Post on 16-Dec-2015
Nursing Executive Center
Transforming Healthcare Through NursingImplications for Practice and Education2015
©2013 The Advisory Board Company • advisory.com
Nursing Executive Center
Practice Manager
Jennifer Stewart
Pascale Chehade
Design Consultant
Steven Berkow
Executive Director
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5
Transforming Healthcare Through NursingImplications for Practice and Education2015
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Road Map
Implications for Nursing Practice and Education
Care Delivery Transformation
Our New Market Reality
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What Business Are We In?Businesses Displaced by Focusing on the Means Rather than the Ends
Study in Brief: What Business Are We in? • Explores how Eastman Kodak Company’s camera and film business was
displaced by alternate mediums that fulfilled customers’ desires for images
• Draws parallels to the challenges that provider organizations face in shifting activities from delivering health services to a broader spectrum of tactics for health
Providing Health, Not Health Care
“…It's always better to define a business by what consumers want than by what a company can produce…whereas doctors and hospitals focus on producing health care, what people really want is health. Health care is just a means to that end—and an increasingly expensive one.”
Source: Asch D., "What Business Are We In? The Emergence of Health as the Business of Health Care,” NEJM, 367,2012: 888-889; Nursing Executive Center interviews and analysis.
”
197690% market share of commercial film business
1990sDigital cameras enter mainstream market
2012Kodak files for bankruptcy
Timeline for Eastman Kodak Business
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Staying Afloat Through Cross-Subsidization
Source: American Hospital Association, “Trendwatch Chartbook 2014,” available at: www.aha.org; Health Care Advisory Board interviews and analysis.
Our Existing Business Model
Hospital Payment-to-Cost Ratio, Private Payer, 2012
149%Hospital Payment-to-Cost
Ratio, Medicare, 2012
86%
• Above-cost pricing
• Robust fee-for-service volume growth
• Steady price growth
• Only one component of our total business
Commercial Insurance Public Payers
Below CostAbove Cost
Traditional Hospital Cross-Subsidy
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Source: American Hospital Association Chartbook, available at: http: www.aha.org/aha/research-and-trends/chartbook/index.html, accessed on April 29, 2011; Advisory Board Company interviews and analysis.
Payer Cross-Subsidy Eroding
Projected Discharges by Payer, 2021 Annualized Commercial Price Growth
52%
20%
27%
Medicare
Medicaid
Commercial
Inpatient Contribution Income
Weighted Per-Case Average
Surgery
Medicine
$6,110
$2,927
Projected
Historical
3.5%
6.5%6-7%
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Medicare Payment Cuts Becoming the Norm
Source: CBO, “Letter to the Honorable John Boehner Providing an Estimate for H.R.6079, The Repeal of Obamacare Act,” July 24, 2012; CBO, “Estimated Impact of Automatic Budget Enforcement Procedures Specified in the Budget Control Act,” September 12, 2011; CBO, “Bipartisan Budget Act of 2013,” December 11, 2013, all www.cbo.gov; Health Care Advisory Board interviews and analysis.
1) Includes hospital, skilled nursing facility, hospice, and home health services; excludes physician services.
2) Disproportionate Share Hospital.
Public-Payer Reimbursement Still in the Crosshairs
2013 2014 2015 2016 2017 2018 2019 2020 2021 2022
($4B)($14B)
($21B) ($25B)($32B)
($42B)
($53B)
($64B)
($75B)
($86B)
ACA’s Medicare Fee-for-Service Payment Cuts
Reductions to Annual Payment Rate Increases1
$260BHospital payment
rate cuts, 2013-2022
Office of the Actuary, CMS
“Notwithstanding recent favorable developments… Medicare still faces a substantial financial shortfall that will need to be addressed with further legislation.”
Not the End of the Story
$56B $151BReduced Medicare and Medicaid DSH2 payments, 2013-2022
Reduced Medicare payments due to sequestration and 2013 budget bill
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But Every Silver Lining Has Its Cloud
Coverage Expansion and the Rise of Individualized Insurance
Source: Gallup, “In U.S., Uninsured Rate Holds at 13.4%,” http://www.gallup.com/poll/178100/uninsured-rate-holds.aspx; Department of Health and Human Services, “Impact of Insurance Expansion on Hospital Uncompensated Care Costs in 2014,” http://aspe.hhs.gov/health/reports/2014/UncompensatedCare/ib_UncompensatedCare.pdf; Health Care Advisory Board interviews and analysis.
ACA (and Recovery) Making a Dent in Uninsurance
18.0%(highest on record)
13.4%(lowest on record)
2013 Q3 2014 Q3
Percentage of U.S. Adults Without Health Insurance
Employer-sponsored coverage grows
Medicaid expansion begins
Insurance exchanges launch
$5.7BReduction in uncompensated care, 2014
A Bargain Still Unbalanced
$14BACA-related reductions in Medicare fee-for-service payment, 2014
vs.
