Trustee talking points
- The 2014 birthrate for women ages 25 to 29 was 106 births per 1,000, just slightly higher than the rate of 101 per 1,000 women ages 30 to 34, according to the Centers for Disease Control and Prevention.
- The only growth in U.S. birthrates in 2014 was among women 30 to 34, 35 to 39, and 40 to 44.
- Women make approximately 80 percent of health care decisions for their families, according to the Department of Labor.
- Recognition is growing that differences exist between men and women in many disease states.
- These trends combined are encouraging hospitals to create new entry points for women beyond maternity care.
When it comes to health care, the differences between men and women go way beyond their reproductive roles. A growing body of evidence finds variance between the genders in disease incidence and manifestation in a number of organ systems — from the heart to the gastrointestinal tract.
As a result, some hospitals are broadening the scope of women’s health services beyond the traditional realms of obstetrics and gynecology. Approaches range from a niche strategy tailored to women’s needs in one specialty all the way to a one-stop center where women can get multispecialty care attuned to their gender.
Strategy 1: One stop for medical care
At the comprehensive end of the women’s services spectrum is the Ripa Center for Women's Health & Wellness, part of Cooper University Health Care’s Voorhees, N.J., campus. The facility is named for TV personality Kelly Ripa and her family, which has supported the Cooper system.
Opened in 2007, the Ripa Center is designed to meet the unique needs of women at all ages and stages of life, explains Adrienne Kirby, the health system’s president and CEO. The facility features internal medicine, obstetrics, gynecology, imaging, cardiology, pulmonology, neurology, endocrinology, gastroenterology, plastic and breast reconstruction surgery, and psychiatry and psychology services.
One founding principle is to make care convenient. “Women tend to put everybody else before themselves,” Kirby says. “As people who provide health care, we thought if we could get a woman in the door and make it easier for her to access multiple services at one stop, we could help her to get better health care.”
An example is the center’s “Half-Day for Health” offering, which enables patients to check off important women’s health to-dos in one visit. During the half-day, women get their annual primary care checkups, their mammograms and/or bone density scans, if needed, and their annual gynecology visits.
The center provides what it has dubbed GPS, which stands for “great personal service.” It involves one phone number women can call to reach a nurse navigator, Bonnie Mannino, R.N., who schedules appointments, answers health questions and guides women through their care across specialties. The number and Mannino’s email address are featured prominently on the Ripa Center’s home page.
Mannino also helps women get medical records from previous providers, sends appointment reminders, emails them physicians’ biographies, makes sure patients know where to go for appointments and follows up to ensure their needs were met. “It increases the number of patient touches that you have,” Kirby says.
The navigator facilitates care coordination between the center’s specialists, especially for women with complex health needs. “She makes sure that everything gets knitted together,” Kirby says.
Of the 19 Ripa Center physicians, 17 are women. It’s that way for a reason — many women like to receive care from female physicians. All of the physicians have an interest in women’s health and understand the subtle nuances and differences, not only of how women seek care, but how conditions may present themselves compared with those of men, Kirby says.
Internal medicine is the center’s backbone. “We’re different in that we’re saying that obstetrics is not the center of women’s health,” Kirby says. “OB is a component of women’s health, but it’s at that one point in the life cycle. The internal medicine doctors are the pivot points around which everything else circles.”
Although most of the center’s internists and many of its OB-GYNs practice there full time, most of the specialists also practice at other locations. Therefore, some specialty services are available at the center each week, but not every day. For example, not enough demand exists for a pulmonologist or endocrinologist to practice there full time, Kirby notes.
The women’s health leadership looks at data on patient demand and usage quarterly to determine where services might be added and where they should be cut back. “It’s about responding to the needs of the community, and you have to be nimble and willing to change,” Kirby says.
Among the metrics are number of patient calls, patient visits, first-time patients and multiple-use patients. Patient visits totaled 16,853 in 2015 — 4,966 for radiology, 5,515 for OB-GYN, 2,539 for primary care and 3,833 for specialty care. There were 2,406 new-patient visits last year.
The Ripa Center also monitors quality dashboards for each specialty and for the center overall, as well as patient satisfaction scores.
The center aspires to be more than a place where women receive medical care. “We really wanted to create a center where women felt it was part of their life,” Kirby says. It has education space, a fitness studio and a demo kitchen for cooking classes. Wellness offerings include yoga, Pilates and mindful meditation. “It’s a nice mix of medical care and fun things centered around how to look and feel better,” Kirby says.
The center has achieved the right balance, she adds. “It’s got comprehensive services, but it’s not so big that it loses any level of intimacy.”
Wellness classes and educational programs on topics such as osteoporosis, diabetes and prenatal nutrition often are the way women find the center. Community mailers let people know about the various offerings.
