Transforming America’s ‘sick care’ system

May 10, 2019 — Rear Admiral Sylvia Trent-Adams has been caring for people since she was just a child. When Trent-Adams was just 12 she volunteered as a candy striper at Lynchburg General Hospital in Virginia. The Rear Admiral later served as a nurse in the U.S. Army before rising up the ranks of the U.S. Public Health Service to become Deputy Surgeon General. In 2017, she was named Acting Surgeon General for six months, becoming just the second nurse, and the first registered nurse to hold that position. Today, Trent-Adams is Principal Deputy Assistant Secretary for Health in the Department of Health.

Throughout her career, Trent-Adams has focused on improving access to care for under-served and marginalized groups. And during a visit to the Harvard Chan School, we took the opportunity to interview Trent-Adams about her career in public health. She spoke about the need to shift America’s health care system to a prevention model, strategies for addressing complex health challenges, and how being a nurse has shaped her career.

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Leading from Where You Are: The Role of the Nurse Innovator (Frontier Nursing University)

Public Health is Community Health (University of Wisconsin-Madison)

Full Transcript

NOAH LEAVITT: Coming up on Harvard Chan: This Week in Health…A conversation with one of America’s top public health officials.

SYLVIA TRENT-ADAMS: Our health care system is based off of payment, payment for certain specific services. We need to shift that, because there’s no incentive to keep the patients healthy to begin with.

NOAH LEAVITT: In this week’s episode we sit down with Rear Admiral Sylvia Trent-Adams, the Principal Deputy Assistant Secretary for Health with the Department of Health and Human Services. We spoke with Trent-Adams about the need to shift America’s health care system to a prevention model, strategies for addressing complex health challenges, and how being a nurse has shaped the Rear Admiral’s career.

Hello and welcome to Harvard Chan: This Week in Health…I’m Noah Leavitt.

AMIE MONTEMURRO: And I’m Amie Montemurro.

NOAH LEAVITT: Rear Admiral Sylvia Trent-Adams knew she wanted to work in a health field when she was just a child—she pestered her mother to let her work as a candy striper at Lynchburg General Hospital in Virginia when she was 12.

AMIE MONTEMURRO: Today, Trent-Adams is one of the top public health officials in the U.S.—serving as Principal Deputy Assistant Secretary for Health in the Department of Health and Human Services.

NOAH LEAVITT: Trent-Adams served as a nurse in the U.S. Army before rising up the ranks of the U.S. Public Health Service, eventually becoming Deputy Surgeon General.

In 2017, she served as Acting Surgeon General for six months, becoming just the second nurse, and the first registered nurse to hold that position.

AMIE MONTEMURRO: Trent-Adams recently visited the Harvard Chan School and we took that opportunity to sit down with her and discuss her career and her work with the Department of Health and Human Services.

NOAH LEAVITT: Throughout her career, Trent-Adams has focused on improving access to care for under-served and marginalized groups. And during my conversation with her, we discussed how improving access to care is critical for shifting America’s health care system from one that’s focused on sickness and treatment—to one that promotes prevention.

AMIE MONTEMURRO: During the conversation, you’ll also hear how nursing has informed Trent-Adam’s public health work, plus how she is working to address complex issues ranging from HIV to America’s opioid epidemic.

Take a listen.

NOAH LEAVITT: Can you explain what you do in your role as the principal deputy assistant secretary for health?

SYLVIA TRENT-ADAMS: We do a lot of work around planning, coordinating program matters as relates to health, specifically public health. And we work on policy and program development. We also work with many of the legislative programs that fall under the office’s secretary for health. Anything from population affairs to adolescent health and also women’s health, minority health. We also manage the 10 regional offices for the regional health administrators across the United States, and many other secretarial advisory committees that we manage with on behalf of the department.

NOAH LEAVITT: So I know we’ll get into kind of your current work in a few minutes, but I do want to talk a little bit about your career and how you got to this point, because I think that’s really interesting. And I know you began as a nurse officer in the US Army. So what made you initially want to work in the health field, and particularly, nursing?

SYLVIA TRENT-ADAMS: Well, I think from a very early age, I liked helping people. My grandmother was one of my role models. And she used to go to relatives’ homes when they were sick. She’d cook for them. She’d make sure they had everything they needed.

