The case describes the challenges facing Shlomit Schaal, MD, PhD, the newly appointed Chair of UMass Memorial Health Care’s Department of Ophthalmology. Dr. Schaal had come to UMass in Worcester, Massachusetts, in the summer of 2016 from the University of Louisville (KY) where she had a thriving clinical practice and active research lab, and was Director of the Retina Service. Before applying for the Chair position at UMass she had some initial concerns about the position but became fascinated by the opportunities it offered to grow a service that had historically been among the smallest and weakest programs in the UMass system and had experienced a rapid turnover in Chairs over the past few years. She also was excited to become one of a very small number of female Chairs of ophthalmology programs in the country. 

Dr. Schaal began her new position with ambitious plans and her usual high level of energy, but immediately ran into resistance from the faculty and staff of the department.  The case explores the steps she took, including implementing a LEAN approach in the department, and the leadership approaches she used to overcome that resistance and build support for the changes needed to grow and improve ophthalmology services at the medical center. 

This case describes efforts to promote racial equity in healthcare financing from the perspective of one public health organization, Community Care Cooperative (C3). C3 is a Medicaid Accountable Care Organization–i.e., an organization set up to manage payment from Medicaid, a public health insurance option for low-income people. The case describes C3’s approach to addressing racial equity from two vantage points: first, its programmatic efforts to channel financing into community health centers that serve large proportions of Black, Indigenous, People of Color (BIPOC), and second, its efforts to address racial equity within its own internal operations (e.g., through altering hiring and promotion processes). The case can be used to help students understand structural issues pertaining to race in healthcare delivery and financing, to introduce students to the basics of payment systems in healthcare, and/or to highlight how organizations can work internally to address racial equity.

Jessie Gaeta, the chief medical officer for Boston Health Care for the Homeless Program (BHCHP), learned on April 7, 2020 that the City of Boston needed BHCHP to design and staff in 48 hours one half of Boston Hope, a 1,000-bed field hospital for patients infected with COVID-19. The mysterious new coronavirus spreading around the world was now running rampant within BHCHP's highly vulnerable patient population: people experiencing homelessness in Boston. A nonprofit community health center, BHCHP for 35 years had been the primary care provider for Boston's homeless community. Over the preceding month, BHCHP's nine-person incident command team, spearheaded by Gaeta and CEO Barry Bock, had spent long hours reorganizing the program. (See Boston Health Care for the Homeless (A): Preparing for the COVID-19 Pandemic.) BHCHP leaders now confronted the most urgent challenge of their long medical careers. Without previous experience in large-scale disaster medicine, Gaeta and her colleagues had in short order to design and implement a disaster medicine model for COVID-19 that served the unique needs of people experiencing homelessness.

This case study recounts the decisive actions BHCHP leaders took to uncover unexpectedly widespread COVID-19 infection among Boston's homeless community in early April 2020. It details how they overcame their exhaustion to quickly design, staff, and operate the newly erected Boston Hope field hospital for the city's homeless COVID-19 patients. It then shows how they adjusted their disaster medicine model when faced with on-the-ground realities at Boston Hope regarding patients' psychological needs, limited English capabilities, substance use disorders, staff stress and burnout, and other issues.

On February 1, 2020, Jessie Gaeta, the chief medical officer for Boston Health Care for the Homeless Program (BHCHP), received news that a student in Boston had tested positive for the novel coronavirus virus that causes COVID-19 disease. Since mid-January, Gaeta had been following reports of the mysterious virus that had been sickening people in China. Gaeta was concerned. Having worked for BHCHP for 18 years, she understood how vulnerable people experiencing homelessness were to infectious diseases. She knew that the nonprofit program, as the primary medical provider for Boston’s homeless population, would have to lead the city’s response for that marginalized community. She also knew that BHCHP, as the homeless community’s key medical advocate, not only needed to alert local government, shelters, hospitals, and other partners in the city’s homeless support network, but do so in a way that spurred action in time to prevent illness and death. 

The case study details how BHCHP’s nine-person incident command team quickly reorganized the program and built a detailed response, including drastically reducing traditional primary care services, ramping up telehealth, and redeploying and managing staff. It describes how the team worked with partners and quickly designed, staffed, and made operational three small alternative sites for homeless patients, despite numerous challenges. The case then ends with an unwelcome discovery: BHCHP’s first universal testing event at a large city shelter revealed that one-third of nearly 400 people there had contracted COVID-19, that most of the infected individuals did not report symptoms, and that other large city shelters were likely experiencing similar outbreaks. To understand how BHCHP and its partners subsequently popped up within a few days a 500-bed field hospital, which BHCHP managed and staffed for the next two months, see Boston Health Care for the Homeless (B): Disaster Medicine and the COVID-19 Pandemic.
 