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Not Currently Participating
28 States + DC Have Opted for Expansion
Medicaid Expansion
Source: Kaiser Family Foundation, “Current Status of State Medicaid Expansion Decisions,” January 27, 2015, available at: http://kff.org/health-reform/slide/current-status-of-the-medicaid-expansion-decision/; CMS, “Medicaid and CHIP: October 2014 Monthly Applications, Eligibility Determinations and Enrollment Report,” December 18, 2014; HHS, “Health Insurance Marketplace: Summary Enrollment Report for the Initial Annual Open Enrollment Period,” May 1, 2014; PricewaterhouseCoopers, “Medicaid 2.0: Health System Haves and Have Nots,” Health Care Advisory Board interviews and analysis.
1) Children’s Health Insurance Program.2) Estimate does not include CT or ME.
Medicaid Expansion Contentious—and Consequential
Increase in Medicaid, CHIP1 enrollment,July-Sept. 2013-Oct. 20142
9.6MAdvisory Board estimate of impact of Medicaid expansion on typical hospital’s 10-year operating margin projection
2.4%
State Participation in Medicaid Expansion
ParticipatingExpansion by Waiver
As of February 2015
6.7%Average Medicaid enrollment increase across non-expansion states
PricewaterhouseCoopers
“For-profit health systems…report far better financial returns through the first half of the year than expected, owed in large part to expanded Medicaid”
Financial Impact
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Challenge to Subsidies Making Its Way Through the Courts
Another Year, Another Lawsuit
2.7M
0.7M4.7M
Does the language of the ACA allow subsidies in states that do not set up their own exchanges?
The Question:
Supreme Court Stepping In
Halbig v. Burwell
D.C. Circuit panel strikes down subsidies on federal exchanges
King v. Burwell
Fourth Circuit rules subsidies legal on Virginia’s federally-run exchange
Potential Impact
Unsubsidized
Subsidized on State-Run Exchanges
Subsidized on Federally-Run Exchanges
Over half of all enrollees collecting potentially unallowable subsidiesSupreme Court agreed to hear King
v. Burwell in November 2014; final ruling expected by June 2015
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No More A’s for Effort
Source: The Advisory Board Company, “Mortality Rates Are Only One of Many VBP Changes to Come,” December 4, 2013, www.advisory.com; CMS, “Request for Information on Specialty Practitioner Payment Model Opportunities,” February 2014, available at www.innovation.coms.gov; Health Care Advisory Board interviews and analysis.
1) Includes Value-Based Purchasing Program, Hospital Readmissions Reduction Program, and Hospital-Acquired Conditions Program.
Increasing Competition for Medicare Dollars
FY 2013 FY 2014 FY 2015 FY 2016
30%
30%
30%
25%
70%
45%
20%10%
25%
30%
40%
20% 25%
Clinical Process
Patient Experience
Outcomes of Care
Efficiency
Medicare Value-Based Purchasing Program Performance Criteria
6%
Other Mandatory Risk Programs
Hospital-Acquired Condition Penalties
Readmission Penalties
No Trivial Thing
Weight in Total Performance Score
Medicare revenue at risk from mandatory pay-for-performance programs1, FY 2017
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Many Facilities Receiving Multiple PenaltiesFew Escaping Penalties Altogether, Almost Half Facing Two or More
Source: CMS, Advisory Board Analysis.
VBPPenalty152 (5%)
HACPenalty112 (3%)
ReadmissionsPenalty 1,071 (32%)
43 (1%)
961 (29%)
318 (9%)
288 (9%)Hospitals receiving
multiple P4P penalties
48%
Hospitals Receiving FY 2015 P4P Penalties1
1) Based on Readmissions and VBP proxy adjustment factors from FY 2015 IPPS Final Rule, proxy HAC adjustments from FY 2015 IPPS Proposed Rule.
NoPenalties423 (13%)
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Overview of Risk-Based Payment Models
1) Center for Medicare and Medicaid Innovation.
Key AttributesBundled Payments
Shared Savings Programs
(ACOs)Capitation
Definition
Purchaser disburses single payment to cover certain combination of hospital, physician, post-acute, or other services performed during an inpatient stay or across an episode of care; providers propose discounts, can gainshare on any money saved
Network of providers collectively accountable for the total cost and quality of care for a population of patients; ACOs are reimbursed through total cost payment structures, such as the shared savings model or capitation
Provider receives a flat per-member, per-month payment for providing all necessary care for a defined population
Purpose
Incent multiple types of providers to coordinate care, reduce expenses associated with care episodes
Reward providers for reducing total cost of care for patients through prevention, disease management, coordination
Reward providers for reducing total cost of care for patients through prevention, disease management, coordination
Source: Health Care Advisory Board interviews and analysis.
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12 Tools for Translating Market Forces into Frontline Terms
The Market Force Course
Source: Nursing Executive Center, The Market Force Course, 2014.
