Dr. Imelda Dacones, President of Washington Optum Care: The 3 “Rs” of Improving the Patient and Provider Experience in Healthcare

Van Ton-Quinlivan: Welcome to WorkforceRx with Futuro Health, where future-focused leaders in education, workforce development and healthcare explore new innovations and approaches. I’m your host, Van Ton-Quinlivan, CEO of Futuro Health. Today, I’m delighted to welcome Dr. Imelda Dacones to WorkforceRx, who, amongst the many meaningful roles that she plays, was a board member of Futuro Health until recently. She is now president of Washington Optum Care in Seattle overseeing several large clinics serving 700,000 people. She assumed that role last year after twenty-two years as a physician and senior leader at Northwest Permanente in Portland, Oregon, including six years as its president.

Dr. Dacones is a nationally recognized leader in healthcare delivery innovation, addressing social determinants of health and the health impacts of climate change, amongst many other issues. What I loved the most about having Dr. Dacones — or maybe Imelda, I can say — on my board were her insights into the future of care and how skillsets would shift. Thanks to her, Futuro Health was ahead of the curve in commissioning a series of education programs to bring the next generation of workers into healthcare. Thank you so much for joining us today, Imelda. It’s so good to see you again.

Dr. Imelda Dacones: Great to see you, Van. Thank you for this opportunity to talk with you, and congratulations again on your amazing podcast and fabulous WorkforceRx book. So, thank you very much for all that you’re teaching our communities and business leaders about this important issue and topic about workforce planning and everything around that.

Van: Well, I’m able to do the good work thanks to the support of leaders like you, Imelda. I would love to start by first having you share your personal story. What called you into medicine and to become a doctor?

Imelda: It’s a very vivid memory of mine. It’s interesting how the brain works. When I was six years old, I remember telling my mother I wanted to be a doctor. At six years old, you might ask, “Where did that come from?” To this day, I couldn’t tell you, other than just watching her and my dad really in the service of people and communities.

My dad was a community activist as well as a politician. Day and night, people came to our home asking for help, advice, and counsel. My mom ran our family business in retail, and so, she too was often asked to consult — not just on business and financial matters in the community, but just in general for help. So, it was about growing up and watching the two of them, and then two of my older siblings were nurses. I think if I had to postulate, it was growing up in that environment. Then over time, I realized I really liked science, and what better application of science, to my mind, than the care of people. I think that’s how it came about if I had to put it all together for you.

Van: I can see that the apple didn’t fall far from the tree. You’ve always articulated the value of being in service to the community. After all your years in medicine and being a physician, it must be very concerning to you to see what is happening in the “Great Resignation.” What does this look like in healthcare, especially to you, because you have responsibility for several clinics?

Imelda: Yes. As I took on greater responsibilities as a physician leader, the first thing I came across was learning more about the physician shortage. I came to my CEO and president role in Northwest Permanente in 2015. One of the things that I tackled right away was, how do we think about workforce planning? That’s when I came across some of the numbers, statistics, and forecasts around the physician shortage that was upon. They showed it becoming more acute by 2025 when it came to primary care physicians, and then by 2030 across all specialties. That was already top of mind when I thought about strategy and how we begin to create a roadmap to mitigate that.

Then, the pandemic. Who had that in the forecasting? So, putting all of that together, I already had that in mind. And then now this pandemic, with the Great Resignation and the attrition in healthcare. If you look at the clinic, we have had attrition in every role — medical assistants, our registration staff, our nurses, people who are responsible for infection control and the cleaning of the facilities.  It has involved every hand that touches care, whether in direct patient care or indirectly supporting care. If we even just look at it from a gender perspective, women have been cutting back hours and leaving the field altogether, through a combination of things — more caregiving, more household work, taking on more responsibility for their children’s education, and other demands on people.

A statistic I saw recently was that 8,000 nurses left hospitals across the country in December. Leading up to that, many more nurses have left the field. Where did they go? Some of them retired earlier, or just retired because it was time. Some have gone to other industries, or if they stayed in healthcare, doing more indirect clinical care. All throughout every role in healthcare, I would say the great attrition and the Great Resignation applies.

Van: Then what is a provider to do, given that context? I understand that even from a retention perspective, some employees are demanding permanent telework arrangements. So, that’s another added stress on the staffing situation.

Imelda: Right. Well, at the clinician level, I would say it goes back to the 3Rs. This was something that I talked about even way before the pandemic, a framework for transforming and innovating care and really re-inventing care delivery. We talk a lot about transformation and innovation, but what is the framework? It’s one thing to talk about it, but how do we begin to get to the specifics of it?

So, to the core or frontline clinician, I talk about the 3Rs: reimagining the care team and reimagining the role of everyone in that community; reengineering the visit and the work; and we reimagine and reengineer in order that we reinvigorate ourselves, reinvigorate the practice of medicine and reinvigorate care delivery for the quadruple aim that’s talked about.

