In this episode of PermanenteDocs Chat, host Alex McDonald, MD, speaks with Eloa Adams, MD, director of Inpatient Pediatrics Quality and Operations for The Permanente Medical Group (TPMG), about leading the future of pediatric care.
They discuss the rise of pediatric care deserts, why TPMG invests in community-based inpatient services, the power of integrated teams and telecritical care, and a sepsis-prevention effort summed up by the motto “more awareness equals more birthdays.”
The conversation also touches on the importance of partnerships between hospitals, communities, and health care systems in caring for children and how transitioning to a value-based, coordinated care approach to pediatrics allows for opportunities to improve access, prevention, and overall care.
Guest
Eloa Adams, MD
Director of Inpatient Pediatrics Quality and Operations, The Permanente Medical Group
Podcast transcript
Transcript is autogenerated. Although edited for clarity, it should not be considered an exact replication of the podcast and may also be updated as needed.
Alex McDonald, MD: Hello everyone. Welcome to today’s PermanenteDocs Chat. I am your host, as always, Alex McDonald. And for those of you who don’t know me, I practice family and sports medicine as part of the Southern California Permanente Medical Group here in Fontana, California. Today we are going to be talking about pediatric care at Kaiser Permanente, and we are joined by a wonderful guest, Dr. Eloa Adams, who is a pediatric ICU doctor. Welcome Dr. Adams.
Eloa Adams, MD: Thank you, Alex. Great to be here.
AM: I am excited to have this conversation with you, and I hope we fix some problems here. I think it’ll be easy to fix these problems together, yeah?
EA: We can solve all the world’s problems!
AM: Great. We’ll make it happen. Well, Dr. Adams, thanks again for joining. I’m going to start with my tried and true first question. Tell us who you are and what you do.
EA: My name is Eloa Adams. I am, as you mentioned, a pediatric intensivist and I practice at our [Kaiser Permanente] medical center in Oakland, California. I also serve as the regional director for Inpatient Pediatrics for [The Permanente Medical Group] here in Northern California. And I work with a tremendous group of inpatient physicians that represent the pediatric hospital medicine world, the neonatal intensive care units, our pediatric intensive care units, our perioperative spaces, newborn care, and all the ways in which we partner with the rest of our organization.
AM: Again, I practice family medicine, so I take care of everyone from newborns all the way to grandma’s and grandpas, mostly in the outpatient setting, although I do some inpatient medicine for adults too. I think it’s interesting how we organize pediatrics where you basically have all of the general peds and all the subspecialties and all the sub subspecialties and all the periop services for [pediatrics] all kind of in one bucket, versus in adult medicine, they’re all like 20 separate buckets. I really find that fascinating from a utilization and a resource point of view. And I think [general pediatrics] has far more in common with me and what I do compared to subspecialty and pediatric periop services and things like that. But I digress.
Before we get in too deep there, let’s talk about the lay of the land, if you will, and talk about some of the challenges facing pediatrics as a whole across the country, and why access to high-quality pediatric care is really reaching a crisis point, which has all kinds of implications for people’s health long-term and down the road.
The challenges facing pediatric care
EA: It’s a fascinating topic and the story I always go back to is being a dad myself. I think most parents, and that includes probably you and many of our physicians out there, can relate to an experience that I believe we all have when we’re going on a trip up to the mountains or somewhere and all of a sudden it dawns on us that where would I go if I needed to get care for my kids? And you realize, especially for those of us in health care, that there just aren’t the same types of institutions and hospitals available for children as there are for adults. And that’s been true for a long time. However, going back about 20 years ago, I would say that the prevalence of community inpatient care across California and across the country was much more prevalent. And so it wasn’t as uncommon for a community hospital to have a small enclave of pediatric inpatient beds where they could serve the members of their community.
However, over the last 20 years or so, we’ve seen a substantial decline in that service where those hospitals that had previously delivered that community level inpatient care have forfeited that care and replaced those pediatric beds with adult beds largely for financial reasons that we know about. And then the expectation was that the larger freestanding children’s hospitals would assume responsibility of that care. And I think from a non-[Kaiser Permanente] standpoint, that seemed like a very good arrangement. The children’s hospitals are such that more patients in those hospitals help with the operations of that hospital and the financial structure of the hospital and the community centers would benefit to some degree because they could then admit adult patients, and that is beneficial for them. But I think what we’re now realizing is that there’s been, as a result of that trend, a growing number of what we call pediatric deserts out there where all of us drive into these situations and we think to ourselves, we’re not going to be able to get to anywhere soon. And that’s directly related to this trend that we’ve seen over the last 20 years.