Customizable Presentations
Plug-and-Play Videos
Interactive Exercises
Nurse Manager “Cheat sheets”
PowerPoint slides and scripting for leaders to brief staff on tough messages
Short, easy-to-digest videos for frontline staff on current market forces
Games for frontline staff and managers aimed at conveying budget constraints
One-page primers on market forces impacting organizational strategy
Sample Toolkit Resources
Ready-to-Use Posters
Visuals that distill complex concepts into concrete actions for frontline staff
To access The Market Force Course, visit advisory.com/nec/publications.
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Operational Economics on the Brink of Failure
Source: Health Care Advisory Board interviews and analysis.
Margin Improvement Analysis Results
Five-Year Margin Projections Ten-Year Margin Projections
Greater than 10% Decline
5-10% Decline
Improvement
3%
13%
84%
Improvement
0-5% Decline
5-10% Decline
Greater than 10% Decline
15%
36% 36%
13%
HCAB Service in Brief: The Margin Improvement Intensive
0-5% Decline
• Combines customized scenarios for key financial and operational metrics with a facilitated onsite session and an institution-specific action plan to help hospitals and health systems improve margin performance
• Available to all Health Care Advisory Board members at no extra cost
• Visit www.advisory.com/MedicareBreakeven to participate
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Road Map
Implications for Nursing Practice and Education
Care Delivery Transformation
Our New Market Reality
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How Much Avoidable Cost Is There in Health Care?
Source: Institute of Medicine, “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America”, 2012; Nursing Executive Center analysis.
$ 7 5 0
0
0 0 00 00000
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A Clear Mandate for Meaningful Change?
Source: Best Care at Lower Cost: The Path to Continuously Learning Health Care in America . Washington, DC: The National Academies Press, 2012; Kelley, Robert, “Where Can $700 Billion in Waste Be Cut Annually from the U.S. Healthcare System?” Thomson Reuters, 2009; Delaune J., Everett W., “Waste and Inefficiency in the U.S. Health Care System,” New England Healthcare Institute, 2008; Nursing Executive Center interviews and analysis.
Areas of OpportunityAvoidable
Costs
Unnecessary Care $210 B
Administrative Inefficiencies $190 B
Inefficiently Delivered Services $130 B
Missed Prevention Opportunities
$55 B
Fraud and Abuse $75 B
High Prices $105 B
Select Studies Analyzing Opportunities
for Reducing Health Care Costs
Estimated Magnitude of Avoidable Cost Opportunities
30Cents of every health care
dollar an unnecessary expense
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Source: Truven Health Analytics, “Avoidable Emergency Department Usage Analysis,” 2013, http://img.en25.com/Web/TruvenHealthAnalytics/EMP_12260_0113_AvoidableERAdmissionsRB_WEB_2868.pdf; Robert Wood Johnson Foundation, Reform in Action: Reducing Avoidable Hospital Readmissions,” 2013, http://www.rwjf.org/en/about-rwjf/newsroom/features-and-articles/reform-in-action--reducing-avoidable-readmissions.html?cid=xtw_qualequal; CMS's 2012 Inpatient Standard Analytical File (SAF); Nursing Executive Center interviews and analysis.
1) Based on Truven Health Analytics analysis of 6,135,002 ED visits in 2010; “Avoidable” includes all ED visits except those for which medical care was required within 12 hours in the ED setting.
2) CMS, 2012.
Huge Opportunity for Improvement
Percentage of ED Visits that are Avoidable in the US1
71%
Estimated number of preventable trips to US
hospitals each year
4.4M
30-day all-cause readmission rate2
18%
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Unnecessarily CrowdedMany Medical Admissions Preventable
Ambulatory-Sensitive1
Inpatient Admissions
Source: MedPAR FY2009; Nursing Executive Center interviews and analysis.
1) Inpatient admissions associated with Agency for Healthcare Research and Quality (AHRQ) Preventable Quality Indicator conditions.
94.6%
5.4%
30 Most Ambulatory-Sensitive DRGs
Overall
$5,623
$8,510
Medicare Revenue per Case
Surgical Medical
An Ounce of Prevention…
CFO
“It’s a lot easier to prevent people from needing a service than it is to eliminate the service once you offer it.”
17%Percent of Medicare discharges considered sensitive to better ambulatory care
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Health System Strategy, c. 2003
“Extractive Growth”
Health System Strategy, 2013-2023
“Value-Based Growth”
Grow by being bigger: Leverage market dominance to secure prime pricing, network status
Grow by being better: Leverage cost, quality, service advantage to attract key decision makers
• Discharges• Service line share• Fee-for-service revenue
• Pricing growth• Occupancy rate• Process quality
• Share of lives• Geographic reach• Risk-based revenue
• Share of wallet• Outcomes quality• Total cost of care
• Inpatient capacity• Outpatient imaging
centers
• Clinical technology• Ambulatory
surgery centers
• Primary care capacity• Care management staff
and systems
• IT analytics• Post-acute care
network
Toward an Economics of Value
Adapting to New Rules of Competition
Source: Advisory Board interviews and analysis.
