harder to pump blood toward the skin. Water and salt loss through our skin can start to cause electrolyte changes that can cause heat cramps and heat exhaustion. We feel tired, nauseated, dizzy. With enough water loss, we may become dehydrated, limiting the blood flow to our brains, causing us to pass out.

These early signs are like a car’s check engine light – systems are already being damaged, but resting, refueling, and, most importantly, turning off the heat are critical steps to prevent fatal injury.

If hazardous heat exposure continues and our internal temperatures continue to rise, nerves stop talking to each other, the proteins in our body unfold and lose their shape, and the cells of our organs disintegrate. This in turn sets off a fire alarm in our blood vessels, where a variety of chemical messengers, including “heat-shock proteins,” are released. The release of these inflammatory proteins, coupled with the loss of blood flow, eventually leads to the death of cells throughout the body, from the brain, to the heart, the muscles, and the kidneys.

This process is referred to as heatstroke. In essence, we melt from the inside.

At a certain point, this cascade can’t be reversed. Just like when you cool a melting block of ice, the parts that have melted will not go back to their original shape. It’s a similar process in our bodies, so delays in cooling and treatment can lead to death rates as high as 80%.

On the outside, we see people who look confused and disoriented, with hot skin and rapid breathing, and they may eventually become unconscious. Core body temperatures over 105° F clinch the diagnosis, but at the first sign of feeling unwell, cooling should be started.

There is no fancier or more effective treatment than that: Cool right away. In emergency rooms in Washington State, doctors used body bags filled with ice and water to cool victims of the heat wave in late June.

“It was all from heat ... that’s the thing, you feel so idiotic ... you’re like, ‘I’ve given you ice’ ... you bring their temperature down. But it’s already set off this cascade that you can’t stop,” Dr. Moseson said.

By the time Dr. Moseson’s patient made it to her, cooling with ice was just the beginning of the attempts to resuscitate and revive. The patient was already showing evidence of a process causing widespread bleeding and clotting, known as disseminated intravascular coagulation, along with damage to the heart and failing kidneys. Over 18 hours, her team cooled the patient, flooded the blood vessels with fluids and blood products, attempted to start dialysis, and inserted a breathing tube – all of the technology that is used to save people from serious cardiovascular collapse from other conditions. But nothing could reverse the melting that had already occurred.

Deaths from heat are 100% preventable. Until they’re not.
 

No respite

As Dr. Ebi says, the key to preventing heat-related death is to cool down enough to stabilize our internal cells and proteins before the irreversible cascade begins.

But for close to 80% of Americans who live in urban areas, temperatures can be even higher and more intolerable compared to surrounding areas because of the way we’ve designed our cities. In effect, we have unintentionally created hot zones called “urban heat islands.”

Jeremy Hoffman, PhD, chief scientist for the Science Museum of Virginia, explains that things like bricks, asphalt, and parking lots absorb more of the sun’s energy throughout the day and then emit that back into the air as heat throughout the afternoon and into the evening. This raises the air and surface temperatures in cities, relative to rural areas. When temperatures don’t cool enough at night, there’s no way to recover from the day’s heat. You start the next day still depleted, with less reserve to face the heat of a new day.

When you dig even deeper, it turns out that even within the same city, there are huge “thermal inequities,” as Dr. Hoffman calls them. In a 2019 study, he found that wealthier parts of cities had more natural spaces such as parks and tree-lined streets, compared to areas that had been intentionally “redlined,” or systematically deprived of investment. This pattern repeats itself in over 100 urban areas across the country and translates to huge temperature differences on the order of 10-20 degrees Fahrenheit within the same city, at the exact same time during a heat wave.

“In some ways, the way that we’ve decided to plan and build our cities physically turns up the thermostat by several tens of degrees during heat waves in particular neighborhoods,” Dr. Hoffman said.

Dr. Hoffman’s work showed that the city of Portland (where the death toll from the heat wave in late June was the highest) had some of the most intense differences between formerly redlined vs. tree-lined areas out of the more than 100 cities that he studied.  

“Watching it play out, I was really concerned, not only as a climate scientist, but as a human. Understanding the urban heat island effect and the extreme nature of the inequity in our cities, thermally and otherwise, once you start to really recognize it, you can’t forget it.”
 

The most vulnerable

When it comes to identifying and protecting the people most vulnerable to heat stress and heat-related death, there is an ever-growing list of those most at risk. Unfortunately, very few recognize when they themselves are at risk, often until it’s too late.

According to Linda McCauley, PhD, dean of the Emory University School of Nursing in Atlanta, “the scope of who is vulnerable is quickly increasing.”

For example, we’re used to recognizing that pregnant women and young children are at risk. Public health campaigns have long advised us not to leave young children and pets in hot cars. We know that adolescents who play sports during hot summer months are at high risk for heat-related events and even death.

In Georgia, a 15-year-old boy collapsed and died after his first day back at football practice when the heat index was 105° F on July 26, even as it appears that all protocols for heat safety were being followed.

We recognize that outdoor workers face devastating consequences from prolonged exertion in the heat and must have safer working conditions.

The elderly and those with long-term medical and mental health conditions are also more vulnerable to heat. The elderly may not have the same warning signs and may not recognize that they are dehydrated until it is too late. In addition, their sweating mechanism weakens, and they may be taking medicines that interfere with their ability to regulate their temperature.

Poverty and inadequate housing are risk factors, especially for those in urban heat islands. For many people, their housing does not have enough cooling to protect them, and they can’t safely get themselves to cooling shelters.

These patterns for the most vulnerable fit for the majority of deaths in Oregon during the late June heat wave. Most victims were older, lived alone, and didn’t have air conditioning. But with climate change, the predictions are that temperatures will go higher and heat waves will last longer.

“There’s probably very few people today that are ‘immune’ to the effects of heat-related stress with climate change. All of us can be put in situations where we are susceptible,” Dr. McCauley said.

Dr. Moseson agreed. Many of her patients fit none of these risk categories – she treated people with no health problems in their 20s in her ICU, and the patient she lost would not traditionally have been thought of as high risk. That 50-something patient had no long-standing medical problems, and lived with family in a newly renovated suburban home that had air conditioning. The only problem was that the air conditioner had broken and there had been no rush to fix it based on past experience with Oregon summers.
 

Preventing heat deaths

Protecting ourselves and our families means monitoring the “simple things.” The first three rules are to make sure we’re drinking plenty of water – this means drinking whether we feel thirsty or not. If we’re not in an air-conditioned place, we’ve got to look for shade. And we need to take regular rest breaks.

Inside a home without air conditioning, placing ice in front of a fan to cool the air can work, but realistically, if you are in a place without air conditioning and the temperatures are approaching 90° F, it’s safest to find another place to stay, if possible.

For those playing sports, there are usually 1-week to 2-week protocols that allow for acclimatization when the season begins – this means starting slowly, without gear, and ramping up activity. Still, parents and coaches should watch advanced weather reports to make sure it’s safe to practice outside.

How we dress can also help us, so light clothing is key. And if we’re able to schedule activities for times when it is cooler, that can also protect us from overheating.

If anyone shows early signs of heat stress, removing clothing, cooling their bodies with cold water, and getting them out of the heat is critical. Any evidence of heatstroke is an emergency, and 911 should be called without delay. The faster the core temperature can be dropped, the better the chances for recovery.

On the level of communities, access to natural air conditioning in the form of healthy tree canopies, and trees at bus stops to provide shade can help a lot. According to Dr. Hoffman, these investments help almost right away. Reimagining our cities to remove the “hot zones” that we have created is another key to protecting ourselves as our climate changes.
 

Reaching our limits in a changing climate

Already, we are seeing more intense, more frequent, and longer-lasting heat waves throughout the country and across the globe.

Dr. Ebi, a coauthor of a recently released scientific analysis that found that the late June Pacific Northwest heat wave would have been virtually impossible without climate change, herself lived through the scorching temperatures in Seattle. Her work shows that the changing climate is killing us right now.

We are approaching a time where extreme temperatures and humidity will make it almost impossible for people to be outside in many parts of the world. Researchers have found that periods of extreme humid heat have more than doubled since 1979, and some places have already had wet-bulb temperatures at the limits of what scientists think humans can tolerate under ideal conditions, meaning for people in perfect health, completely unclothed, in gale-force winds, performing no activity. Obviously that’s less than ideal for most of us and helps explain why thousands of people die at temperatures much lower than our upper limit.

Dr. Ebi pointed out that the good news is that many local communities with a long history of managing high temperatures have a lot of knowledge to share with regions that are newly dealing with these conditions. This includes how local areas develop early warning and response systems with specific action plans.