And I watched that over my– early in my childhood, as well as having role models that were nurses. I had a great aunt who was a nurse. And I loved her stories about her patients and the interesting things that she learned throughout her career inspired me to want to look at other career fields in health.

And I think nursing stuck when I became a candy striper when I was 12 years old. I bugged my mother literally from the time I was 10 till I was 12 to let me become a volunteer. I wanted to be a candy striper.

And we checked into it, and I learned that I couldn’t do it until I was 12. But it exposed me to the sights and sounds of the hospital, and learning more about how many roles there were for people to play in the clinical environment. And I really enjoyed working with the staff, but I was intrigued by the work that nurses did, and also their amount of– the amount of contact that they had with patients and just the relationships that you build with patients and their families, and what a difference you can make in someone’s life.

NOAH LEAVITT: So I know after the Army, you joined the US Public Health Service Commission. So what made you kind of– having had that background in nursing, kind of more in the clinical, patient side, what made you then interested in kind of branching out into public health?

SYLVIA TRENT-ADAMS: Well, it started actually while in the Army. I became– I did a lot of things clinically when I was in the Army, but one of the areas that I worked in was preventive medicine and infectious diseases. And one of the infectious diseases that I worked with was HIV.

When I came out of nursing school in 1987– dating myself here. But in 1987, we were at the height of the AIDS epidemic. And I saw so many patients who were being discriminated against, who were being left without care, and just seeing so many of them not receiving the type of treatment that they needed or deserved.

And I got involved. I wanted to– I became a volunteer at some of the AIDS service organizations. And I learned through the military how to provide HIV care clinically by training as a preventive medicine expert, as well as being a community health nurse.

And so from that, I had an opportunity to meet some nurses at the National Institute of Health at a conference, and one of them just recruited me directly. She says, oh, I hear you do HIV? And I said, I do.

And she said, I think you would be great for one of our programs. And I said, OK. Had a meeting, and not knowing that was my interview, and was hired to help stand up some of the Ryan White programs, and the rest is history.

NOAH LEAVITT: And so for people who aren’t familiar, what were the Ryan White programs? Can you give us a sense of what that was?

SYLVIA TRENT-ADAMS: Certainly. So the Ryan White Program started in 1990. And it has now grown into one of the largest– what is it? One of the largest HIV care delivery systems in this country.

And they have– the program is set up so that the state, the local jurisdictions, and the community-based organizations all have their own specific category of funding within the law. What it does is it provides comprehensive HIV care for individuals living with HIV who are uninsured or underinsured, or who lack some access to care. And it provides it in their own community, culturally appropriate, family-centric care, and meets a holistic– meets the holistic requirement of an individual.

So some people need clinical care, but others may need just transportation. Some people may need food or nutritional services. And others may simply need counseling. And so depending on where you come into the system, you can get any service that you need based on the priority and the availability of services in that community.

But there is a mechanism to do an assessment every year on what the needs in the community may be and then a mechanism to prioritize those needs and then pay for it through the Ryan White Program.

NOAH LEAVITT: So you mentioned that experience of working with HIV patients and seeing discrimination or access to care issues. I mean, how did that experience, I think, as a nurse affect your career in public health, given that it gives you a different perspective on issues, and maybe Soto doesn’t have that background?

SYLVIA TRENT-ADAMS: I would think so. I think, having had that firsthand experience, it was very emotional for me, being a young nurse and seeing the dynamics play out. But the fear of some of the providers about HIV is still very clear in my mind and how that felt to see providers afraid to take care of a patient. But what I experienced was meeting people who were just like everybody else. They just happened to have HIV.

And I wanted to be able to make a difference. I could do continue to do it one patient at a time, but I wanted to see, what could we do for a community or for a state or for a region? And that’s what the Ryan White Program allowed me to do, is to use those clinical skills in a way that I was able to have an impact on policy but also developing programs both domestically and internationally.

NOAH LEAVITT: It’s interesting to hear you say that, because I think so many of our students say that, especially if they come from more of a clinical background, that I saw this inequity in a patient, or I saw this, and I realized I could make a difference for one person, but I couldn’t affect the whole. It seems that’s such a powerful argument for the power of public health.