Other patients discover the center because they’re already using other Cooper system services or by being referred by independent primary care doctors. Community physicians send patients with complex medical needs to the center because it offers multispecialty care under one roof.
“That’s much better for the patient, and it’s easier for the provider,” Kirby says.
Strategy 2: Care across life’s stages
Bon Secours Richmond (Va.) Health System aims to be a resource for women ages 13 to 113, says Julie Reagan, administrative director of women’s services.
The Bon Secours life stages webpage sets the tone. It’s organized into “infancy and childhood,” “discovering you” (ages 13 to 18), “taking the stage” (18 to 40), “hitting prime” (40 to 55), “transitions” (55 to 75) and “living well” (75-plus). A click on any of these stages generates a comprehensive list of health needs for that age group. From there, a click on any of the health needs takes the user to a page full of health information and a link to the Bon Secours physician locator site.
Childbirth still is usually the reason for a woman’s first hospital visit, says Blake Slusser, Bon Secours director of educational programs for women’s services. So one strategy is to court women for obstetrics, build trust and loyalty through that service and then maintain a lifelong relationship through other services.
Because more women are having children later in life or not at all, the life-stages approach provides other entry points into the health system. Although the “taking the stage” webpage for women 18–40 features a link for pregnancy care, it also includes cancer, colorectal, continence, hormone, immune system, infectious disease and orthopedic health links.
Older Americans are using the internet more than ever before — 81 percent of people 50 to 64 and 58 percent of those 65 and older in 2015, according to the Pew Research Center. With so many baby boomer women online, the question for hospitals is how to reach them digitally. The answer at Bon Secours: “Let’s use that opportunity to educate them and build relationships with them,” Slusser says. The system’s “transitions” and “living well” webpages contain content tailored to women in the boomer generation and beyond.
It’s not enough to put educational information and links to the physician locator online, Reagan says. The effort needs to be backed up with access to doctors.
Bon Secours has a network of physicians, often women, with an interest in how diseases manifest in females versus males in various specialties. For example, within a group of gastroenterologists, there will be some who have a special interest in women’s GI health, Reagan says.
The system is redesigning its virginia.bonsecours.com website so it offers more topic-specific videos by physicians, including specialists with a focus on women’s health.
Bon Secours also attracts women through educational seminars and special events. The system has partnered with the American Heart Institute locally and is a sponsor of its annual Go Red for Women luncheon. The February event attracted 600 people and featured a Bon Secours cardiologist as a speaker.
“It’s a prime opportunity to highlight how our cardiac services for women stand apart at Bon Secours,” Slusser says.
Strategy 3: A specific focus
Recognition that heart disease often presents differently in women than in men prompted Allina Health to create its Women’s Heart Health Program. The goal is to address disparities in recognizing and treating cardiovascular disease in women.
Located in the Minneapolis Heart Institute on the system’s Abbott Northwestern Hospital campus, the program focuses on primary prevention for at-risk women and secondary prevention for those who’ve had a cardiac event.
“When you’re talking preventive medicine, it isn’t the fireman, it’s more Smokey the Bear,” says Susan White, administrative and program lead for prevention and women’s heart health at the Minneapolis Heart Institute. That’s why the outpatient program focuses not just on medication but the lifestyle changes women can make to reduce their risk of a heart problem.
The program has three components — nutrition, exercise and a consultation with one of the program’s four cardiologists. Elizabeth Grey, M.D., is director for the program, and its nurse practitioner and physician assistant are both female. “A lot of women like seeing women,” White says. “They feel that it’s a different conversation with a woman. It’s a different comfort level versus a male.”
In the program’s nutrition arm, a dietitian creates an individualized plan for the patient. “We’re addressing nutrition therapy in terms of weight control, lipid management and hypertension, so we’re looking at its inroads on many of the risk factors,” says White, a clinical dietitian.
Patients work with exercise physiologists at Abbott Northwestern’s LiveWell Fitness Center. “We really try to look at the management of cardiovascular disease from a panoramic view,” White says.
The Minneapolis Heart Institute fosters a spirit of camaraderie among patients who have heart disease and those trying to prevent it by providing space for the Weekly Women's-Only Cardiac Support Group. “The idea is to have a dialogue in terms of support and education,” White says.
Twice a year, the Women’s Heart Health Program offers community educational sessions specific to women’s cardiovascular disease. Outreach to women’s business groups and churches helps to draw attendees. The spring 2016 session will focus on microvascular disease in women.
The heart institute’s prevention program sees 400 patients, both men and women, quarterly. “It elevates to the consumer our commitment to cardiovascular health,” White says.
Geri Aston is a freelance writer in Chicago.
Hospitals rethink childbirth
Childbirth is still the most common reason for women’s first hospitalizations, so hospitals have to make sure their labor and delivery departments meet expectant mothers' evolving needs and preferences.