In August of 2020, after a day treating patients, John McAdams, MD, gets ready to meet with a young couple from the community. He is excited to share the latest progress on his institution’s Cancer Treatment and Control Center, which is set to open in 3 years. The $230+ million project is something that Dr. McAdams has been building in his mind for years. Its brick and mortar location will strive to be a truly different cancer center that emphasizes population health alongside acute treatment. Cutting edge technologies and innovative public health initiatives working in tandem will close the gap between rural and urban cancer patient outcomes.

After decades of diligence, vision, and advocacy from John, Midwest Regional Health (MRH) has purchased the physical location of what will be a state-of-the-art cancer treatment and control center—a rarity for rural America. The site is on the main campus and will be connected to the inpatient and pediatric hospitals by tunnels to have the cancer center be better integrated into the continuum of cancer care than an outpatient center at a separate location. According to John, “The architects have worked very hard to make the center what we wanted…very welcoming and reassuring but intertwining all the workings of the various departments.”

However, with just three years before the grand opening, questions remain about how to structure the management of the cancer center relative to the medical center and the oncology service line, how to expand the research base in oncology, and how to drum up excitement and support in the community.

The Envision Healthcare (EVHC) case examines the operations of one of EVHC's divisions, EmCare, a national physician services outsourcing company. The case describes EmCare's controversial use of out-of-network billing for a significant share of its revenues. As the company faced increasingly negative scrutiny for these practices, the case highlights the different perspectives and vantage points- both good and bad- of this strategic decision, and delves into the question of ethical practices as it relates to out-of-network billing. Students will explore the legal, societal, and economic implications of EmCare's business model, grappling with questions of business ethics and responsibility to customers. As EVHC contemplates reducing the out-of-network billing practices of its divisions including EmCare, the company faces important questions around financial viability, which serve as an opportunity for students to develop recommendations and novel approaches to EVHC's strategic quandary.

Ethical challenges are common to healthcare organizations as they develop and implement strategy. Organizations must deal with questions of profitability and performance against the backdrop of making self-guided decisions around social responsibility and ethical practices. The case provides relevant context regarding emergency medicine, out-of-network billing, and payer-provider-hospital relationships. With this background, students are encouraged to consider the gamut of considerations, some of which are not so obvious, when weighing strategic decisions that bear in mind social and ethical implications.

Elizabeth, a middle-aged African American woman living in Minnesota, develops chest pain and eventually presents to a local emergency room, where she is diagnosed with stress-related pain and given Vicodin. Members of a non-profit wellness center where she is also seen reflect on the connection between her acute chest pain and underlying stress related to her socioeconomic status. On a larger level, how much of her health is created or controlled by the healthcare system? What non-medical policy decisions impacted Elizabeth such that she is being treated with Vicodin for stress?

In 2011 in response to two high profile cases of maternal death during labor and delivery, Ugandan citizens mobilized to prevent maternal mortality by improving the delivery of healthcare services in public hospitals. The Coalition to Stop Maternal Mortality ignited a social movement by utilizing strategic advocacy to hold the Government of Uganda accountable to its constitutional provisions on health service delivery. This case examines the Coalition to Stop Maternal Mortality and its landmark legal initiative, Constitutional Petition No. 16 of 2011, that focused the nation’s attention on the state of health services in Uganda and initiated a nationwide conversation about the role of government in delivering the right to health for all Ugandans.  What tactics and strategies can effectively mobilize power to bring about legal and policy change?  Would these be enough to achieve the change that the Coalition sought?

This case describes and explores the development of the first medical transitions clinic in Louisiana by a group of community members, health professionals, and students at Tulane Medical School in 2015.  The context surrounding health in metro New Orleans, the social and structural determinants of health, and mass incarceration and correctional health care are described in detail. The case elucidates why and how the Formerly Incarcerated Transitions (FIT) clinic was established, including the operationalization of the clinic and the challenges to providing healthcare to this population. The case describes the central role of medical students as case managers at the FIT clinic, and how community organizations were engaged in care provision and the development of the model.  The case concludes with a discussion of the importance of advocacy amongst health care professionals.