Description
Performance Metrics
Critical Infrastructure
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Disaggregating Health Care Reform
Source: Nursing Executive Center analysis.
Coverage Expansion
Financing
Delivery System Reform
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Economics Aligning with Mission
Source: Nursing Executive Center interviews and analysis.
Evolving Market Demand
Managing Chronic Care for High-Risk
Patients
Building Long-Term Patient Relationships
for Ongoing, Coordinated Care
Improving Overall Health
and Wellness of the Population
Centering Hospital Care on the Patient
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Establishing the Medical PerimeterExtensive Ambulatory Care Network Addresses Medical Demand
Source: Nursing Executive Center interviews and analysis.
Medical Management Investments
Health Information Exchanges
Electronic Medical Records
Medical Home Infrastructure
Primary Care Access
Population Health
Analytics
Patient Activation
Post-Acute Alignment
Disease Management
Programs
The New Reality
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If We Were Building from Scratch…Governing Principles of the Transformed Care Enterprise
Aligned Across the Continuum
Outcomes-Driven System
• Dashboard aligned to key cost, quality goals for improving population health
• Information available across the continuum to track utilization
• Multidisciplinary team works together to maintain unified care plan across patient needs
• Data transparency, sharing to ensure streamlined patient care
• Care management appropriately matched to individual patient, population need
• Oriented toward patient-centered goals that will drive clinical metric improvement
• Click to add iconDo not use Microsoft generic icons
• Click to add iconDo not use Microsoft generic icons
• Click to add iconDo not use Microsoft generic icons
Source: Nursing Executive Center interviews and analysis.
• Click to add iconDo not use Microsoft generic icons
• Team available to patient for access, education, decision support
• Accessible when, where patient needs care
Accessible Primary Care Personalized Management
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Key Factor Driving The Change Today:The Rise of The Retail Triple-Threat
Purchase
Spend
LifestyleIntegration
Unleashing the consumer… a force incumbent health systems are ill prepared to cope with!
Retail consumer behavior at the
point of…Confronted with choices and spending our own money, we make very different purchasing decisions
High deductibles and narrow networks make us price sensitive with a high demand for value
Health and healthcare must fit into our lives and be convenient; we will reward those who can deliver and retailers are lining up for the opportunity
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Aggregate Numbers in Line With Expectations; Enrollee Mix Older
Source: HHS, “Health Insurance Marketplace: Summary Enrollment Report for the Initial Annual Open Enrollment Period,” May 1, 2014; Cheney K and Haberkorn J, “Obama: 8 Million Enrolled Under ACA,” Politico, April 17, 2014, www.politico.com; Cheney K and Norman B, “Insurers See Brighter Obamacare Skies,” Politico, April 15, 2014, www.politico.com; Health Care Advisory Board interviews and analysis.
1) Numbers do not add precisely due to rounding.
One Year In, Insurance Exchanges Generally on Track
October to December
January to February
March Total
2.2M
2.1M
3.8M 8.0M
Initial Public Exchange Enrollment1
2013-2014
7.0M(Original CBO
Projection)
91%Of enrollees still enrolled as of September 2014
25M Projected exchange enrollment by 2018
Enrollees aged 18-34
28%
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Fewer Glitches, Greater Awareness Driving Increased Enrollment
Early Year Two Enrollment Outpacing First Round
106K Enrollment during first month
A Solid Start for Both Federal, State Exchanges
11K Enrollment during first four days
First Round Enrollment Second Round Enrollment
462K Enrollment during first week
11K Enrollment during first fifteen days
FEDERAL EXCHANGE
CALIFORNIA EXCHANGE
MARYLAND EXCHANGE 16K Enrollment during
first two months 16K Enrollment during first week
COLORADO EXCHANGE 204 Enrollment during
first week 6K Enrollment during first week
Source: CNBC, ‘'Solid' Obamacare start: More than 1M apply in first week,” http://www.cnbc.com/id/102218144; Baltimore Sun, “Md. health exchange enrolls 16,700 in first week,” http://www.baltimoresun.com/health/bs-hs-exchange-week-one-20141121-story.html; Colorado Public Radio, “Colorado health exchange: Enrollment rate outpacing last year,” http://www.cpr.org/news/story/colorado-health-exchange-enrollment-rate-outpacing-last-year#.dpuf; Los Angeles Times, “California enrolls 11,357 in first 4 days of Obamacare open enrollment,” http://www.latimes.com/business/healthcare/la-fi-obamacare-enrollment-california-20141120-story.html; Health Care Advisory Board interviews and analysis.
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Source: HHS, “Health Insurance Marketplace: Summary Enrollment Report for the Initial Annual Open Enrollment Period,” May 1, 2014; Health Care Advisory Board interviews and analysis.
1) Data from federally-facilitated exchanges only.