But, she cautions, it’s going to take a lot of coordination and a lot of behavior change to stabilize the earth’s climate, understand our weak points, and protect our health.

For Dr. Moseson, this reality has hit home.

“I already spent the year being terrified that I as an ICU doctor was going to be the one who gave my mom COVID. Finally I’m vaccinated, she’s vaccinated. Now I’ve watched someone die because they don’t have AC. And my parents, they’re old-school Oregonians, they don’t have AC.”

A version of this article originally appeared on WebMD.com.

Millions of Americans have been languishing for weeks in the oppressive heat and humidity of a merciless summer. Deadly heat has already taken the lives of hundreds in the Pacific Northwest alone, with numbers likely to grow as the full impact of heat-related deaths eventually comes to light.

In the final week of July, the National Weather Service issued excessive heat warnings for 17 states, stretching from the West Coast, across the Midwest, down south into Louisiana and Georgia. Temperatures 10° to 15° F above average threaten the lives and livelihoods of people all across the country.

After a scorching heat wave in late June, residents of the Pacific Northwest are once again likely to see triple-digit temperatures in the coming days. With the heat, hospitals may face another surge of people with heat-related illnesses.

Erika Moseson, MD, a lung and intensive care specialist, witnessed firsthand the life-threatening impacts of soaring temperatures. She happened to be running her 10-bed intensive care unit in a suburban hospital in Gresham, Ore., about 15 miles east of Portland, the weekend of June 26. Within 12 hours, almost half her ICU beds were filled with people found unconscious on the street, in the bushes, or in their own beds, all because their body’s defenses had become overwhelmed by heat.

“It was unidentified person after unidentified person, coming in, same story, temperatures through the roof, comatose,” Dr. Moseson recalled. Young people in their 20s with muscle breakdown markers through the roof, a sign of rhabdomyolysis; people with no other medical problems that would have put them in a high-risk category.

As a lifelong Oregonian, she’d never seen anything like this before. “We’re all trained for it. I know what happens to you if you have heatstroke, I know how to treat it,” she trailed off, still finding it hard to believe. Still reeling from the number of cases in just a few hours. Still shocked that this happened on what’s supposed to be the cooler, rainforest side of Oregon.

Among those she treated and resuscitated, the memory of a patient that she lost continues to gnaw at her.

“I’ve gone back to it day after day since it happened,” she reflected.

Adults, in their 50s, living at home with their children. Just 1 hour prior, they’d all said goodnight. Then 1 hour later, when a child came to check in, both parents were unconscious.

Dr. Moseson shared how her team tried everything in their power for 18 hours to save the parent that was brought to her ICU. But like hundreds of others who went through the heat wave that weekend, her patient didn’t survive.

It was too late. From Dr. Moseson’s experience, it’s what happens “if you’re cooking a human.”
 

How heat kills

Regardless of where we live on the planet, humans maintain a consistent internal temperature around 98° F for our systems to function properly. 

Our bodies have an entire temperature-regulating system to balance heat gain with heat loss so we don’t stray too far from our ideal range. The hypothalamus functions as the thermostat, communicating with heat sensors in our skin, muscles, and spinal cord. Based on signals about our core body temperature, our nervous system makes many decisions for us – opening up blood vessels in the peripheral parts of our body, pushing more blood toward the skin, and activating sweat glands to produce more sweat.  

Sweat is one of the most powerful tools we have to maintain a safe internal temperature. Of course, there are some things under our control, such as removing clothing, drinking more water, and finding shade (or preferably air conditioning). But beyond that, it’s our ability to sweat that keeps us cool. When sweat evaporates into the air, heat from our skin goes with it, cooling us off.

Over time, our sweat response can work better as we get used to warmer environments, a process that’s known as acclimatization. Over the period of a few days to weeks, the sweat glands of acclimated people can start making sweat at lower temperatures, produce more sweat, and absorb more salt back into our system, all to make us more efficient “sweaters.”

While someone who’s not used to the heat may only produce 1 liter of sweat per hour, people who have become acclimated can produce 2-3 liters every hour, allowing evaporation to eliminate more than two times the amount of heat.   

Because the process of acclimatization can take some time, typically it’s the first throes of summer, or heat waves in places where people don’t typically see high temperatures, that are the most deadly. And of course, the right infrastructure, like access to air conditioning, also plays a large role in limiting heat-related death and hospitalization.

A 2019 study showed that heat-related hospitalizations peak at different temperatures in different places. For example, hospitalizations typically peak in Texas when the temperature hits 105° F. But they might be highest in the Pacific Northwest at just 81° F.

Even with acclimatization, there are limits to how much our bodies can adapt to heat. When the humidity goes up past 75%, there’s already so much moisture in the air that heat loss through evaporation no longer occurs.

It’s this connection between heat and humidity that can be deadly. This is why the heat index (a measure that takes into account temperature and relative humidity) and wet bulb globe temperature (a measure commonly used by the military and competitive athletes that takes into account temperature, humidity, wind speed, sun angle, and cloud cover) are both better at showing how dangerous the heat may be for our health, compared to temperature alone.

Kristie L. Ebi, PhD, a professor in the Center for Health and the Global Environment at the University of Washington, Seattle, has been studying the effects of heat and other climate-sensitive conditions on health for over 20 years. She stresses that it’s not just the recorded temperatures, but the prolonged exposure that kills.

If you never get a chance to bring down that core body temperature, if your internal temperatures stay above the range where your cells and your organs can work well for a long time, that’s when you can have the most dangerous effects of heat.

“It depends then on your age, your fitness, your individual physiology, underlying medical conditions, to how quickly that could affect the functioning of those organs. There’s lots of variability in there,” Dr. Ebi said.

Our hearts take on the brunt of the early response, working harder to pump blood toward the skin. Water and salt loss through our skin can start to cause electrolyte changes that can cause heat cramps and heat exhaustion. We feel tired, nauseated, dizzy. With enough water loss, we may become dehydrated, limiting the blood flow to our brains, causing us to pass out.

These early signs are like a car’s check engine light – systems are already being damaged, but resting, refueling, and, most importantly, turning off the heat are critical steps to prevent fatal injury.

If hazardous heat exposure continues and our internal temperatures continue to rise, nerves stop talking to each other, the proteins in our body unfold and lose their shape, and the cells of our organs disintegrate. This in turn sets off a fire alarm in our blood vessels, where a variety of chemical messengers, including “heat-shock proteins,” are released. The release of these inflammatory proteins, coupled with the loss of blood flow, eventually leads to the death of cells throughout the body, from the brain, to the heart, the muscles, and the kidneys.

This process is referred to as heatstroke. In essence, we melt from the inside.

At a certain point, this cascade can’t be reversed. Just like when you cool a melting block of ice, the parts that have melted will not go back to their original shape. It’s a similar process in our bodies, so delays in cooling and treatment can lead to death rates as high as 80%.

On the outside, we see people who look confused and disoriented, with hot skin and rapid breathing, and they may eventually become unconscious. Core body temperatures over 105° F clinch the diagnosis, but at the first sign of feeling unwell, cooling should be started.

There is no fancier or more effective treatment than that: Cool right away. In emergency rooms in Washington State, doctors used body bags filled with ice and water to cool victims of the heat wave in late June.

“It was all from heat ... that’s the thing, you feel so idiotic ... you’re like, ‘I’ve given you ice’ ... you bring their temperature down. But it’s already set off this cascade that you can’t stop,” Dr. Moseson said.

By the time Dr. Moseson’s patient made it to her, cooling with ice was just the beginning of the attempts to resuscitate and revive. The patient was already showing evidence of a process causing widespread bleeding and clotting, known as disseminated intravascular coagulation, along with damage to the heart and failing kidneys. Over 18 hours, her team cooled the patient, flooded the blood vessels with fluids and blood products, attempted to start dialysis, and inserted a breathing tube – all of the technology that is used to save people from serious cardiovascular collapse from other conditions. But nothing could reverse the melting that had already occurred.

Deaths from heat are 100% preventable. Until they’re not.
 

No respite

As Dr. Ebi says, the key to preventing heat-related death is to cool down enough to stabilize our internal cells and proteins before the irreversible cascade begins.

But for close to 80% of Americans who live in urban areas, temperatures can be even higher and more intolerable compared to surrounding areas because of the way we’ve designed our cities. In effect, we have unintentionally created hot zones called “urban heat islands.”