Women want options — from having a midwife or doula on hand during delivery to having newborns room in with them instead of going to the nursery, says Madhavi Kasinadhuni, senior consultant for research and insights at the Advisory Board Co.
Bon Secours Richmond (Va.) Health System’s three birthing centers have stayed on top of the latest trends. Women have access to certified nurse midwives, and labor-delivery nurses are cross-trained as doulas, says Julie Reagan, administrative director of women’s services. The birthing centers, located at the system’s Memorial Regional, St. Francis and St. Mary’s locations, have policies to support breast-feeding and offer women the option to have their babies stay in the mothers’ rooms.
In March 2014, St. Mary’s was the first hospital in Virginia to offer nitrous oxide to birthing women as a low-intervention tool for pain management during labor. The system expanded the nitrous oxide option to its St. Francis and Memorial Regional locations in December 2015.
The centers have maternal-fetal medicine programs, and the system offers a perinatal transport service for women who have a complication that would be treated better at another Bon Secours hospital.
The birthing centers’ neonatal intensive care units have cameras with secure internet connections so parents can see their babies 24/7 from their own home or workplace.
“We really focus on having a very wide spectrum of services,” Reagan says.
Gender difference snapshots
- Because women’s esophagi are more sensitive to irritants, they may experience heartburn more strongly than men, but they generally have less damage in their esophagi than men.
- Irritable bowel syndrome occurs two to six times more often in women than in men.
- Women often have slower gallbladder emptying than men and are twice as likely to develop gallstones.
- Obstructive sleep apnea symptoms often reported by men include snoring, waking up gasping for air or snorting, but many women report other symptoms, such as fatigue, anxiety and depression.
- Sleep apnea in women is commonly mistaken for depression, hypertension, hypochondria or other disorders.
- Women are more likely than men to report insomnia.
- The classic heart attack symptoms of feeling pressure or squeezing in the chest and down the arm aren’t always present in women. Instead, many women feel sharp, burning chest pain, and they’re more likely to have neck, jaw, throat, abdomen or back pain.
- In men, angina tends to worsen with physical activity and go away with rest. Women are more likely than men to have angina while they’re resting or sleeping.
- Women tend to have more heart-failure symptoms, such as shortness of breath, difficulty exercising and swelling around their ankles more frequently than men.
- Women have less loss of balance and coordination when having strokes. They have more changes in mental status (confusion, unconsciousness) and more nausea, heart attack-like symptoms, and severe headaches than men.
- Men have more atherosclerotic strokes, and women have more cardioembolic strokes.
- Women have additional risk factors for stroke — birth control pill use, pregnancy, hormone replacement therapy and migraines.
- Many autoimmune diseases, such as rheumatoid arthritis, multiple sclerosis and lupus, are more common in women than men.
- The severity of autoimmune diseases differs between genders. For example, psoriasis is more severe in males, while the clinical course in Crohn’s disease is more severe in women.
- Males with systemic lupus erythematosus are more likely to suffer renal and cardiovascular comorbidities, while females are more likely to suffer from urinary tract infections, hypothyroidism, depression, esophageal reflux, asthma and fibromyalgia.
Type 2 diabetes
- Type 2 diabetes increases the risk of heart disease more markedly in women than in men, and females with diabetes have a greater risk of mortality than males with diabetes.
- Women with Type 2 diabetes more often have depression, anxiety and low energy levels compared with diabetic men.
- Diabetic men are more likely to have foot ulcers and lower limb amputations, while diabetic women are prone to urinary tract and vaginal infections.
New women's health services: What's involved
Many factors should be considered when planning and building a women’s service-line expansion, says Madhavi Kasinadhuni, senior consultant for research and insights at the Advisory Board Co. Among the considerations are:
Health care market:
Community demographics, current and future demand for services, potential service gaps in the area and what competitors offer should be evaluated when deciding whether and how to expand women’s health services.
Current service level:
Medium or large organizations that already offer the services in house could opt to package and brand several women’s health services across departments. A smaller organization might prefer to focus on a single specialty where it already has a strong presence, such as cardiology or gastroenterology.
When stretching beyond traditional OB-GYN services, hospitals typically don’t colocate the offerings in a women’s health center. However, service line leaders should work together to determine what services they want to focus on for women, how to build programming and how to create a unified women’s health campaign.
The organization should create one landing page for women’s health services. It should describe the various specialty offerings and make it easy for women to find resources and to make appointments. Ideally, it would provide one phone number for women to call for scheduling.
Some hospitals have one person serve as the public face of the women’s health program. Sometimes this person is a women’s health navigator who takes calls, helps to coordinate appointments, facilitates care transitions or simply handles social media. Other times, it’s a physician champion with a particular interest in women’s health.
Hospitals should make sure employed and independent primary care physicians and OB-GYNs know about the breadth of women’s services they offer. The task can be taken on by the hospital’s physician liaison.