Individuals Gravitating Toward Leaner Plans
20%65%
9% 5%2%
Bronze
Level 1: Choice of Metal Tier
GoldPlatinum
Catastrophic
Silver
People Choosing Cheaper Premiums and Higher Deductibles
Factors Influencing Metal Level
Deductible
Copays
Out-of-Pocket Maximum
Non-Essential Services Covered
Network Composition
Level 2: Plan Choice Within Metal Tier
43%
21%
36%Any Other Plan
Lowest-Cost Plan
Second-Lowest-Cost Plan
All Metal Levels1
Scope of Non-Essential Benefits
Negotiated Payment Rates to Providers
Utilization Patterns, Trends
Premium Levers Beyond Benefit Design
Negotiated Rates
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Aggressive Cost Sharing Troublesome for Provider Strategy
Source: Breakaway Policy Strategies, “Eight Million and Counting: A Deeper Look at Premiums, Cost Sharing and Benefit Design in the New Health Insurance Marketplaces,” May 2014; eHealth, “Health Insurance Price Index Report for Open Enrollment and Q1 2014,” May 2014; Health Care Advisory Board interviews and analysis.
High Deductibles Accelerating Consumerism
$6,000+
$3,000-$5,999
Individual Deductibles Offered On Public Exchanges2014
Median
16%
16%
39%
30%
$1,000-$2,999
<$1,000
Individual Deductibles Chosen on eHealth Individual Marketplace
$2,500 $6,250Maximum
High out-of-pocket costs discourage appropriate utilization
Challenges for Providers
Large patient obligations lead to more bad debt, charity care
Price-sensitive patients more likely to seek lower-cost options
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Convenience Consistently a Top Consumer Priority
Source: The Advisory Board Company, 2014 Primary Care Consumer Choice Survey, Marketing and Planning Leadership Council; Health Care Advisory Board interviews and analysis.
Incr
ea
sin
g C
on
sum
er P
refe
ren
ce
Emailing provider with symptoms
How Convenient Is Convenient?
Consumers Want Virtual, 24/7 Access
Clinic location near work
Clinic located near errands
Clinic located near the home
Cost
Service
Access, Convenience
Convenience Outranking Service and Cost
Top Preferences for On-Demand Care
6 OF TOP 10 FEATURES
RELATED TO ACCESS,
CONVENIENCE
#1 out of 56“Walking in without appointment and being seen within 30 minutes”
#5 out of 56“The clinic is open 24 hours, 7 days a week”
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Cost-Conscious Behavior Affecting Pillars of Profitability
Source: KFF, “2012 Employer Health Benefits Survey,” available at: www.kff.org; New Choice Health, “New Choice Health Medical Cost Comparison,” available at: www.newchoicehealth.com; Healthcare Blue Book, “Healthcare Pricing,” available at: www.healthcarebluebook.com; Kliff S, “How much does an MRI cost? In D.C., anywhere from $400 to $1,861,” Washington Post, March 13, 2013, available at: www.washingtonpost.com; Health Care Advisory Board interviews and analysis.
1) High-deductible health plan.2) $2,086; based on KFF report of average HDHP
deductible.3) $733; based on KFF report of average PPO deductible.
Price Sensitivity at the Point of Care
Consumers Paying More Out-of-Pocket
Fall within HDHP deductible2
$150 $275 $400$900 $1K
$2K
$6K
$9K
$18K $730
$900
$1,269
$2,183
$411
• Price-sensitive shoppers will be acutely aware of price variation
• MRI prices range from $400 to $2,183
MRI Price Variation Across Washington, DC
Fall within PPO deductible3
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Meet Our New Competitors
Walgreens Aims to Become the Premier Health Destination
Source: Japsen B, “How Flu Shorts Became Big Sales Booster for Walgreen, CVS,” Forbes, February 8, 2013, available at: www.forbes.com; “Take Care Clinics at Select Walgreens Expand Service Offerings,” Reuters, May 31, 2012, available at: www.reuters.com; Murphy T, “Drugstore Clinics Expand Care into Chronic Illness,” The Salt Lake Tribune, April 4, 2013, available at: www.sltrib.com, Walgreens, “Company Overview,” available at: www.walgreens.com; Health Care Advisory Board interviews and analysis.
Retail Clinics
2009: Launches flu vaccine campaign
Simple Acute Services
Vaccinations and Physicals
Chronic Disease Monitoring
Chronic Disease Diagnosis and Management
2013: Launches three ACOs; begins diagnosing and managing chronic disease
Case in Brief: Walgreen Co.
• Largest drug retail chain in the United States, with 372 Take Care Clinics
• In April 2013, became first retail clinic to offer diagnosis and treatment of chronic diseases
2007: Acquires Take Care Health Systems
2012: Offers three new chronic disease tests
Not Just a Drugstore
“Our vision is to become ‘My Walgreens’ for everyone in America by transforming the traditional drugstore into a health and daily living destination...”
Walgreen Co. Overview
”
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Saving Money—For Its Associates and Customers
Source: Canales MW, “Wal-Mart Opening Clinic in Cove,” Killeen Daily Herald, April 18, 2014, www.kdhnews.com; Health Care Advisory Board interviews and analysis.