Jeremy Hoffman, PhD, chief scientist for the Science Museum of Virginia, explains that things like bricks, asphalt, and parking lots absorb more of the sun’s energy throughout the day and then emit that back into the air as heat throughout the afternoon and into the evening. This raises the air and surface temperatures in cities, relative to rural areas. When temperatures don’t cool enough at night, there’s no way to recover from the day’s heat. You start the next day still depleted, with less reserve to face the heat of a new day.

When you dig even deeper, it turns out that even within the same city, there are huge “thermal inequities,” as Dr. Hoffman calls them. In a 2019 study, he found that wealthier parts of cities had more natural spaces such as parks and tree-lined streets, compared to areas that had been intentionally “redlined,” or systematically deprived of investment. This pattern repeats itself in over 100 urban areas across the country and translates to huge temperature differences on the order of 10-20 degrees Fahrenheit within the same city, at the exact same time during a heat wave.

“In some ways, the way that we’ve decided to plan and build our cities physically turns up the thermostat by several tens of degrees during heat waves in particular neighborhoods,” Dr. Hoffman said.

Dr. Hoffman’s work showed that the city of Portland (where the death toll from the heat wave in late June was the highest) had some of the most intense differences between formerly redlined vs. tree-lined areas out of the more than 100 cities that he studied.  

“Watching it play out, I was really concerned, not only as a climate scientist, but as a human. Understanding the urban heat island effect and the extreme nature of the inequity in our cities, thermally and otherwise, once you start to really recognize it, you can’t forget it.”
 

The most vulnerable

When it comes to identifying and protecting the people most vulnerable to heat stress and heat-related death, there is an ever-growing list of those most at risk. Unfortunately, very few recognize when they themselves are at risk, often until it’s too late.

According to Linda McCauley, PhD, dean of the Emory University School of Nursing in Atlanta, “the scope of who is vulnerable is quickly increasing.”

For example, we’re used to recognizing that pregnant women and young children are at risk. Public health campaigns have long advised us not to leave young children and pets in hot cars. We know that adolescents who play sports during hot summer months are at high risk for heat-related events and even death.

In Georgia, a 15-year-old boy collapsed and died after his first day back at football practice when the heat index was 105° F on July 26, even as it appears that all protocols for heat safety were being followed.

We recognize that outdoor workers face devastating consequences from prolonged exertion in the heat and must have safer working conditions.

The elderly and those with long-term medical and mental health conditions are also more vulnerable to heat. The elderly may not have the same warning signs and may not recognize that they are dehydrated until it is too late. In addition, their sweating mechanism weakens, and they may be taking medicines that interfere with their ability to regulate their temperature.

Poverty and inadequate housing are risk factors, especially for those in urban heat islands. For many people, their housing does not have enough cooling to protect them, and they can’t safely get themselves to cooling shelters.

These patterns for the most vulnerable fit for the majority of deaths in Oregon during the late June heat wave. Most victims were older, lived alone, and didn’t have air conditioning. But with climate change, the predictions are that temperatures will go higher and heat waves will last longer.

“There’s probably very few people today that are ‘immune’ to the effects of heat-related stress with climate change. All of us can be put in situations where we are susceptible,” Dr. McCauley said.

Dr. Moseson agreed. Many of her patients fit none of these risk categories – she treated people with no health problems in their 20s in her ICU, and the patient she lost would not traditionally have been thought of as high risk. That 50-something patient had no long-standing medical problems, and lived with family in a newly renovated suburban home that had air conditioning. The only problem was that the air conditioner had broken and there had been no rush to fix it based on past experience with Oregon summers.
 

Preventing heat deaths

Protecting ourselves and our families means monitoring the “simple things.” The first three rules are to make sure we’re drinking plenty of water – this means drinking whether we feel thirsty or not. If we’re not in an air-conditioned place, we’ve got to look for shade. And we need to take regular rest breaks.

Inside a home without air conditioning, placing ice in front of a fan to cool the air can work, but realistically, if you are in a place without air conditioning and the temperatures are approaching 90° F, it’s safest to find another place to stay, if possible.

For those playing sports, there are usually 1-week to 2-week protocols that allow for acclimatization when the season begins – this means starting slowly, without gear, and ramping up activity. Still, parents and coaches should watch advanced weather reports to make sure it’s safe to practice outside.

How we dress can also help us, so light clothing is key. And if we’re able to schedule activities for times when it is cooler, that can also protect us from overheating.

If anyone shows early signs of heat stress, removing clothing, cooling their bodies with cold water, and getting them out of the heat is critical. Any evidence of heatstroke is an emergency, and 911 should be called without delay. The faster the core temperature can be dropped, the better the chances for recovery.

On the level of communities, access to natural air conditioning in the form of healthy tree canopies, and trees at bus stops to provide shade can help a lot. According to Dr. Hoffman, these investments help almost right away. Reimagining our cities to remove the “hot zones” that we have created is another key to protecting ourselves as our climate changes.
 

Reaching our limits in a changing climate

Already, we are seeing more intense, more frequent, and longer-lasting heat waves throughout the country and across the globe.

Dr. Ebi, a coauthor of a recently released scientific analysis that found that the late June Pacific Northwest heat wave would have been virtually impossible without climate change, herself lived through the scorching temperatures in Seattle. Her work shows that the changing climate is killing us right now.

We are approaching a time where extreme temperatures and humidity will make it almost impossible for people to be outside in many parts of the world. Researchers have found that periods of extreme humid heat have more than doubled since 1979, and some places have already had wet-bulb temperatures at the limits of what scientists think humans can tolerate under ideal conditions, meaning for people in perfect health, completely unclothed, in gale-force winds, performing no activity. Obviously that’s less than ideal for most of us and helps explain why thousands of people die at temperatures much lower than our upper limit.

Dr. Ebi pointed out that the good news is that many local communities with a long history of managing high temperatures have a lot of knowledge to share with regions that are newly dealing with these conditions. This includes how local areas develop early warning and response systems with specific action plans.

But, she cautions, it’s going to take a lot of coordination and a lot of behavior change to stabilize the earth’s climate, understand our weak points, and protect our health.

For Dr. Moseson, this reality has hit home.

“I already spent the year being terrified that I as an ICU doctor was going to be the one who gave my mom COVID. Finally I’m vaccinated, she’s vaccinated. Now I’ve watched someone die because they don’t have AC. And my parents, they’re old-school Oregonians, they don’t have AC.”

A version of this article originally appeared on WebMD.com.

Chronic diseases affect a substantial proportion of the US population, with 25% of adults diagnosed with 2 or more chronic health conditions.¹ In 2010, 2 chronic diseases, heart disease and cancer, accounted for nearly 48% of deaths.² Due to the significant public heath burden, strategies to improve chronic disease management have attracted a great deal of focus.^3,4 Within increasingly complex health care delivery systems, policy makers are promoting care coordination (CC) as a tool to reduce fragmented care for patients with multiple comorbidities, improve patient experience and quality of care, and decrease costs and risks for error.^3-8

Background

The Agency for Healthcare Research and Quality (AHRQ) defines care coordination as “deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care.”⁵ Nationally, large scale investments have expanded health care models that provide team-based CC, such as patient-centered medical homes, known as patient-aligned care teams (PACTs) within the Department of Veterans Affairs (VA), accountable care organizations, and other complex care management programs.^9-12 Additionally, incentives that reimburse for CC, such as Medicare’s chronic care management and transition care management billing codes, also are emerging.^13,14

While there is significant interest and investment in promoting CC, little data about the specific activities and time required to provide necessary CC exist, which limits the ability of health care teams to optimize CC delivery.⁶ Understanding the components of CC has implications for human resource allocation, labor mapping, reimbursement, staff training, and optimizing collaborative networks for health care systems, which may improve the quality of CC and health outcomes for patients. To date, few tools exist that can be used to identify and track the CC services delivered by interdisciplinary teams within and outside of the health care setting. 

This article describes the development and preliminary results of the implementation of a CC Template that was created in the VA Computerized Patient Record System (CPRS) to identify and track the components of CC services, delivered by a multidisciplinary team, as part of a quality improvement (QI) pilot project. Through use of the template, the team sought a formative understanding of the following questions: (1) Is it feasible to use the CC Template during routine workflow? (2) What specific types of CC services are provided by the team? (3) How much time does it take to perform these activities? (4) Who is the team collaborating with inside and outside of the health care setting and how are they communicating? (5) Given new reimbursement incentives, can the provision of CC be standardized and documented for broad applicability?

In complex systems, where coordination is needed among primary, specialty, hospital, emergency, and nonclinical care settings, a tool such as the CC Template offers a sustainable and replicable way to standardize documentation and knowledge about CC components. This foundational information can be used to optimize team structure, training, and resource allocation, to improve the quality of CC and to link elements of CC with clinical and operational outcomes.