SYLVIA TRENT-ADAMS: It is. I think public health– the field allows you to be very diverse in your skill set. But it definitely allows you to build on those leadership building blocks and those competencies to be able to influence policy, to be able to position yourself to negotiate for your patients or for a community or for a state or nationally in a way that you can’t when you’re in that one-on-one patient-care environment. And that’s very powerful, because you can make a difference.

You can also see the change over time on population and be able to back it up with facts. You can look at the data. You can see that the incidence of HIV is decreasing in a community when you’ve helped to build a care delivery system or you’ve been able to implement mental health counseling for a population who may have had high suicide rates.

And you see that those numbers start to decline. You can measure the impact. And that’s so powerful. It’s important. And I think those are the skill sets that we develop in public health. You learn how to be the scientist, the statistician, the policymaker, but also using those clinical skills, the public health skills, to be able to impact change in a given environment.

NOAH LEAVITT: And so now I know, in your current role, as you mentioned in the beginning, I mean, you really are focused on the policy side. So what are some of the big issues that you’re working on now? What are some of your top priorities at the moment?

SYLVIA TRENT-ADAMS: Right now, our top priorities is getting a handle on the opioid epidemic, helping to implement the 10-year HIV strategy, and also, for the first time, is doing a sexually transmitted disease strategy and moving forward on a number of population health issues to help improve both access, quality, and the cost of care.

NOAH LEAVITT: And so when it comes to access to care, what are some of the biggest barriers, I guess, that you’re seeing in this role, and how do you work to address those?

SYLVIA TRENT-ADAMS: So I think one thing in the Office of the Assistant Secretary for Health is that we are the innovations engine for the department. And we leverage our relationships with the optives, the HRSAs the NIHs, and the CDCs, who are the operating divisions of HHS, to be able to help them to launch new initiatives, to fund new projects, new programs. We may come up with the idea, and we may do some of the testing and then work with those larger agencies to be able to implement it.

And once we see some science and some outcomes from those programs, we can then leverage it across all of the other components within HHS, such as the Centers for Medicare and Medicaid. You have lessons learned from the NIH that can change trajectory of care. We’re seeing great work coming out of the sickle cell arena coming out of NIH. Now, we’re working with CMS and other partners to look at what can be done to now improve the health outcomes for that population.

And it may be something very different as it relates to TB or HIV. Specifically as it relates to HIV, we know that prep works. We know that we can decrease a community viral load. You can decrease the likelihood of infection in a given community. So those are the kinds of things that OASH pushes, is that taking what we know and making a policy, implementation strategy for a given community or within the optives.

NOAH LEAVITT: So is one of your challenges, I guess, that NIH, all these different other arms might have different priorities, different funding needs? So it’s part of your job making the case of, hey, this is something that you do need to support or that you do need to implement.

SYLVIA TRENT-ADAMS: We do some of that, yes. But I think what we do is we build these relationships and build partnerships with the other agencies to help them understand what they may not know about the HRSAs and the– what NIH does, HRSA may not know about. I think our assistant secretary for health does a fantastic job of building relationships with the leadership of individual agencies, bringing them to the table, having robust discussions about how we can improve access or quality or decrease in disparities and inequities in health, and then working through those partnerships to build programs or new initiatives that will break down those barriers or increase communication to allow us to fund or change the way in which we do business to have better outcomes in a community.

NOAH LEAVITT: I was listening to a presentation you gave. And it was interesting you mentioned innovation, because there was the presentation on the role of nurses as innovators. And I really liked what you said. You said, America doesn’t have a health care system. It has a sick care system. So why is that? And how do you, in your role, in your office’s role, work to shift that balance?

SYLVIA TRENT-ADAMS: That is an excellent question. I think this is something we’re grappling with right now, is our health care system, or the lack thereof, is based off of payment, payments for certain specific services. For many, many years, it was a fee-for-service model. A provider would get a fee for every visit. So it was volume based.

And then we moved to a capitated system, where you have a per-capita rate per patient or per insured beneficiary for a given year. And the providers were then encouraged to have fewer visits to maximize the cost of the care that they were delivering over a course of a year. We need to shift that, because in both those scenarios, there’s no incentive to keep the patients healthy to begin with. And I think if we look at, as the secretary has outlined and the OASH has talked about as well, value-based care, we would build a model of care and reimbursement that pays for health outcomes. The healthier you keep your patients, the better your outcomes are going to be and the better your reimbursement should be.