Walmart Enters Full Primary Care
The Largest “Activated Employer” Yet
“As the largest private employer in the U.S., we are committed to finding ways to drive down health care costs for our 1.3 million U.S. associates and the 140 million customers who shop our stores each week.”
Labeed DiabPresident of Health and Wellness, Wal-Mart
Visit fee for Walmart associates
$4
Visit fee for Walmart customers
$40
Walmart Care Clinic Model
Walmart associate or customer visits Care Clinic
Care Clinic staffed by two NPs from QuadMed, an employer onsite clinic provider
NP provides primary care services, refers to external specialists and hospitals
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Retail Clinics Expected to Continue Growing
1) As of Oct. 2014.Source: Accenture, "Retail medical clinics: From Foe to Friend?," 2013; Ritchie J, "After a stall, Kroger could add clinics," Cincinnati Business Courier, July 5, 2013; Robeznieks A, "Retail clinics at tipping point," Modern Healthcare, May 4, 2013; Health Care Advisory Board interviews and analysis.
2000-20151
Estimated Total Number of Retail Clinics in the US
2000 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
202
868
1135 1172 12201355 1418
1743
2243
2868Growth trajectory depends on preferred payer relations, PCP capacity, and health system partnerships
Retailer
Operational Retail Clinics1 900+ 400+ 135 14 75+
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Differentiating Effective Population Health
Source: Health Care Advisory Board interviews and analysis.
Keep patient healthy, loyal to the system
Avoid unnecessary higher-acuity, higher-cost spending
Trade high-cost services for low-cost management
High- Risk
Patients
Rising-Risk Patients
Low-Risk Patients
60-80% of patients; any minor conditions are easily managed
15-35% of patients; may have conditions not under control
5% of patients; usually with complex disease(s), comorbidities
Managing Three Distinct Patient Populations
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Chronic Disease Growth Outpacing Population Population Growth
Source: Milken Institute, available at: http://www.milkeninstitute.org/ pdf/chronic_disease_report.pdf, accessed April 27, 2011; Nursing Executive Center interviews and analysis.
Projected Increase in Chronic Disease Cases
2003-2023
Stroke
Pulm
onar
y Con
ditio
ns
Hyper
tens
ion
Heart
Diseas
e
Diabe
tes
Men
tal D
isord
ers
Cance
r
29% 31%
39% 41%
53% 54%
62%
19%: Projected population growth, 2003-2023
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Plenty of Room for Improvement in Managing Care
Source: Milliman; Nursing Executive Center interviews and analysis.
Difference Between “Loosely-Managed” and “Well-Managed” PMPM1 Spending
2011
Series1
$449.79
Loosely Managed
WellManaged
MedicareCommercial
Series1
$131.84
Loosely Managed
WellManaged
Medicaid
Series1
$100.48
Loosely Managed
WellManaged
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Source: Nursing Executive Center interviews and analysis.
Building a System that Never Discharges the Patient
Evolution of Patient Care Perspective
Perfecting Individual Transitions Achieving Care Continuity
SNF
Home
Rehab
PCP
Home Health
Retail Clinic
Acute Care
ED
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Finding the 80/20
Key Root Causes of Patients Receiving Fragmented, Episodic Care
Patients receive fragmented, episodic care
Clinicians don’t have time
Patients face economic
roadblocks
Clinicians’ incentives focus on
site-specific care
Patients don’t know how
Patients lack motivation
Clinicians don’t have necessary
patient information
Clinicians have a siloed, setting-
specific perspective
Clinicians only feel accountable for their
immediate setting
Clinicians don’t know how
Clinicians not equipped to provide
continuous care
Patients and families don’t manage their
care effectively
Source: Nursing Executive Center interviews and analysis.
To access Achieving Top-of-License Nursing Practice, visit advisory.com/nec/publications.
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Investing in Nursing with Good Reason
Source: MEDPAR 2001, 2005, 2010; Needleman J, et al., “Nurse-Staffing Levels and the Quality of Care in Hospitals,” New England Journal of Medicine, 346 (2002): 1715-1722; Aiken L, et al., “Educational Levels of Hospital Nurses and Surgical Patient Mortality,” JAMA, 290 (2003): 1617-1623; Kane RL, et al., “The Association of Registered Nurse Staffing Levels and Patient Outcomes: Systematic Review and Meta-Analysis,” Medical Care 45 (2007): 1195-1204; McHugh M, et al., “Hospitals with Higher Nurse Staffing Had Lower Odds of Readmissions Penalties than Hospitals with Lower Staffing,” Health Affairs, 32(2013): 1740-1747; Nursing Executive Center analysis.
1) Case Mix Index (CMI) in short-stay hospitals participating in Medicare’s Inpatient Prospective Payment System; excludes Medicare Advantage patients.