AM: I think it’s interesting that some of those market forces which have driven consolidation amongst pediatrics is maybe even more pronounced than against general medicine and adult medicine in general.
EA: That’s correct.
AM: The economies of scale certainly makes sense. If you have one or two pediatric beds and they’re not filled on a regular basis to shift those, consolidate those one or two beds here and there certainly makes sense on one point of view, but then ultimately, how does it serve our members and serve our communities? The other factor which I think is interesting is how pediatrics in many respects is funded and compensated. Much of it’s through Medicaid or Medi-Cal here in California. And also a lot of donations; everyone wants to donate to pediatrics. I never realized before doing my research for this podcast how much these freestanding pediatric hospitals rely on philanthropic donations, which is really very unique, I think, in the health care space.
EA: Exactly. And what you’ve seen, in addition to the trend of our children’s hospitals growing and increasing the number of beds and capacity that they have, they’ve also become quite dependent on billionaire benefactors. And not only just the benefactors, because a lot of children’s hospitals and freestanding children’s centers are directly related to academic centers, there is also a substantial contribution coming from federal funding for research grants and funding of that nature as well.
AM: Practicing here at [Kaiser Permanente], one of the things I love is if I have one of my primary care patients admitted to the hospital, I can literally walk across the street [to] visit them during my lunch and just touch base, see how they’re doing. And seeing a friendly face in the hospital I think really helps them in many ways. If you’re a primary general pediatrician in the county and the community and your patient is admitted 60 miles, 100 miles away, there’s no way that you can have that comprehensive inpatient or services to really wrap around the patient. And that’s one thing I really love about working here at [Kaiser Permanente] is again, I can connect with my colleagues in the hospital in the subspecialty services very, very easily. If you don’t necessarily have proximity or relationships with some of these services which are hundreds of miles away, you lose a lot of that patient-centered care.
EA: Right. I’m a huge fan of the services that our children’s hospitals provide. They just do a tremendous amount of work. But in addition to the concentration, there are vulnerable communities and deserts that we talk about. I think that the access to care for rural children is just not discussed enough across the country. We know over the years that rural children have a much higher mortality rate than urban children do. And while it’s hard to draw a hard line and connection to that access to care, it definitely does exist. But the wraparound care that you’re getting at is really part of the magic that can employ with our system and how when we’re thinking about providing care to our kids, we’re always thinking about this comprehensive approach that isn’t just about the brick and mortar children’s hospital, but about how we’re providing these services in the communities where our members live.
Why being in the community is a key to pediatric care
AM: You read my mind with the lead up to the next question. Given a lot of these challenges we just talked about and that you just outlined, how does the pediatrics program where you are at, Kaiser Permanente in Northern California in Oakland, try to counteract or respond to some of these [challenges] to make a tangible difference to recenter kids and families at the center of the health care system, as opposed to being caught in this never ending wheel of hyper-concentration complication?
EA: It’s a great question. We’ve been on a journey in inpatient pediatrics since nearly the beginning. Some of the big highlights along the way have been our investment in neonatal care back in the 70s and the 80s. And then we had a lot of investment in our intensive care units in the 90s and in the early 2000s. So we’ve had a journey of growth in our organization as well.
I would say that the big difference is that we haven’t been hyper-focused on concentration, and in fact, our vision and our mission are much more focused on maintaining a presence in the communities where our members live and thrive. We want to be able to be there for them and that baseball injury, or that sepsis illness that they need a hospitalization for, and we can create spaces in their communities with doctors that live in their communities that address their communities.
Community care is so important for us. One of the things I always come back and think about, because I do have the opportunity to visit our hospitals across Northern California, and one of the most fascinating observations I think about the hospitals in our communities is that they are a reflection of the needs of that community. And I think in turn, that community can also be a reflection of the care that we provide them. That is just a beautiful relationship that we have. So getting back to the inpatient pediatric journey and the pediatric journey in general, we have not felt that same financial pressure to concentrate our care. We actually feel the pressure to provide access to care for our members. And so for that reason, we have intentionally strengthened and fortified and invested in those community spaces to the point now where we actually have some of the only inpatient care in communities throughout Northern California. In places like Santa Rosa or Modesto, you’re not going to find inpatient pediatric beds outside of our hospitals. And I think that that is a growing trend, and that’s something that we’re very proud of and we want to continue to invest in that.
AM: I love what you talked about, being in the community, being part of the community to really build relationships and just an ounce of prevention. Most of pediatrics is prevention. We know that’s really the key. And if we can catch that infection early, we can prevent sepsis, we can prevent a hospitalization. And so being where patients live, work, and play and go to school is really key. But then having this network of easily accessible hospital pediatric beds, when things do escalate and you need higher levels of care, is really, really great.