To your point about what do you do…I’m a clinician. When I look at the care team — we have medical assistants and registration staff and nurses who are doing the outreach or maybe doing care management — how do we begin to think about redeploying them differently? How do we think about medical assistants more as a population health navigator? As we automate vital signs checking, as we have remote patient monitoring where people can do their vital signs before they even come to the clinic…a lot of things that our medical assistants do now, we can digitize or automate. When you do that, what then is left that our medical assistants and only really a human being can do? They can talk with the patients about closing care gaps, but even that you can automate. So, really, it’s beginning to think about how we redeploy our roles, our teammates, and our care team members differently to do more of the higher touch.

Automation is huge in how we can reimagine the role. The digital front door is key to doing a lot of reengineering the work. We need to think about how we use all the tools that are already around us. Certainly the pandemic has accelerated adoption and accelerated scaling of these capabilities. Then lastly, reinvigorating, because let’s face it, all of our mental health has suffered from this pandemic. So, beyond working harder, how do you work differently so that we can reinvigorate ourselves, and so that we’re not running on that treadmill seeing one patient after another. As we just talked about, due to attrition, there’s fewer of all these people. How do we reinvent care altogether for the consumers and patients that we serve, but also for ourselves, because there just are not going to be enough nurses, doctors, medical assistants, and so on, coming into the future.

Van: Imelda, in terms of the digital front door, one piece of advice you provided me earlier on as the pandemic took its toll was that telehealth and telemedicine would be here to stay. It would not be one of the set of practices that would revert to a pre-pandemic state. Does that create an opportunity? What do you see for care moving to the home, for example?

Imelda: It’s the final frontier, right? When you think back, medicine has come full circle. In the not-too-distant past when we had fewer capabilities and fewer medicines and care to offer, we often took the care to the patient at home. Then, with the advent of more technology and advancements in diagnostics and therapeutics, we stood up hospitals. Now, it’s come full circle as we are figuring out, and have figured out, the care model of how to take care of a patient with severe pneumonia at home and figured out the logistics…bringing the nurse to the bedside in the home, bringing the physical therapist or the phlebotomist and all those things to the patient’s home, and the technology in terms of 24/7 connectivity with the care team. Patients can have their doctor “at the bedside” remotely, and the nurse remotely, and then have their remote patient monitoring equipment at the bedside. The patient’s blood pressure, the temperatures, their weight, their oxygen levels — all of those things can be ascertained at the patient’s home, and a team of doctors and nurses is monitoring that 24/7, much like on a medical surgical unit in a hospital. That’s all out there. That’s happening. We’re going to make that even better and scale it.

Van: Do you think that’s in the 10-year horizon where it goes more mainstream? Or do you think that the pandemic has pulled that timeline tighter?

Imelda: When I was in Oregon, one of the things that we were working on with a partner was being able to take care of patients in their homes for their hospitalization instead of in a hospital. By all accounts, as of September last year, that program had admitted over 1,000 patients. Imagine, over 1,000 patients hospitalized, but hospitalized at home. That’s something I’m very proud of being a part of in Oregon, but that exists across the country more and more. Certainly, with the pandemic and the demand for hospital beds, it’s important to figure out how to add to the hospital bed capacity without building more brick and mortar. Frankly, people were afraid to go into the hospital and catch COVID. There are just a lot of things in terms of safety to being at home — like reduction in hospital-acquired infections, hospital-acquired blood clots, and complications. People are just more mobile in their home compared to a hospital, and from a mental health perspective, who wouldn’t want to be in more familiar and comfortable surroundings? There’s a lot that we are learning about the positives of having your hospital stay at home.

Van: When you were addressing the physician shortage and physician retention situation at Northwest Permanente, you focused very much on joy for physicians. I wonder, as care moves to the home and maybe doctors are more centralized, how do you think they would receive the transition?

Imelda: When I think about how do we rekindle joy in medicine — while we also address all these stressors that contribute to burnout — having capabilities like a digital front door or telehealth provides flexibility as well as variety in practice. One of the key focus areas that we continue to work on is in primary care. It might be that for a half day, you’re seeing patients face-to-face in the clinic, and for the other half day, it might be all video visits. Or you might be the primary care doctor on call for the service area, so you would help support nurses who might need a doctor’s help to address the patient’s concern when they’re calling in. So, really thinking about how do we reinvigorate — that third R — to add variety to the process.

This is an opt-in model for physicians who want to do this work, who want the flexibility in hours. Once you go into things like 24/7 access to a primary care or urgent care physician, somebody might want to work at night and be free in the daytime because of young children. So, you begin to create an ecosystem of care that is even more consumer-centric in terms of availability and providing convenience, access, and options. On the clinician side, it provides flexibility in shifts and hours, as well as in the diversity of things to do and how you begin to really either take care of your panel or take care of the populations.