2001 2005 2010
1.44
1.50
1.60
Average Medicare Case Mix1
Mounting Evidence Linking Nursing to Patient Outcomes
Patient Complexity Increasing
Representative Studies on the Impact of Nurse Staffing
Primary Author
Top-Level Findings
Needleman et al., 2002
An increase in the number of RN hours per day from the 25th to the 75th percentile was associated with better outcomes for medical and surgical patients
Aiken et al., 2003
An increase in the proportion of RNs with a Bachelor’s or Master’s degree across the entire institution was associated with better outcomes in mortality and failure to rescue
Kane et al., 2007
A review of the literature finds consistent associations between increased RN staffing and lower odds of hospital-related mortality and adverse patient events
McHugh et al., 2013
Hospitals with higher nurse staffing had 25% lower odds of incurring Medicare readmissions penalties than similar hospitals with lower nurse staffing
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An Alarming Dichotomy
Source: American Hospital Association, “Trendwatch Chartbook 2013: Trends Affecting Hospitals and Health Systems,” available at: http://www.aha.org/research/reports/tw/chartbook/index.shtml, accessed on December 2, 2013; CBO, “Letter to the Honorable John Boehner Providing an Estimate for H.R.6079, The Repeal of Obamacare Act,” July 24, 2012, available at: www.cbo.gov, accessed on December 2, 2013; Bureau of Labor Statistics, “Employer Costs for Employee Compensation Historical Listing March 2004 – June 2013,” available at: ftp://ftp.bls.gov/pub/special.requests/ocwc/ect/ececqrtn.pdf, accessed on November 12, 2013; Nursing Executive Center analysis.
1) Reductions to annual payment rate increases; includes hospital, skilled nursing facility, hospice, and home health services; excludes physician services.
2) Does not include capital.
$36.21
$48.02
Total RN Compensation per Hour Worked
Care Team EconomicsHealth System Economics
Percentage of Hospital Costs2 Comprising Wages and Benefits
2013 2014 2015 2016 2017
($4B)
($14B)($21B)
($25B)($32B)
Affordable Care Act’s Medicare Fee-for-Service Payment Cuts1
Expenses per Adjusted Admission
$6,980
$10,533
20112001
59%
2012
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Population Health Efforts Shaping Volume Outlook
Utilization Patterns Difficult to Predict
2012 2017 2022
40.8M
42.6M
39.6M
40.5M
41.9M
39.5M
40M
No Additional Population Health Management
Typical Management
Aggressive Management
Inpatient Volume Under Different Population Health Assumptions
Quite a Difference
7.6%Total inpatient volume
growth, 2012-2022, with no additional population health
management effort
1.1%Total inpatient volume
growth, 2012-2022, with aggressive population health
management efforts
Source: Health Care Advisory Board interviews and analysis.
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2747Designing the Care Team
for Accountable Care
Source: Nursing Executive Center interviews and analysis.
Inefficient, Interprofessional Care Team
Nurses and other caregivers collaborate to provide care, but nurses do not practice at top of license
Efficient, Siloed Care Team
Nurses practice to the full extent of their training and skills but within professional silo
Efficient, Interprofessional Care Team
Interprofessional care team collaborates efficiently and effectively, providing high-quality, low-cost care
Two Dimensions of Care Team Design
Inefficient, Siloed Care Team
Nurses do not practice to the full extent of their training and skills; caregivers work in professional silos
Nursing Team Efficiency
Interprofessional Team Integration
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2748A Unique Moment in Time to Build a
Different Kind of Care Team
Source: US Department of Health and Human Services, Health Resources and Services Administration, The Registered Nurse Population: Findings from the 2008 National Sample Survey of Registered Nurses, 2010, available at: http://bhpr.hrsa.gov/healthworkforce/rnsurveys/rnsurveyfinal.pdf, accessed on April 25, 2013; US Department of Health and Human Services, Health Resources and Services Administration, The U.S. Nursing Workforce: Trends in Supply and Education, 2013, available at: http://bhpr.hrsa.gov/healthworkforce/reports/nursingworkforce, accessed on May 7, 2013; Nursing Executive Center interviews and analysis.
Opportunities to Redefine the Care Team
Instill a new care team philosophy in new hires
Age Distribution of Practicing Registered Nurses in the US
20-29 30-39 40-49 50-59 60-69 70+
9.4%
20.0%
25.8%29.2%
12.7%
2.9%
2008
~1,000,000Number of RNs reaching retirement
age in the next 10-15 years
Fill vacant positions with a different skill set
Use attrition (rather than cuts) to eliminate positions
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A Nurse Isn’t a Nurse Isn’t a Nurse
Source: Aiken L, et al., “Educational Levels of Hospital Nurses and Surgical Patient Mortality,” JAMA, 290 (2003): 1617-1623; Nursing Executive Center analysis.
1) Percentage of hospital staff nurses with BSN degree.
Patient Mortality
Failure to Rescue
20% BSN 40% BSN 60% BSN
21.119.2 17.5
20% BSN 40% BSN 60% BSN
83.1
76.2
Estimated Rate of Adverse Outcomes per 1,000 Patients by Hospital-Wide Level of Nurse Education1
90.4
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Three Paths for Building the High-Value Care Team
Source: Nursing Executive Center interviews and analysis.