Pact Intensive Management

Despite the implementation of PACT within VA, patients with complex medical conditions combined with socioeconomic stressors, mental health comorbidities, and low health literacy are at high risk for preventable hospitalizations and acute care utilization.^17,18 Due to unmet needs that are beyond what PACTs are able to deliver, these high-risk patients may benefit from additional services to coordinate care within and outside the VA health care system, as suggest by the Extended Chronic Care Model.^19-21

In 2014, the Office of Primary Care Services sponsored a QI initiative at 5 VA demonstration sites to develop PACT Intensive Management (PIM) interventions targeting patients at high risk for hospitalization and acute care utilization within VA. The PIM program design is based on work described previously, with patients identified for enrollment based on 90-day hospitalization risk ≥ 90th percentile, based on a VA risk modeling tool, and an acute care episode in the previous 6 months. ¹⁹ A common component of all PIM programs is the provision of intensive care management and CC by an interdisciplinary team working in conjunction with PACT. The CC Template was developed to assist in documenting and rigorously understanding the implementation of CC by the PIM team.

Local Setting

The Atlanta VA Medical Center (AVAMC) was chosen as one of the PIM demonstration sites. The Atlanta PIM team identified and enrolled a random sample of eligible, high-risk patients from 1 community-based outpatient clinic (CBOC) in an urban location with 7,524 unique patients. Between September 2014 and September 2016, 300 patients were identified, and 86 patients agreed to participate in the PIM program.

In the CC Template pilot, the Atlanta PIM team included 2 nurse practitioners (NP), 2 social workers (SW), and 1 telehealth registered nurse (RN). Upon enrollment, members of the PIM team conducted comprehensive home assessments and offered intensive care management for medical, social, and behavioral needs. The main pillars of care management offered to high-risk patients were based on previous work done both inside and outside VA and included home visits, telephone-based disease management, co-attending appointments with patients, transition care management, and interdisciplinary team meetings with a focus on care coordination between PACT and all services required by patients.^11,19

The Atlanta PIM team performed a variety of tasks to coordinate care for enrolled patients that included simple, 1-step tasks, such as chart reviews, and multistep, complex tasks that required the expertise of multiple team members (Figure 1). 

Additionally, inconsistency in delivery of CC between PIM team members was noted. For example, there was significant variability in CC services provided by different team members in the provision of transition care management (TCM) and coordinating care from hospitalization back to home. Some PIM staff coordinated care and communicated with the patient, hospital team, home-care service, and primary-care team, while other staff only reviewed the chart and placed orders in CPRS. Additionally, much of the CC work was documented in administrative notes that did not trigger workload credit. This made it difficult to show how to appropriately labor map PIM staff or how staff were spending their time caring for patients.

In order to standardize documentation of the interdisciplinary CC activities performed by the PIM team and account for staff time, the Atlanta PIM team decided to develop a CPRS CC Template. The objective of the CC Template was to facilitate documentation of CC activities in the EHR, describe the types of CC activities performed by PIM team members, and track the time to perform these activities for patients with various chronic diseases.

Template Design and Implementation

The original design of the template was informed by the Atlanta PIM team after several informal focus groups and process mapping of CC pathways in the fall of 2015. The participants were all members of the Atlanta PIM team, 2 primary care physicians working with PIM, an AVAMC documentation specialist and a clinical applications coordinator (CAC) assigned to work with PIM. The major themes that arose during the brainstorming discussion were that the template should: (1) be feasible to use during their daily clinic workflow; (2) improve documentation of CC; and (3) have value for spread to other VA sites. Discussion centered on creating a CC Template versatile enough to:

• Decrease the number of steps for documenting CC;
• Consist only of check boxes, with very little need for free text, with the option to enter narrative free text after template completion;
• Document time spent in aggregate for completing complex CC encounters;
• Document various types of CC work and modes of communication;
• Allow for use by all PIM staff;
• Identify all team members that participated in the CC encounter to reduce redundant documentation by multiple staff;
• Adapt to different clinic sites based on the varied disciplines participating in other locations;
• Use evidence-based checklists to help standardize delivery of CC for certain activities such as TCM; and
• Extract data without extensive chart reviews to inform current CC and future QI work.

Following the brainstorming sessions, the authors performed a literature review to identify and integrate CC best practices. The AHRQ Care Coordination Atlas served as the main resource in the design of the logic model that depicted the delivery and subsequent documentation of high-quality, evidence-based CC in the CC Template (Figure 2).⁶ 

After reaching consensus about the key components of the CC Template, the CAC created a pilot version (Figure 3). All of the elements within the CC Template allowed for data abstraction from the VA Corporate Data Warehouse (CDW) via discrete data elements known as health factors. 

Over the course of implementation, the team became more enthusiastic about using the CC template to document previously unrecognized CC workload. Because the CC Template only was used to document CC workload and excluded encounters for clinical evaluation and management, specific notes were created and linked with the CC Template for optimal capture of encounters.

All components of the template were mandatory to eliminate the possibility of missing data. The Atlanta PIM site principal investigator developed a multicomponent training designed to increase support for the template by describing its value and to mitigate the potential for variability in how data are captured. Training included a face-to-face session with the team to review the template and work through sample CC cases. Additionally, a training manual with clear operational definitions and examples of how to complete each element of the CC Template was disseminated. The training was subsequently conducted with the San Francisco VA Medical Center PIM team, a spread site, via video conference. The spread site offered significant feedback on clarifying the training documents and adapting the CC template for their distinct care team structure. This feedback was incorporated into the final CC Template design to increase adaptability.

Implementation Evaluation

The RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance)framework served as the basis for evaluation of CC Template implementation. The RE-AIM framework is well established and able to evaluate the implementation and potential successful spread of new programs.^23,24 Using RE-AIM, the authors planned to analyze data to explore the reach effectiveness, adoption, implementation, and maintenance of the CC Template use while providing complex care management for high-risk patients.

All data for the evaluation was extracted from the CDW by a data analyst and stored on a secure server. A statistical process control (SPC) chart was used to analyze the implementation process to assess variation in template use.

Results

After implementation, 35 weeks of CC Template pilot data were analyzed from June 1, 2015 to January 5, 2016. The PIM team completed 393 CC Templates over this collection period. After week 23, the CC template was linked to specific CC notes automatically. From weeks 23 to 35 an average of 20.3 CC Templates were completed per week by the team. The RE-AIM was used to assess the implementation of the CC Template.

Reach was determined by the number of patients enrolled in PIM with CC Template documentation. Of patients enrolled in Atlanta PIM, 90.1% had ≥ 1 CC encounter documented by the CC Template; 74.4% of Atlanta PIM patients had ≥ 1 CC encounter documented; 15.5% of patients had > 10 CC encounters documented; and 1 patient had > 25 CC encounters documented by the CC template.

Effectiveness for describing CC activities was captured through data from CC Template. The CC Template documentation by the PIM team showed that 79.4% of CC encounters were < 20 minutes, and 9.9% of encounters were > 61 minutes. Telephone communication was involved in 50.4% of CC encounters, and 24% required multiple modes of communication such as face-to-face, instant messenger, chart-based communication. Care coordination during hospitalization and discharge accounted for 5.9% of template use. Of the CC encounters documenting hospital transitions, 94.4% documented communication with the inpatient team, 58.3% documented coordination with social support, and only 11.1% documented communication with primary care teams. Improving communication with PACT teams after hospital discharge was identified as a future QI project based on these data. The PIM team initiated 83.2% of CC encounters.

Adoption was determined by the use of the CC Template by the team. All 5 team members used the CC template to document at least 1 CC encounter.

Implementation allowed for improvement based on feedback from the PIM team. Mean completion of CC Templates rose from 10.9 per week to 20.3 per week after automatically linking the CC Template to specific CC notes. (Figure 4)

Maintenance was monitored over the course of the pilot. Consistent use of the CC Template over 35 full work weeks of data collection was seen, and mean utilization per week nearly doubled in the latter half of the pilot period.

Because several elements were added to the CC Template over the course of the pilot period, our ability to analyze the data for descriptive statistics about the types of CC services, related diagnoses, collaborators, and PIM staff involved in CC encounters was limited.

Discussion

Though all components of CC encounters could not be assessed during the pilot phase due to continuous improvement of the CC Template, the authors showed that it is feasible to use this tool to document and describe granular details about team-based CC. Pilot data from AVAMC show that the use of the CC Template standardized team CC documentation in a busy clinic setting provided data about the complexity of coordination activities and duration of CC activities. It also informed future CC QI projects, such as improving communication with primary care during the hospital discharge process.