But we can only do that through having a prevention model that allows people to stay healthy to begin with, and having better knowledge provided to individuals over the span of their lives about how to be healthy and how to stay healthy, and building models that incentivize positive behavior around having options for healthy eating, encouraging people to exercise more, to move more, and recognize that there are different cultural and linguistic barriers to getting information as well as care, and helping to level set those environments so they can get the information that they need and also make the right choices to be healthy.

NOAH LEAVITT: And we touched on access to care a few minutes ago. But to dig a little deeper into that, I mean, how important is access to care as part of that shift towards prevention, especially with the barriers? Maybe it’s a doctor isn’t available in your community. There’s language barriers. So how important is improving access to care in terms of meeting that goal of prevention?

SYLVIA TRENT-ADAMS: Access is really important, but it’s access to the right kind of care. I know many people who have health insurance, so they have access to the care, to a provider, but they don’t have the time to go see a provider because they work from xyz hours, and the doctor is only available during those hours. But even beyond that, where are their providers located?

I think we need to get back to basics and take care out of an environment whereby the patients have to always go see the provider and get the provider out to where the patients are. And that applies to a primary care model but also the prevention model, whereby we have providers in the community who are where people eat, sleep, work, and pray, where they can gain information and access to modalities of health interventions in their schools, in their faith-based community as well as in the community centers, but also looking at novel models whereby people can get the messaging, but also having care available.

We’ve done it with a lot of the immunization work. I know many of our providers now understand that it’s OK for the pharmacy that’s open 24 hours a day to provide immunizations around the clock if that’s more convenient for patients, because we’ve definitely been able to increase access. We’ve been able to increase prevention efforts around smoking cessation by having pharmacists who are educated on being able to mitigate some of the– doing tobacco training with their community. So it can work. You just need to understand what the needs of that community are and having a system that is based off of prevention and trying to keep people well instead of waiting until someone’s sick to have an intervention with a provider.

NOAH LEAVITT: And it’s interesting you talk about listening to the community, because, in another set of remarks I was reading, you were talking about public health as community health and this importance of going to the community and listening. So how do you do that? Because one community here might have different needs than an other community all the way across the country, so how do you go about doing that, assessing what the different community needs might be and how they differ?

SYLVIA TRENT-ADAMS: Well, in my current role, it’s working with the stakeholders at the local level. And the stakeholders may vary from community to community. Or within one community, you could have subpopulations that have different needs. And I think we need to be very cognizant of how we engage, as health policy leaders, as health care providers, how we engage with the leaders in a given community. And I will tell you, it varies from one community to the other. I learned this in working in the Ryan White Program.

I can tell you that working in the southeast of the United States, you cannot get to certain populations at the highest risk for HIV unless you had buy-in from the faith-based community. In other areas, you could not reach those communities of youth unless you work with the school systems, unless you work with the athletic programs, because that’s where they spent their time, and having an understanding of how to reach people, what do they do, doing that needs assessment, if you will, and I call it getting your inside information.

Do some reconnaissance, as we say in the military. Get the intel on what makes your community tick, and know how to engage. Who are the stakeholders? Who are the leaders, the informal leaders, not just the mayor or not just the state health officer? But who do they trust? Who do they believe when they say that this intervention is going to be successful? Those are the people we should be working with.

And some of them may be the moms. Some may be the coaches. Some of them may be the barbershop or the beauty salon owner. That’s where people get their information. And those trusted stakeholders will be able to speak in a language and address, with respect, the needs of that community and will definitely be able to give you some insight on how and what will work in that community.

NOAH LEAVITT: It’s interesting because, on one hand, I mean, there is a medical health challenge. But it seems like the biggest barriers at first is that trust and communication. If you can get over that, then you have your way in and you can start to address things on the ground.

SYLVIA TRENT-ADAMS: I think one of the things I learned in nursing school is that you can’t teach people who are not ready to learn. And you can’t have people to trust you if you’re not invested in that relationship so that they have something to trust with you. They have that trusted relationship with you. You want them to trust you? Then you have to invest the time to make sure they understand that you are there to help them, to work with them, but not there just to give them a didactic lesson on, you must be healthy, and here’s what you have to do to get there.