Van: As a consumer of healthcare, I certainly like the options that you’re laying out in that future. Imelda, every crisis creates opportunity. I wonder what your prescription is for the healthcare workforce as we recover from the pandemic?

Imelda: I’m going to be a broken record on this, Van, about the 3Rs because, again, even before the pandemic we needed to challenge ourselves to work differently and smarter. Consumerism has forever changed expectations. I think for a time, we in healthcare thought ourselves different from the consumers’ expectations of technology, retail, and so on. But the attitude of “give it to me when I want it, how I want it” caught up with us.  People are also expecting care to be provided in a culturally competent, sensitive matter — as we think more about equity, inclusion, and diversity — and weave all of that into care delivery.

So, my prescription is the same. We have to reimagine all these roles that we’ve been comfortable with and blow up that mental model and say, “Now that we have other tools at our disposal, how do we reimagine a medical assistant?” The outreach, which you and I have discussed previously, about community health workers…how do we have extenders of the care team from the clinic out in the communities who look like our patients, and know the language, and know the community, to make them feel comfortable with ongoing care?

Lastly, I would say that, as a society, I think we should lessen the emphasis on clinical care for outcomes of wellness and health, and focus more on all those things that really contribute to wellness. It’s the family, however you define that. How do we support family? How do we support educational attainment? We know that the health outcomes for a pregnant teen are different from a pregnant woman with a college education, and how even that unborn child is going to do. How do we help that?  Financial health and housing play a large part.

I knew this 15-year-old who was in and out of the ER thirty-eight times over eighteen months. But when we really dug into what was driving the health needs, it was that her mom worked two jobs and was not home often. Their home had holes in the floors and was cold, and it was a very unstable home situation and she wasn’t doing well in school. When we had a community health worker work with her and her mom and her brother and get them affordable housing and connect them to resources in the community, the ED visits stopped. I’m glad to know that she went on to college. Last I heard, she was thinking of a career in healthcare.

So, no amount of insulin — this young girl with a diabetic too, of all things — no amount of insulin was going to fix her thirty-eight visits to the ED and all that she was dealing with at home. It was really filling the gaps and addressing the gaps in the social health, financial health, and well-being of her and her family that has ultimately changed the trajectory of the outcome.

Everybody who is in healthcare knows what I’m talking about. So, I guess that would be my prescription for this: reimagine and reengineer so that we can reinvigorate ourselves, but at the same time, really look hard at what we’re doing or not doing as a society to create these opportunities for success in families and individuals.

Van: I love the story that you shared because it makes it vivid in terms of understanding that when a person comes in and needs care, not all of what they need is medical. There’s a whole bunch of other services that they may need. Does that mean that community health workers become a part of the hospital system? Or is it more about building the capacity of the community to have these types of occupations that then are good handoffs for the hospital systems?

Imelda: I would say it’s both, Van, because people spend 99.9% of their time in the community, not in the building of clinics or hospitals, right? So, we need to partner as much as possible with community-based organizations that support people — whether it’s a financial need or housing need, transportation need, legal help…there’s so many. There’s a whole ecosystem of social needs and community-based organizations that are in partnership with the ecosystem of healthcare. I think it has to be that, and to create that complete, total care: mental, physical, social, financial. I think it’s that partnership. It’s hospital, it’s ambulatory, it’s the community-based organizations working together, and then having the right policies and infrastructure in schools. We’re getting into truly a systemic, systems-based point of view of how do we knit all of these institutions together to help the citizenry be better, do better, and feel better.

Van: Well, that’s actually a really good segue to my next question. As you know, I recently published a book, WorkforceRx: Agile and Inclusive Strategies for Employers, Educators, and Workers. It advocates for something that we lived at Futuro Health — and that you’re alluding to — which is that organizations don’t have to tackle things alone, especially on the workforce issues and especially of this magnitude. When you’re thinking about workforce development these days, especially in your current duties, do these concepts of partnership, of collaboration, of consortia, of braiding efforts resonate with the work that you’re doing today?

Imelda: Absolutely. Some of the things that we’re doing are partnering with community colleges, for example, to fortify, if not develop, a medical assistant curriculum and standing this up and providing our clinics and facilities as places where the students can learn. On a bigger scale, we’d eventually like to get the health systems and community here in Washington to partner in figuring this out together as opposed to trying to do it alone.

That’s definitely on the to-do list for me here in Washington, and I’m really enjoying meeting system leaders here in Washington who are like-minded. Frankly, we’re all facing these challenges. So, that’s on the horizon. I also did reach out to you and think about bringing you over at some point to talk with health system leaders about what you’ve done at Futuro Health in California, and what that could look like in Washington.