Future evaluation of CC Template data can be used to (1) describe types of CC activities for high-risk PIM patients; (2) quantify the time required to complete CC activities to assist with staff labor mapping; (3) describe staff roles and referrals needed to complete specific CC activities inside and outside VA; (4) describe modes of communication between PIM and collaborators; (5) relate patient demographics and associated diagnoses with quantity of CC encounters; and (6) quantify frequency and time frame of CC after hospitalizations and ED care and subsequent impact on repeat hospitalizations and ED visits. Future research also can explore the link between CC activities and effort with clinical and patient-reported outcomes.

Social network analysis could be used with CC Template data to understand the network of referrals and collaborators involved in the care of a CC team’s patients. This type of analysis would assist teams to strengthen and formalize ties with collaborators as appropriate. For example, if data show that the team frequently collaborates with the cardiology clinic for a large subset of its patients, they may consider creating a CC agreement with formalized modes of communication that would streamline collaboration.

In order to improve the quality of the CC Template and to assess factors that may lead to sustainable use in clinical practice, qualitative assessment through survey, interview, or usability testing with staff would be beneficial to identify strategies to increase its adoption among clinical providers. This type of assessment will add knowledge about the CC Template implementation process, including contextual barriers or facilitators, feasibility of use during day-to-day operations, versatility of template use within construct of team-based care, and overall satisfaction with the template.

Limitations

Though the CC Template offers a large amount of data about the components of CC delivery, the information is based on self-report by staff. Training to ensure that all team members are documenting in the same manner is crucial to maintain the internal validity of the data. The template is limited to the fields currently developed, and future research could explore additional data elements that are critical to include based on feedback from VA staff.

Conclusion

To our knowledge, this VA medical center CC Template is the first tool described in the literature that standardizes and captures data about CC components in the EHR. This pilot data show that the template is feasible for use in a busy clinic setting and can streamline the process for capturing CC data that may otherwise not be documented.

During the pilot phase, the CC template allowed the PIM team to identify a small subset of patients within the PIM complex management who have a high level of CC needs. By identifying these patients, further work can be done to understand the specific needs of these higher utilizers and the types of CC activities required to assist them so that resources can be directed appropriately to that smaller subset. Telephone CC accounted for a large proportion of delivery, which has implications for ensuring that staff have access to mobile phones and EHR capability to document this additional workload. The PIM staff maintained use of the template throughout the pilot period and increased documentation when the CC Template was easily accessible and already linked to their CPRS notes, suggesting that in future implementation, ensuring that the template is linked to notes in use by the care team will be important for successful spread.

Additionally, CC Template data identified gaps in high-quality, evidence-based CC that can be addressed in real time, for example during the discharge process. Data from the CC Template showed that only 11.1% of CC encounters had documentation of communication between the PIM and primary care teams during transitions from hospital to home. Improving communication with PACT teams after hospital discharge was identified as a future PIM QI project based on these data. By improving documentation of CC in the EHR, the resulting information is foundational for future work that can improve the quality of team-based CC; plan staffing, team composition, and labor mapping; determine the cost of CC activities and improve reimbursement in certain settings; and assess outcomes of CC.

This tool has potential for application beyond the PIM team in the VA. The CC Template and training manual is scalable to any setting with team-based CC, including PACT, homeless programs, palliative care, Mental Health Intensive Case Management (MHICM) programs, nurse navigator programs, and other complex care delivery models involving care coordinators. Future study of its implementation and data may inform initiatives to develop ongoing team-based care coordination programs.

Acknowledgments
The authors thank the following colleagues for their input and support: Florence Longchamp, RN, Clinical Applications Coordinator at the Atlanta VA Medical Center without whom the CC Template would not have been created; the Atlanta and San Francisco VA PIM teams for their thoughtful comments and enthusiastic embrace of the CC Template; and the PIM National Evaluation Center for their support of this QI project. PACT Intensive Management demonstration sites are funded by the VA Office of Patient Care Services. During the implementation of the CC Template pilot and the preparation of this paper, the primary author was supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Academic Affiliations, Advanced Fellowships, VA Quality Scholars Program.

Chronic diseases affect a substantial proportion of the US population, with 25% of adults diagnosed with 2 or more chronic health conditions.¹ In 2010, 2 chronic diseases, heart disease and cancer, accounted for nearly 48% of deaths.² Due to the significant public heath burden, strategies to improve chronic disease management have attracted a great deal of focus.^3,4 Within increasingly complex health care delivery systems, policy makers are promoting care coordination (CC) as a tool to reduce fragmented care for patients with multiple comorbidities, improve patient experience and quality of care, and decrease costs and risks for error.^3-8

Background

The Agency for Healthcare Research and Quality (AHRQ) defines care coordination as “deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care.”⁵ Nationally, large scale investments have expanded health care models that provide team-based CC, such as patient-centered medical homes, known as patient-aligned care teams (PACTs) within the Department of Veterans Affairs (VA), accountable care organizations, and other complex care management programs.^9-12 Additionally, incentives that reimburse for CC, such as Medicare’s chronic care management and transition care management billing codes, also are emerging.^13,14

While there is significant interest and investment in promoting CC, little data about the specific activities and time required to provide necessary CC exist, which limits the ability of health care teams to optimize CC delivery.⁶ Understanding the components of CC has implications for human resource allocation, labor mapping, reimbursement, staff training, and optimizing collaborative networks for health care systems, which may improve the quality of CC and health outcomes for patients. To date, few tools exist that can be used to identify and track the CC services delivered by interdisciplinary teams within and outside of the health care setting. 

This article describes the development and preliminary results of the implementation of a CC Template that was created in the VA Computerized Patient Record System (CPRS) to identify and track the components of CC services, delivered by a multidisciplinary team, as part of a quality improvement (QI) pilot project. Through use of the template, the team sought a formative understanding of the following questions: (1) Is it feasible to use the CC Template during routine workflow? (2) What specific types of CC services are provided by the team? (3) How much time does it take to perform these activities? (4) Who is the team collaborating with inside and outside of the health care setting and how are they communicating? (5) Given new reimbursement incentives, can the provision of CC be standardized and documented for broad applicability?

In complex systems, where coordination is needed among primary, specialty, hospital, emergency, and nonclinical care settings, a tool such as the CC Template offers a sustainable and replicable way to standardize documentation and knowledge about CC components. This foundational information can be used to optimize team structure, training, and resource allocation, to improve the quality of CC and to link elements of CC with clinical and operational outcomes.

Pact Intensive Management

Despite the implementation of PACT within VA, patients with complex medical conditions combined with socioeconomic stressors, mental health comorbidities, and low health literacy are at high risk for preventable hospitalizations and acute care utilization.^17,18 Due to unmet needs that are beyond what PACTs are able to deliver, these high-risk patients may benefit from additional services to coordinate care within and outside the VA health care system, as suggest by the Extended Chronic Care Model.^19-21

In 2014, the Office of Primary Care Services sponsored a QI initiative at 5 VA demonstration sites to develop PACT Intensive Management (PIM) interventions targeting patients at high risk for hospitalization and acute care utilization within VA. The PIM program design is based on work described previously, with patients identified for enrollment based on 90-day hospitalization risk ≥ 90th percentile, based on a VA risk modeling tool, and an acute care episode in the previous 6 months. ¹⁹ A common component of all PIM programs is the provision of intensive care management and CC by an interdisciplinary team working in conjunction with PACT. The CC Template was developed to assist in documenting and rigorously understanding the implementation of CC by the PIM team.

Local Setting

The Atlanta VA Medical Center (AVAMC) was chosen as one of the PIM demonstration sites. The Atlanta PIM team identified and enrolled a random sample of eligible, high-risk patients from 1 community-based outpatient clinic (CBOC) in an urban location with 7,524 unique patients. Between September 2014 and September 2016, 300 patients were identified, and 86 patients agreed to participate in the PIM program.

In the CC Template pilot, the Atlanta PIM team included 2 nurse practitioners (NP), 2 social workers (SW), and 1 telehealth registered nurse (RN). Upon enrollment, members of the PIM team conducted comprehensive home assessments and offered intensive care management for medical, social, and behavioral needs. The main pillars of care management offered to high-risk patients were based on previous work done both inside and outside VA and included home visits, telephone-based disease management, co-attending appointments with patients, transition care management, and interdisciplinary team meetings with a focus on care coordination between PACT and all services required by patients.^11,19

The Atlanta PIM team performed a variety of tasks to coordinate care for enrolled patients that included simple, 1-step tasks, such as chart reviews, and multistep, complex tasks that required the expertise of multiple team members (Figure 1). 