EA: It’s about the beds and it’s also about the teams that are in place to support those beds. We are so fortunate to have primary care doctors that are constantly on the front lines and are supporting the health of our members, spreading the good news of preventable ways that we can keep kids out of the hospital and keep them healthy. We have subspecialists that are available to the members of those communities as well that are dealing with the more complex medical issues. We have the surgeons that can help address the surgical needs for those patients as well. And then you have our inpatient teams that all work together. One of the things that I think is really amazing about our pediatric teams is that we really do feel connected. Prior to my work here at TPMG, I could count on one hand the number of times I actually would engage with a general pediatrician as a pediatric intensivist.
But now because of our network and the ability to reach out and to create bridges across not only the subspecialties and the inpatient care, but also the outpatient care as well, what they do ultimately has a tremendous impact on the care that we provide. Their ability to provide awareness around preventable diseases and making sure that there’s awareness around vaccines and that they’re actually very helpful, in spite of what goes around in the internet today, really does have a major impact on the inpatient side. And then I think the care that we provide in the inpatient space also has an impact on our subspecialist and our primary care doctors. So it really is about the wraparound care that you talk about.
Wraparound care: Navigating the pediatric care journey
AM: Can you help me understand a little bit more about how these teams are structured? How does a patient get from point A to point B within the system? And how do those relationships with the ICU and general pediatrics, how does that work? Help me understand a bit better.
EA: Well, across Northern California, we have multiple sites with pediatric care. We have hospitals that range from our tertiary care centers that have all of the pediatric subspecialties, inpatient acute care, critical care, neonatal ICUs, maternal care, newborn nurseries, so those would be our tertiary centers. And then we have our community sites that may have some access to our subspecialists and some access to surgical care, but then we do have telecom communication with them. So we can have our intensivists support the acute care patients over telemedicine and our community sites. And then we have sites that primarily just provide care in the emergency department, or they have a newborn nursery. And the pediatric hospital medicine group will consult with the emergency department as needed. So there’s lots of variable places where our members can get care. And going back to our mission around not concentrating our care, I think we could have envisioned a world where we would’ve, rather than having 3 pediatric ICUs and 7 neonatal intensive care units, we could have concentrated all of that. That might’ve been a path of least resistance in some way, shape, or form, but it would not serve our members in the communities where they live and provide that access to care.
AM: That makes perfect sense.
EA: Branching out on that, you talk about how does somebody traverse this landscape of care from the outpatient to home and into the [emergency room]? I think about it in this lifecycle of care, that we provide this wraparound care where maybe you have a baby that’s born in the hospital that needs neonatal care or a child that shows up in the ER. And our focus and our interventions in those spaces are to provide high-quality protocols and access to some specialists in the emergency department. And if a patient needs to be admitted to the hospital, we have wonderful transport services that can go out to get that patient and bring them to the place where they need, whether that’s the intensive care unit or acute care, and within those tertiary centers or the community centers where our patients are getting care, there is access to subspecialists, and we’re working together to move that patient along in their journey and providing them care along the way.
And then they get to a point where they’re ultimately transitioning home and going back to their primary care provider. And then we have that opportunity to reach out and communicate and make sure that all of the patient has all the information that they need, what their next steps are, what their follow-up is going to be. So we are there every step of the way. And I think going back to the concentration that we talked about and comparing our process to what’s happening is you’ve got this concentrated care, and again, the children’s hospitals provide an excellent service, and it’s amazing the things that they do, but their primary care doctor, their emergency department, the transport experience, that the hospital that they end up at eventually are not necessarily connected. And at each step along the way, there are potential for issues and problems and areas for improvement.
AM: I love having access to specialists at your fingertips is phenomenal. I have a patient, or a story specifically, I had a four month well-baby visit, and there was some abnormal renal imaging during a utero and follow up. And rather than send the patient to another appointment a couple miles away to see the pediatric nephrologist, I was able to get an ultrasound and just send a message to the nephrologist. They reviewed the images, they reviewed stuff with me, and we were like, Nope, this is okay. We’ll just keep an eye on it. And so it was really, really helpful to not waste the patient’s time and energy to go see the pediatric nephrologist. I love them. They’re some of my best friends actually, but we could really care for that patient where they lived and not have to worry about multiple referrals and things like that. So that’s one example that I can think right off the top of my head is so helpful. Do you have any specific success stories or positive outcomes from your program that you’d like to share?