Van: Absolutely. Please let us know how Futuro Health can help. We’ve been designing solutions that really pay attention to scale, equity, and identity, and would love to share those playbooks.

As I mentioned in the introduction, you are known as a thought leader on so many issues, including value-based care, social determinants of health, and the health implications of climate change. What’s your advice to our listeners, who are largely workforce professionals, in anticipating the trends and skill changes in the future of care?

Imelda: Maybe just thinking about climate change for a minute, one of the things we might reimagine and reengineer as an industry is that healthcare is a big producer of greenhouse gas. If healthcare as an industry was a country, we would be ahead of Great Britain in greenhouse gas emissions. So that means thinking about sourcing for hospital systems and clinics and organizations. With whom are you partnering from a supply chain perspective?  Are you picking vendors that are more climate-friendly? In your own facility, what are those things that create a lot of waste, and how might we partner with some of our vendors, for example, to reduce that packaging or waste footprint?

For physicians and clinicians who use a lot of these things, we can think about where there are differences in products. One thing I’m familiar with is anesthesia gases — desflurane versus sevoflurane. One stays in the atmosphere for decades and decades, and another gets broken down in less than several years. So, beginning to think about those things and the impact we’re making.

Even connecting that to telehealth. One of the things published with Dr. Colin Cave around telehealth were some guesstimates and estimates around how people are not driving to doctors’ offices. We’re not driving to pharmacies. How do we begin to create an ecosystem of care with a footprint of what we can do as consumers of care? That paper talks about having more video visits and e-visits mitigates greenhouse gas emissions, for example. Every care team member and clinician can also think about their own footprint. There’s a whole white paper on this that the American College of Physicians and others have published about what we, as clinicians, can do in our own practice and at the patient’s bedside to begin to impact and mitigate what we’ve done with the climate.

Van: This is a whole set of skills that I had not even considered were related to healthcare. Thank you for pointing those out. Now, you’re known as a proponent of the Quadruple Aim, and I was wondering if you could share with our audience what this means and how it guides your decisions as a leader?

Imelda: Yes. It’s really the complexity of how we balance all the priorities. The aims are: we absolutely want quality of care; we absolutely strive for a great care experience; affordability of care, and caregiver experience. In the past, it was the Triple Aim, and it evolved to Quadruple Aim, adding on there the caregiver experience — whether it’s physicians, nurses, medical assistants…everybody. So, those are the aims as we think about prioritization and about the finite resources that we have. We work to balance and serve all of those aims in what we do and how we do.

Van: That’s a helpful framework. You were on the board of the Kaiser Permanente School of Medicine at one point. How does medical education need to evolve to meet the many challenges confronting healthcare and the future of care?

Imelda: I think that’s another podcast or ten, Van. When I look back at my own medical education, I guess what I would say was missing—and I’m glad that Kaiser Permanente School of Medicine and other medical schools now have come to embrace and promote this —was around how we think about equity, inclusion, and diversity in how we choose our medical students, and how we train our medical students. How do we teach that in taking care of the patient, we need to participate in the community and lean into the communities that we serve? Having medical students going out into the communities and doing parts of the clerkship and work in the community…that was not there for me a long, long time ago when I was in medical school, so I’m glad that that’s really now front and center for many medical schools in the training.

The notion of social determinants of health wasn’t even a term when I was going to medical school. Clinicians need to understand how all of those drive health outcomes more so than what we do as doctors with patients in clinics or hospitals.  Picking it up further, how are systemic and institutional racism at the root of that? How do you unpack that? I know these are hard conversations to have, but as physicians we’re trained to have hard conversations, and so it would be better to have these conversations.

Van: It sounds like the skills have shifted, or the content has shifted a bit. It’s not just what you would expect in terms of the clinical skills and the ability to deal with patients. You have this DEI overlay, and then I’ve also understood that being technology-comfortable is also a set of skills that will be expected of physicians as well?

Imelda: Yes. I’m less worried about that, actually, because when you look at the Gen Z’s and the generations after, they think texting is intimate and relational. They think Face Timing is intimate, whereas some other physicians and clinicians might say, “I need to touch my patient to have a relationship.” The generations now and to come, I believe, are going to blow that out of the water and say a relationship is based on X, Y, Z.  So, I’m hopeful that the future generations and the younger generations now get it about connecting with people. How we connect with people is going to be defined and redefined by the technology and the environment they’ve grown up in.

Van: Well, I want to celebrate you for inspiring so many people in the healthcare and medical field and inspiring me to do my work. Thank you very much, Imelda, for being with us. It’s such a delight to spend time with you.  I am Van Ton-Quinlivan with Futuro Health. Thanks for checking out this episode of WorkforceRx. I hope you will join us again as we continue to explore how to create a future-focused workforce in America.