Additionally, inconsistency in delivery of CC between PIM team members was noted. For example, there was significant variability in CC services provided by different team members in the provision of transition care management (TCM) and coordinating care from hospitalization back to home. Some PIM staff coordinated care and communicated with the patient, hospital team, home-care service, and primary-care team, while other staff only reviewed the chart and placed orders in CPRS. Additionally, much of the CC work was documented in administrative notes that did not trigger workload credit. This made it difficult to show how to appropriately labor map PIM staff or how staff were spending their time caring for patients.

In order to standardize documentation of the interdisciplinary CC activities performed by the PIM team and account for staff time, the Atlanta PIM team decided to develop a CPRS CC Template. The objective of the CC Template was to facilitate documentation of CC activities in the EHR, describe the types of CC activities performed by PIM team members, and track the time to perform these activities for patients with various chronic diseases.

Template Design and Implementation

The original design of the template was informed by the Atlanta PIM team after several informal focus groups and process mapping of CC pathways in the fall of 2015. The participants were all members of the Atlanta PIM team, 2 primary care physicians working with PIM, an AVAMC documentation specialist and a clinical applications coordinator (CAC) assigned to work with PIM. The major themes that arose during the brainstorming discussion were that the template should: (1) be feasible to use during their daily clinic workflow; (2) improve documentation of CC; and (3) have value for spread to other VA sites. Discussion centered on creating a CC Template versatile enough to:

• Decrease the number of steps for documenting CC;
• Consist only of check boxes, with very little need for free text, with the option to enter narrative free text after template completion;
• Document time spent in aggregate for completing complex CC encounters;
• Document various types of CC work and modes of communication;
• Allow for use by all PIM staff;
• Identify all team members that participated in the CC encounter to reduce redundant documentation by multiple staff;
• Adapt to different clinic sites based on the varied disciplines participating in other locations;
• Use evidence-based checklists to help standardize delivery of CC for certain activities such as TCM; and
• Extract data without extensive chart reviews to inform current CC and future QI work.

Following the brainstorming sessions, the authors performed a literature review to identify and integrate CC best practices. The AHRQ Care Coordination Atlas served as the main resource in the design of the logic model that depicted the delivery and subsequent documentation of high-quality, evidence-based CC in the CC Template (Figure 2).⁶ 

After reaching consensus about the key components of the CC Template, the CAC created a pilot version (Figure 3). All of the elements within the CC Template allowed for data abstraction from the VA Corporate Data Warehouse (CDW) via discrete data elements known as health factors. 

Over the course of implementation, the team became more enthusiastic about using the CC template to document previously unrecognized CC workload. Because the CC Template only was used to document CC workload and excluded encounters for clinical evaluation and management, specific notes were created and linked with the CC Template for optimal capture of encounters.

All components of the template were mandatory to eliminate the possibility of missing data. The Atlanta PIM site principal investigator developed a multicomponent training designed to increase support for the template by describing its value and to mitigate the potential for variability in how data are captured. Training included a face-to-face session with the team to review the template and work through sample CC cases. Additionally, a training manual with clear operational definitions and examples of how to complete each element of the CC Template was disseminated. The training was subsequently conducted with the San Francisco VA Medical Center PIM team, a spread site, via video conference. The spread site offered significant feedback on clarifying the training documents and adapting the CC template for their distinct care team structure. This feedback was incorporated into the final CC Template design to increase adaptability.

Implementation Evaluation

The RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance)framework served as the basis for evaluation of CC Template implementation. The RE-AIM framework is well established and able to evaluate the implementation and potential successful spread of new programs.^23,24 Using RE-AIM, the authors planned to analyze data to explore the reach effectiveness, adoption, implementation, and maintenance of the CC Template use while providing complex care management for high-risk patients.

All data for the evaluation was extracted from the CDW by a data analyst and stored on a secure server. A statistical process control (SPC) chart was used to analyze the implementation process to assess variation in template use.

Results

After implementation, 35 weeks of CC Template pilot data were analyzed from June 1, 2015 to January 5, 2016. The PIM team completed 393 CC Templates over this collection period. After week 23, the CC template was linked to specific CC notes automatically. From weeks 23 to 35 an average of 20.3 CC Templates were completed per week by the team. The RE-AIM was used to assess the implementation of the CC Template.

Reach was determined by the number of patients enrolled in PIM with CC Template documentation. Of patients enrolled in Atlanta PIM, 90.1% had ≥ 1 CC encounter documented by the CC Template; 74.4% of Atlanta PIM patients had ≥ 1 CC encounter documented; 15.5% of patients had > 10 CC encounters documented; and 1 patient had > 25 CC encounters documented by the CC template.

Effectiveness for describing CC activities was captured through data from CC Template. The CC Template documentation by the PIM team showed that 79.4% of CC encounters were < 20 minutes, and 9.9% of encounters were > 61 minutes. Telephone communication was involved in 50.4% of CC encounters, and 24% required multiple modes of communication such as face-to-face, instant messenger, chart-based communication. Care coordination during hospitalization and discharge accounted for 5.9% of template use. Of the CC encounters documenting hospital transitions, 94.4% documented communication with the inpatient team, 58.3% documented coordination with social support, and only 11.1% documented communication with primary care teams. Improving communication with PACT teams after hospital discharge was identified as a future QI project based on these data. The PIM team initiated 83.2% of CC encounters.

Adoption was determined by the use of the CC Template by the team. All 5 team members used the CC template to document at least 1 CC encounter.

Implementation allowed for improvement based on feedback from the PIM team. Mean completion of CC Templates rose from 10.9 per week to 20.3 per week after automatically linking the CC Template to specific CC notes. (Figure 4)

Maintenance was monitored over the course of the pilot. Consistent use of the CC Template over 35 full work weeks of data collection was seen, and mean utilization per week nearly doubled in the latter half of the pilot period.

Because several elements were added to the CC Template over the course of the pilot period, our ability to analyze the data for descriptive statistics about the types of CC services, related diagnoses, collaborators, and PIM staff involved in CC encounters was limited.

Discussion

Though all components of CC encounters could not be assessed during the pilot phase due to continuous improvement of the CC Template, the authors showed that it is feasible to use this tool to document and describe granular details about team-based CC. Pilot data from AVAMC show that the use of the CC Template standardized team CC documentation in a busy clinic setting provided data about the complexity of coordination activities and duration of CC activities. It also informed future CC QI projects, such as improving communication with primary care during the hospital discharge process.

Future evaluation of CC Template data can be used to (1) describe types of CC activities for high-risk PIM patients; (2) quantify the time required to complete CC activities to assist with staff labor mapping; (3) describe staff roles and referrals needed to complete specific CC activities inside and outside VA; (4) describe modes of communication between PIM and collaborators; (5) relate patient demographics and associated diagnoses with quantity of CC encounters; and (6) quantify frequency and time frame of CC after hospitalizations and ED care and subsequent impact on repeat hospitalizations and ED visits. Future research also can explore the link between CC activities and effort with clinical and patient-reported outcomes.

Social network analysis could be used with CC Template data to understand the network of referrals and collaborators involved in the care of a CC team’s patients. This type of analysis would assist teams to strengthen and formalize ties with collaborators as appropriate. For example, if data show that the team frequently collaborates with the cardiology clinic for a large subset of its patients, they may consider creating a CC agreement with formalized modes of communication that would streamline collaboration.

In order to improve the quality of the CC Template and to assess factors that may lead to sustainable use in clinical practice, qualitative assessment through survey, interview, or usability testing with staff would be beneficial to identify strategies to increase its adoption among clinical providers. This type of assessment will add knowledge about the CC Template implementation process, including contextual barriers or facilitators, feasibility of use during day-to-day operations, versatility of template use within construct of team-based care, and overall satisfaction with the template.

Limitations

Though the CC Template offers a large amount of data about the components of CC delivery, the information is based on self-report by staff. Training to ensure that all team members are documenting in the same manner is crucial to maintain the internal validity of the data. The template is limited to the fields currently developed, and future research could explore additional data elements that are critical to include based on feedback from VA staff.

Conclusion

To our knowledge, this VA medical center CC Template is the first tool described in the literature that standardizes and captures data about CC components in the EHR. This pilot data show that the template is feasible for use in a busy clinic setting and can streamline the process for capturing CC data that may otherwise not be documented.