It’s not that easy and not that simple. It’s hard work. And I know in many communities, it’s took us years to have people accept HIV as a part of their community. Even though we knew there were cases in high numbers in some communities, it wasn’t accepted, and it was not seen as a value to the community to even talk about HIV.

Now, after investing the time, find the stakeholders, and having trusted ambassadors, if you will, to work with us to build trust and build a relationship over time, we were able to intervene and have programs built and resources being deployed in that community and having some success in building a program that is still in existence in a lot of those communities. But rural and underserved is challenging always because of the lack of trust with government, lack of trust with providers. And those are things we have to overcome by building relationships with them.

NOAH LEAVITT: You talked a second ago about that lesson from the Ryan White programs. And I’m wondering if there’s anything from your experience working around HIV that can maybe be applied to what you’re currently dealing with with the opiate epidemic. Are there lessons learned from there that you might be able to apply today?

SYLVIA TRENT-ADAMS: That is exactly the case with opioids. I think with the opioid epidemic, we’re seeing it in rural and underserved communities. What we learned with the HIV epidemic was that to build systems of care, systems of delivery in those types of populations, populations that didn’t trust the government, you had to have just what I talked about, ambassadors within the community who were willing to work with you to bring services in and be able to raise the knowledge and awareness and have people believe that you were there to help and you were going to do it on their terms.

And I think that’s a lot of what’s happening right now. A lot of great work is happening in some of the opioid programming that’s going on in the country. We’re seeing declines in some areas. And I know that that’s because– having naloxone available– it’s critical at the community level, not just in provider settings but in the community, because the vast majority of overdoses is not happening in hospitals and in clinics. It’s happening in the community. And so working with the community to understand that you being trained on how to administer naloxone and being able to have it available if you’re around a high-using community– then those things can save a life. And those are basic skills that any provider, any community, anyone in the community could learn.

NOAH LEAVITT: It’s so interesting you mention that, because I was at my pharmacy the other day, and they actually had a flier for naloxone and getting a dosage in training. So I mean, it was one of those things where it hit me that, one, the scope of the problem, but two, that every day, people are experiencing that. And most times, the first person responding is not going to be an EMT. It could just be someone on the street.

SYLVIA TRENT-ADAMS: Absolutely, and I think the Surgeon General, Vice Admiral Adams, has done a phenomenal job in messaging about the importance of having naloxone available in high-risk communities. He issued an advisory last year about the importance of having a standing order in every pharmacy, making community leaders aware of the risk associated with opioid overdoses, equipping the community with the information that they needed but also training on how to administer naloxone, and then decreasing the stigma associated with substance misuse and decreasing some of the barriers for people who wanted to get involved and help, decreasing those barriers for them to be able get access to naloxone.

We have seen significant increases in the prescriptions for naloxone. We’ve seen significant uptake in the delivery of naloxone as well. But we have a long way to go. We still have a lot of work to do. And I think the more we talk about it, the more we engage with community leaders and folks and family members– family members as well as with leaders– the better off we are in being able to get the message to those who need it most.

NOAH LEAVITT: And just a last question– you even just talked about there some of those intermediate positive steps along the way. But as you’re dealing with really, really broad, complex issues, whether it’s opioids, how do you measure success? How do you measure success personally but then the office in general? How do you measure success?

SYLVIA TRENT-ADAMS: Well, I think the metric in a lot of the interventions that we’ve implemented have been looking at the data, looking at actual encounters as it relates to number of individuals who are seeking care for substance misuse, looking at the naloxone prescriptions, looking at the decrease in the number of overdoses, looking at the decrease in deaths associated with opioid overdoses as well.

But personally, I think the success for us at the highest levels within the department is knowing that we’re working towards finding solutions, working with partners to bring them to the table to decrease the barriers, implementing policies and programs, and also making funding available. And I think a lot of work has been done in the last two years around recognizing the importance of having a response to the opioid epidemic.

And so, I think, over the course of this year alone, $1.4 billion will go out in those state opioid-response programs. It’s funded through SAMHSA. That’s a lot of money for care and treatment and interventions that will help people who are dealing with opioid overdoses and substance misuse.