EA: Oh my goodness, so many. Well, of course, we had just a litany of stories of pediatric patients that were taken care of in our hospital and might’ve endured very difficult chronic critical illnesses and have gone through that process. And some of these kids were young children and are now in college, and they come back and they’ll say hi. But I think for me, if I had to call out one of the areas where I’m most proud is we have a group of clinicians and nurses and professionals in Northern California that focus on pediatric sepsis. And this group is amazing. They meet every couple of weeks. They talk about how they can improve sepsis care. Sepsis kills thousands of children across the country, I think last time I looked something like 75,000 hospitalized patients a year and largely preventable. And so this group is really about trying to identify sepsis early and not only reduce mortality, but reduce any of the morbidities or hospitalizations associated from this.
They’ve taken this work and really leaning into the emergency department space and into the inpatient space and have since developed protocols. They’re working on decision support strategies. They’re actively involved in education, leaning into things like cognitive bias that might get in the way of our physicians identifying sepsis and getting the treatments early. They have expanded their work to include a collaboration with Southern California Permanente Medical Group. So they have an interregional aspect to their work. They’re engaging with Hawaii and Northwest and the Mid-Atlantic, and it’s just incredible what they do. But they have a slogan that it’s just so inspirational to me, and their slogan in this group is: more awareness equals more birthdays. And every time I see them or every time I’m engaging with them and just the passion and what they’re doing, and you just couldn’t do that without our network of integrated hospitals and the ability to engage with the emergency department and have those real conversations: What is it that gets in the way of them identifying these potentially life-threatening illness? So that’s probably my favorite. My favorite. I have lots of favorites, but that’s one of ’em.
AM: I have a couple more questions I want to ask. Kids are often really brave and really tough, and sometimes the parents are more anxious and more worried in some respects. How does this system, and I kind of gave one example earlier, but how does this system really help support parents, making sure they’re getting the right care at the right place at the right time?
EA: Dealing with parents and being there and being present with them while they’re struggling with an illness of a child is just paramount to what we do in pediatrics, and that’s true in our outpatient space. Our subspecialists deal with this all the time, our inpatient doctors. And I think it’s about really just listening to them and supporting them and reassuring them that we are focused on getting them the care that they need when they need it, and always in lockstep and hand in hand with them all along the way. To help make sure we are supporting the whole family.
The importance of patient education and gaining trust
AM: And I found sometimes connection with the primary care doctor who knows them and has that relationship with them can be really valuable when care is being transitioned in and out of the hospital as well. Absolutely.
We know that as pediatricians and primary care physicians, we are really focused on helping educate our patients and make sure that they stay healthy both mentally and physically. Now, there was a recent statistic I read that shows the average patient sees their primary care doctor for 15 or 20 minutes twice a year, but they spend an average of two hours per day on social media and games and screen time. So in this age of information overloading interconnectedness, how can we as pediatricians and primary care physicians really help educate our pediatric patients and our parents to make sure that they’re engaged in their care and they’re not dealing with some of the negative ramifications of social media and games and AI?
EA: That’s a great question, and it is just so relevant, the amount of time that people spend engaging with their screen. And as a parent, I can say that no matter how much I try to limit the screen time, it is a constant battle. But one of the most interesting and truthful comments I’ve heard made lately is just because you flood the world with information doesn’t mean truth rises to the top.
And I think with that in mind, I feel like as a physician and a pediatrician and a member of this organization, I think it’s our responsibility to make sure our members know the truth and whatever ways they are engaging with social media, I think we need to be there with them and out in front so that they’re not listening to a podcast that is telling them that vaccines are evil and pointing them in a different direction, and so engaging with them. And I think sometimes the tendency is to just look at these things and say, oh, it’s just a bunch of nonsense. And the tendency may be to ignore it, but I think ignoring it may cause us to miss an opportunity to allow truth to rise to the top, and then to really engage that next generation that we know is so important. When I hear people talking about the next generation, I’m thinking about the five-year-old and the 10-year-old that is going to raise up in our system and be cared for over the course of many, many years and turn into an adult and really value that trusted relationship and the fact that we were there for them and engaged with them and telling the truth all along the way.
AM: Your quote makes me think of another quote I saw recently. We are drowning in information, but we’re lacking in knowledge in this day. I always tell my patients, look, I want you to make the best health decisions for yourself and your family and your kids, but I want you to make those decisions based on good information. And that’s where your primary care doctor really comes in to be that conduit to help you filter through the noise and figure out what applies to you and how best to make those decisions. So it’s just a very interesting landscape in which we’re all operating in this day and age.
EA: Absolutely. The physician-patient relationship is always built on trust, and I think that’s one amazing way to build that trust going forward in the future.