During the pilot phase, the CC template allowed the PIM team to identify a small subset of patients within the PIM complex management who have a high level of CC needs. By identifying these patients, further work can be done to understand the specific needs of these higher utilizers and the types of CC activities required to assist them so that resources can be directed appropriately to that smaller subset. Telephone CC accounted for a large proportion of delivery, which has implications for ensuring that staff have access to mobile phones and EHR capability to document this additional workload. The PIM staff maintained use of the template throughout the pilot period and increased documentation when the CC Template was easily accessible and already linked to their CPRS notes, suggesting that in future implementation, ensuring that the template is linked to notes in use by the care team will be important for successful spread.

Additionally, CC Template data identified gaps in high-quality, evidence-based CC that can be addressed in real time, for example during the discharge process. Data from the CC Template showed that only 11.1% of CC encounters had documentation of communication between the PIM and primary care teams during transitions from hospital to home. Improving communication with PACT teams after hospital discharge was identified as a future PIM QI project based on these data. By improving documentation of CC in the EHR, the resulting information is foundational for future work that can improve the quality of team-based CC; plan staffing, team composition, and labor mapping; determine the cost of CC activities and improve reimbursement in certain settings; and assess outcomes of CC.

This tool has potential for application beyond the PIM team in the VA. The CC Template and training manual is scalable to any setting with team-based CC, including PACT, homeless programs, palliative care, Mental Health Intensive Case Management (MHICM) programs, nurse navigator programs, and other complex care delivery models involving care coordinators. Future study of its implementation and data may inform initiatives to develop ongoing team-based care coordination programs.

Acknowledgments
The authors thank the following colleagues for their input and support: Florence Longchamp, RN, Clinical Applications Coordinator at the Atlanta VA Medical Center without whom the CC Template would not have been created; the Atlanta and San Francisco VA PIM teams for their thoughtful comments and enthusiastic embrace of the CC Template; and the PIM National Evaluation Center for their support of this QI project. PACT Intensive Management demonstration sites are funded by the VA Office of Patient Care Services. During the implementation of the CC Template pilot and the preparation of this paper, the primary author was supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Academic Affiliations, Advanced Fellowships, VA Quality Scholars Program.

Chronic diseases affect a substantial proportion of the US population, with 25% of adults diagnosed with 2 or more chronic health conditions.¹ In 2010, 2 chronic diseases, heart disease and cancer, accounted for nearly 48% of deaths.² Due to the significant public heath burden, strategies to improve chronic disease management have attracted a great deal of focus.^3,4 Within increasingly complex health care delivery systems, policy makers are promoting care coordination (CC) as a tool to reduce fragmented care for patients with multiple comorbidities, improve patient experience and quality of care, and decrease costs and risks for error.^3-8

Background

The Agency for Healthcare Research and Quality (AHRQ) defines care coordination as “deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care.”⁵ Nationally, large scale investments have expanded health care models that provide team-based CC, such as patient-centered medical homes, known as patient-aligned care teams (PACTs) within the Department of Veterans Affairs (VA), accountable care organizations, and other complex care management programs.^9-12 Additionally, incentives that reimburse for CC, such as Medicare’s chronic care management and transition care management billing codes, also are emerging.^13,14

While there is significant interest and investment in promoting CC, little data about the specific activities and time required to provide necessary CC exist, which limits the ability of health care teams to optimize CC delivery.⁶ Understanding the components of CC has implications for human resource allocation, labor mapping, reimbursement, staff training, and optimizing collaborative networks for health care systems, which may improve the quality of CC and health outcomes for patients. To date, few tools exist that can be used to identify and track the CC services delivered by interdisciplinary teams within and outside of the health care setting. 

This article describes the development and preliminary results of the implementation of a CC Template that was created in the VA Computerized Patient Record System (CPRS) to identify and track the components of CC services, delivered by a multidisciplinary team, as part of a quality improvement (QI) pilot project. Through use of the template, the team sought a formative understanding of the following questions: (1) Is it feasible to use the CC Template during routine workflow? (2) What specific types of CC services are provided by the team? (3) How much time does it take to perform these activities? (4) Who is the team collaborating with inside and outside of the health care setting and how are they communicating? (5) Given new reimbursement incentives, can the provision of CC be standardized and documented for broad applicability?

In complex systems, where coordination is needed among primary, specialty, hospital, emergency, and nonclinical care settings, a tool such as the CC Template offers a sustainable and replicable way to standardize documentation and knowledge about CC components. This foundational information can be used to optimize team structure, training, and resource allocation, to improve the quality of CC and to link elements of CC with clinical and operational outcomes.

Pact Intensive Management

Despite the implementation of PACT within VA, patients with complex medical conditions combined with socioeconomic stressors, mental health comorbidities, and low health literacy are at high risk for preventable hospitalizations and acute care utilization.^17,18 Due to unmet needs that are beyond what PACTs are able to deliver, these high-risk patients may benefit from additional services to coordinate care within and outside the VA health care system, as suggest by the Extended Chronic Care Model.^19-21

In 2014, the Office of Primary Care Services sponsored a QI initiative at 5 VA demonstration sites to develop PACT Intensive Management (PIM) interventions targeting patients at high risk for hospitalization and acute care utilization within VA. The PIM program design is based on work described previously, with patients identified for enrollment based on 90-day hospitalization risk ≥ 90th percentile, based on a VA risk modeling tool, and an acute care episode in the previous 6 months. ¹⁹ A common component of all PIM programs is the provision of intensive care management and CC by an interdisciplinary team working in conjunction with PACT. The CC Template was developed to assist in documenting and rigorously understanding the implementation of CC by the PIM team.

Local Setting

The Atlanta VA Medical Center (AVAMC) was chosen as one of the PIM demonstration sites. The Atlanta PIM team identified and enrolled a random sample of eligible, high-risk patients from 1 community-based outpatient clinic (CBOC) in an urban location with 7,524 unique patients. Between September 2014 and September 2016, 300 patients were identified, and 86 patients agreed to participate in the PIM program.

In the CC Template pilot, the Atlanta PIM team included 2 nurse practitioners (NP), 2 social workers (SW), and 1 telehealth registered nurse (RN). Upon enrollment, members of the PIM team conducted comprehensive home assessments and offered intensive care management for medical, social, and behavioral needs. The main pillars of care management offered to high-risk patients were based on previous work done both inside and outside VA and included home visits, telephone-based disease management, co-attending appointments with patients, transition care management, and interdisciplinary team meetings with a focus on care coordination between PACT and all services required by patients.^11,19

The Atlanta PIM team performed a variety of tasks to coordinate care for enrolled patients that included simple, 1-step tasks, such as chart reviews, and multistep, complex tasks that required the expertise of multiple team members (Figure 1). 

Additionally, inconsistency in delivery of CC between PIM team members was noted. For example, there was significant variability in CC services provided by different team members in the provision of transition care management (TCM) and coordinating care from hospitalization back to home. Some PIM staff coordinated care and communicated with the patient, hospital team, home-care service, and primary-care team, while other staff only reviewed the chart and placed orders in CPRS. Additionally, much of the CC work was documented in administrative notes that did not trigger workload credit. This made it difficult to show how to appropriately labor map PIM staff or how staff were spending their time caring for patients.

In order to standardize documentation of the interdisciplinary CC activities performed by the PIM team and account for staff time, the Atlanta PIM team decided to develop a CPRS CC Template. The objective of the CC Template was to facilitate documentation of CC activities in the EHR, describe the types of CC activities performed by PIM team members, and track the time to perform these activities for patients with various chronic diseases.

Template Design and Implementation

The original design of the template was informed by the Atlanta PIM team after several informal focus groups and process mapping of CC pathways in the fall of 2015. The participants were all members of the Atlanta PIM team, 2 primary care physicians working with PIM, an AVAMC documentation specialist and a clinical applications coordinator (CAC) assigned to work with PIM. The major themes that arose during the brainstorming discussion were that the template should: (1) be feasible to use during their daily clinic workflow; (2) improve documentation of CC; and (3) have value for spread to other VA sites. Discussion centered on creating a CC Template versatile enough to:

• Decrease the number of steps for documenting CC;
• Consist only of check boxes, with very little need for free text, with the option to enter narrative free text after template completion;
• Document time spent in aggregate for completing complex CC encounters;
• Document various types of CC work and modes of communication;
• Allow for use by all PIM staff;
• Identify all team members that participated in the CC encounter to reduce redundant documentation by multiple staff;
• Adapt to different clinic sites based on the varied disciplines participating in other locations;
• Use evidence-based checklists to help standardize delivery of CC for certain activities such as TCM; and
• Extract data without extensive chart reviews to inform current CC and future QI work.