The future of pediatric care is value-based
AM: Outside of Kaiser Permanente and outside of your model, you’ve talked about some of this fragmented care where things just don’t connect and there’s opportunities for mistakes and errors. What lessons could the rest of the health care system learn from the integrated pediatric care that you’re a part of, and how can we really improve pediatric care by adopting some of these systems and some of these practices?
EA: I would say it’s been great to engage with my colleagues outside of [Kaiser Permanente] and across the country and children’s hospitals and seeing them pivot towards value-based care. And I believe that it’s all value-based care, [it] has been a part of what we do from the beginning of our journey. And so for those reasons, I feel like we have an opportunity to really lead in this space. And as the children’s hospitals and non-[Kaiser Permanente] centers that provide care for children really start to lean into what value-based care for children looks like, that’s our opportunity to lead and to help them with that, because we are really all in this together. We had, I don’t know if you remember, but I think it was three years ago, we had the tripledemic right after the pandemic, where we had RSV, flu, and COVID-19 and all of our ERs were full, all of our inpatient spaces were full. And as a matter of a response to that, many of the leaders of children’s care in the state were meeting together. And at one point somebody said, this isn’t a time for us to see ourselves as competitors, but as partners and the ability to provide care for children. And I would make the case that we should always see providing care for children in that way. And for us, that might mean learning where our responsibility to our communities is important and how we can invest in that. But then how do we partner with children’s hospitals to also make sure that our children that we’re responsible for can receive the care that maybe they need to provide for them, so that we’re providing that seamless transition, leading in value-based care, seeing children as a value in the way that we need to break down these barriers and walls and silos and partner together to make sure that kids are taken care of. I think those are the areas that we can focus in on.
AM: As we alluded, pediatrics care is really facing some challenges, but being an integrated value-based model shows what’s possible. My next question is, what’s happening in the future? The future will depend on how well we adapt to the shifting landscape and continue to meet the needs of children and families, and making sure the children and families are at the center of these systems, not an afterthought. So, what do you see happening in the next 5 to 10 years regarding pediatric care delivery and how are we going to need to continue to adapt?
EA: So for us, I would speak to our mission and our vision, which is to maintain a presence of inpatient care in the communities that we serve, but to be able to provide a full spectrum of services to our members so that we’re providing equitable care across our inpatient services. And that’s going to require a lot of collaboration, as it always does, between our inpatient doctors, our outpatient doctors, our subspecialists, our surgeons, and the ability to be innovative in that space. So we look into expanding our telemedicine presence. Right now, our pediatric intensivists are providing telecritical care consultations in the emergency department, which is turning out to be a really wonderful intervention. So it gives that emergency doctor, that tether and that connection to the specialist. So when they see a critically ill child, they know that they can get support for taking care of that patient.
So expanding on those types of interventions and then partnering with other health care institutions and capitalizing on our experience with value-based care and really trying to influence that. I think there’s a place for us to advocate for our model of care because we do have a huge responsibility for our members to make sure that we’re providing the care that then they need. And so as health care continues to concentrate and standards change and become influenced by higher concentration of care in certain areas, we also need to advocate for ourselves and make sure that the community of health care providers realize that it’s important to be able to provide care in these communities and that we can show them how to do it.
AM: Well said. Last question. Tell me what makes you most proud to be a Permanente physician?
EA: I am most proud to be a Permanente physician because we are aligned with the needs and the health of our members. And when our members are doing well, we are doing well and vice versa. And I think that the ability for us to collaborate and create partnerships and real tangible interventions that are really focused on collaboration and focused on keeping the patient at the center is really what I think makes me most proud of what we do. I just feel like any intervention that we do, any sort of care that we provide, anything that we do has to have a few components. And that is the first one, is that the patient always has to be at the center of what we do. And the second one is, how do we work together to bring that care to that patient in the best way that we possibly can? And I think going beyond that, what has always attracted me to this organization is the opportunity to build on that foundation. And that’s an area where we can do things that no other organization can do because they’re locked into a certain type of model, whereas we can build on a foundation that can lead us in lots of different directions that ultimately lead to better care.
AM: Strong, robust, comprehensive pediatrics is really all about prevention and minimizing any potential impact to really set our patients up for health and success for their entire life. That’s so critically important about education and prevention within pediatrics.
EA: Yeah, one of the jokes that we have sometimes is that if we’re really good at what we’re doing, then as a pediatric ICU doctor, I may not have a job in the future, but that would be okay with me, I’m all right with it.
AM: Good problem to have. Thank you so much, Dr. Adams, for joining us. Really appreciate your time and insights.