Following the brainstorming sessions, the authors performed a literature review to identify and integrate CC best practices. The AHRQ Care Coordination Atlas served as the main resource in the design of the logic model that depicted the delivery and subsequent documentation of high-quality, evidence-based CC in the CC Template (Figure 2).⁶ 

After reaching consensus about the key components of the CC Template, the CAC created a pilot version (Figure 3). All of the elements within the CC Template allowed for data abstraction from the VA Corporate Data Warehouse (CDW) via discrete data elements known as health factors. 

Over the course of implementation, the team became more enthusiastic about using the CC template to document previously unrecognized CC workload. Because the CC Template only was used to document CC workload and excluded encounters for clinical evaluation and management, specific notes were created and linked with the CC Template for optimal capture of encounters.

All components of the template were mandatory to eliminate the possibility of missing data. The Atlanta PIM site principal investigator developed a multicomponent training designed to increase support for the template by describing its value and to mitigate the potential for variability in how data are captured. Training included a face-to-face session with the team to review the template and work through sample CC cases. Additionally, a training manual with clear operational definitions and examples of how to complete each element of the CC Template was disseminated. The training was subsequently conducted with the San Francisco VA Medical Center PIM team, a spread site, via video conference. The spread site offered significant feedback on clarifying the training documents and adapting the CC template for their distinct care team structure. This feedback was incorporated into the final CC Template design to increase adaptability.

Implementation Evaluation

The RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance)framework served as the basis for evaluation of CC Template implementation. The RE-AIM framework is well established and able to evaluate the implementation and potential successful spread of new programs.^23,24 Using RE-AIM, the authors planned to analyze data to explore the reach effectiveness, adoption, implementation, and maintenance of the CC Template use while providing complex care management for high-risk patients.

All data for the evaluation was extracted from the CDW by a data analyst and stored on a secure server. A statistical process control (SPC) chart was used to analyze the implementation process to assess variation in template use.

Results

After implementation, 35 weeks of CC Template pilot data were analyzed from June 1, 2015 to January 5, 2016. The PIM team completed 393 CC Templates over this collection period. After week 23, the CC template was linked to specific CC notes automatically. From weeks 23 to 35 an average of 20.3 CC Templates were completed per week by the team. The RE-AIM was used to assess the implementation of the CC Template.

Reach was determined by the number of patients enrolled in PIM with CC Template documentation. Of patients enrolled in Atlanta PIM, 90.1% had ≥ 1 CC encounter documented by the CC Template; 74.4% of Atlanta PIM patients had ≥ 1 CC encounter documented; 15.5% of patients had > 10 CC encounters documented; and 1 patient had > 25 CC encounters documented by the CC template.

Effectiveness for describing CC activities was captured through data from CC Template. The CC Template documentation by the PIM team showed that 79.4% of CC encounters were < 20 minutes, and 9.9% of encounters were > 61 minutes. Telephone communication was involved in 50.4% of CC encounters, and 24% required multiple modes of communication such as face-to-face, instant messenger, chart-based communication. Care coordination during hospitalization and discharge accounted for 5.9% of template use. Of the CC encounters documenting hospital transitions, 94.4% documented communication with the inpatient team, 58.3% documented coordination with social support, and only 11.1% documented communication with primary care teams. Improving communication with PACT teams after hospital discharge was identified as a future QI project based on these data. The PIM team initiated 83.2% of CC encounters.

Adoption was determined by the use of the CC Template by the team. All 5 team members used the CC template to document at least 1 CC encounter.

Implementation allowed for improvement based on feedback from the PIM team. Mean completion of CC Templates rose from 10.9 per week to 20.3 per week after automatically linking the CC Template to specific CC notes. (Figure 4)

Maintenance was monitored over the course of the pilot. Consistent use of the CC Template over 35 full work weeks of data collection was seen, and mean utilization per week nearly doubled in the latter half of the pilot period.

Because several elements were added to the CC Template over the course of the pilot period, our ability to analyze the data for descriptive statistics about the types of CC services, related diagnoses, collaborators, and PIM staff involved in CC encounters was limited.

Discussion

Though all components of CC encounters could not be assessed during the pilot phase due to continuous improvement of the CC Template, the authors showed that it is feasible to use this tool to document and describe granular details about team-based CC. Pilot data from AVAMC show that the use of the CC Template standardized team CC documentation in a busy clinic setting provided data about the complexity of coordination activities and duration of CC activities. It also informed future CC QI projects, such as improving communication with primary care during the hospital discharge process.

Future evaluation of CC Template data can be used to (1) describe types of CC activities for high-risk PIM patients; (2) quantify the time required to complete CC activities to assist with staff labor mapping; (3) describe staff roles and referrals needed to complete specific CC activities inside and outside VA; (4) describe modes of communication between PIM and collaborators; (5) relate patient demographics and associated diagnoses with quantity of CC encounters; and (6) quantify frequency and time frame of CC after hospitalizations and ED care and subsequent impact on repeat hospitalizations and ED visits. Future research also can explore the link between CC activities and effort with clinical and patient-reported outcomes.

Social network analysis could be used with CC Template data to understand the network of referrals and collaborators involved in the care of a CC team’s patients. This type of analysis would assist teams to strengthen and formalize ties with collaborators as appropriate. For example, if data show that the team frequently collaborates with the cardiology clinic for a large subset of its patients, they may consider creating a CC agreement with formalized modes of communication that would streamline collaboration.

In order to improve the quality of the CC Template and to assess factors that may lead to sustainable use in clinical practice, qualitative assessment through survey, interview, or usability testing with staff would be beneficial to identify strategies to increase its adoption among clinical providers. This type of assessment will add knowledge about the CC Template implementation process, including contextual barriers or facilitators, feasibility of use during day-to-day operations, versatility of template use within construct of team-based care, and overall satisfaction with the template.

Limitations

Though the CC Template offers a large amount of data about the components of CC delivery, the information is based on self-report by staff. Training to ensure that all team members are documenting in the same manner is crucial to maintain the internal validity of the data. The template is limited to the fields currently developed, and future research could explore additional data elements that are critical to include based on feedback from VA staff.

Conclusion

To our knowledge, this VA medical center CC Template is the first tool described in the literature that standardizes and captures data about CC components in the EHR. This pilot data show that the template is feasible for use in a busy clinic setting and can streamline the process for capturing CC data that may otherwise not be documented.

During the pilot phase, the CC template allowed the PIM team to identify a small subset of patients within the PIM complex management who have a high level of CC needs. By identifying these patients, further work can be done to understand the specific needs of these higher utilizers and the types of CC activities required to assist them so that resources can be directed appropriately to that smaller subset. Telephone CC accounted for a large proportion of delivery, which has implications for ensuring that staff have access to mobile phones and EHR capability to document this additional workload. The PIM staff maintained use of the template throughout the pilot period and increased documentation when the CC Template was easily accessible and already linked to their CPRS notes, suggesting that in future implementation, ensuring that the template is linked to notes in use by the care team will be important for successful spread.

Additionally, CC Template data identified gaps in high-quality, evidence-based CC that can be addressed in real time, for example during the discharge process. Data from the CC Template showed that only 11.1% of CC encounters had documentation of communication between the PIM and primary care teams during transitions from hospital to home. Improving communication with PACT teams after hospital discharge was identified as a future PIM QI project based on these data. By improving documentation of CC in the EHR, the resulting information is foundational for future work that can improve the quality of team-based CC; plan staffing, team composition, and labor mapping; determine the cost of CC activities and improve reimbursement in certain settings; and assess outcomes of CC.

This tool has potential for application beyond the PIM team in the VA. The CC Template and training manual is scalable to any setting with team-based CC, including PACT, homeless programs, palliative care, Mental Health Intensive Case Management (MHICM) programs, nurse navigator programs, and other complex care delivery models involving care coordinators. Future study of its implementation and data may inform initiatives to develop ongoing team-based care coordination programs.

Acknowledgments
The authors thank the following colleagues for their input and support: Florence Longchamp, RN, Clinical Applications Coordinator at the Atlanta VA Medical Center without whom the CC Template would not have been created; the Atlanta and San Francisco VA PIM teams for their thoughtful comments and enthusiastic embrace of the CC Template; and the PIM National Evaluation Center for their support of this QI project. PACT Intensive Management demonstration sites are funded by the VA Office of Patient Care Services. During the implementation of the CC Template pilot and the preparation of this paper, the primary author was supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Academic Affiliations, Advanced Fellowships, VA Quality Scholars Program.