Align Interprofessional Goals and Work
2Change the
Nursing Skill Mix
1
1. Achieve Top-of-License Nursing Practice
2. Right-Size the Proportion of RNs in the Skill Mix
3. Trade a Nursing Position for an Expert RN Role to Improve Unit Performance
4. Give All Care Team Members the Same Set of Goals
5. Transfer Work to Specialized Team Members
6. Gather Physicians and Staff at the Bedside at the Same Time
7. Keep Teams as Consistent as Possible
Uncoordinated Interprofessional Care
Overreliance on Bedside RNs
Root Cause of Inefficiency
Path to Higher Value
Deploy the Minimum Core Team and Selectively
Scale Up Support
3
8. Select Your Patient Population of Focus
9. Identify Patients Needing Additional Support
10. Define the Core and Expanded Care Teams
11. Layer Additional Support onto the Core Team
12. Regularly Reassess Patient Need for Support
A “One-Size-Fits-All” Care Team
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2
3
1
Road Map
Implications For Nursing Practice and Education
Care Delivery Transformation
Our New Market Reality
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Nursing at the Heart of Transformative Change
Future of Nursing: Leading Change, Advancing Health
Working on the front lines of patient care, nurses can play a vital role in helping realize the objectives set forth in the 2010 Affordable Care Act, legislation that represents the broadest health care overhaul since the 1965 creation of the Medicare and Medicaid programs. Institute of Medicine
Source: Institute of Medicine, “The Future of Nursing: Leading Change, Advancing Health,” available at: http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health, accessed November 11, 2011; Nursing Executive Center analysis.
”
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Then and Now….Single-needs patient an endangered species
Mr. Jones; 1975 Mr. Jones; 2015
AMI AMI, HF, diabetes, obese
PCP PCP, cardiologist, endocrinologist, hospitalist, geriatric NP
2 meds 15 meds
Lives at home Lives in assisted living
Wife is caregiver Multiple family members, no one designated
LOS: 10 days LOS: 2.5 days
One admission in 1973 Third admission in 2013
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Imperatives for Nursing and Nursing Practice
Top of License Practice Inter-Professional Collaboration
Enhancing the Patient Experience Frontline Accountability
• Value-based care
• Activity ‘completion’ not enough
• Ownership of outcomes the key
• Care team as core in all settings
• Roles clearly defined, supported, aligned with patient needs
• Beyond satisfaction
• Processes and systems patient-’centered’
• Patient as partner
• Non-valued added work eliminated
• Core responsibilities clear
• Professional practice model as foundation
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The Future of Nursing: Leading Change, Advancing Health
Endorsing “Top-of-License” Nursing Practice
Source: Institute of Medicine, “The Future of Nursing: Leading Change, Advancing Health,” available at http://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health, accessed November 11, 2011; Fairman J, et al., “Broadening the Scope of Nursing Practice,” New England Journal of Medicine, 364 (2011):193-196; Nursing Executive Center analysis.
Imperative: Top of License Practice
Institute of Medicine
“Nurses should practice to the full extent of their education and training.”
”
Broadening the Scope of Nursing Practice
Julie A. Fairman, PhD, RNJohn W. Rowe, MD
Susan Hasmiller, PhD, RN, FAAN Donna Shahala, PhD
“All health care professionals should support an expanded, standardized scope of practice for nurses as a way to improve health care in the United States.”
”
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Defining “Top-of-License” Practice by Patient NeedsEstablishing Consensus on Core Responsibilities
Imperative: Top of License Practice
Core Nursing Responsibilities Across Settings
Source: Nursing Executive Center interviews and analysis.
Assess Clinical and Psychosocial Patient Needs
1
Establish Patient Goals and Track Progress
2
Provide Patient-Centered, Outcomes-Focused Care
3
Educate and Engage Patients and Their Families
4
Manage Key Components of the Clinical Record
5
Coordinate Care with Interprofessional Caregivers
6
Facilitate Safe Patient Transitions
to the Next Care Setting
7
Assess and Incorporate New Technologies and
Evidence-Based Practice
8
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An All-Too-Common Reality
Imperative: Top of License Practice
Real Nurses’ Stories from the Front Line
Source: Nursing Executive Center interviews and analysis.
Primary Care Office
Emergency Department
Inpatient Skilled Nursing Facility
Home Health
• 10 minutes looking for patient’s suicide risk in the EMR
• Hunted down catheter because no one else available and care time-sensitive
• Wheeled patient to radiology so wouldn’t miss scheduled ultrasound
• Transported resident to dining room and stayed for the entire meal to assist him with feeding
• Drove 20 miles to agency office to document care in the electronic record
• Stuck waiting for
physician’s order to administer pain medication
• Physician kept referring to the medical assistants as “nurses”
• Called hospital charge nurse to decipher hand-written discharge instructions
• Made four calls to physician to have patient’s medication adjusted
• 20 minutes cleaning up large spill to prevent an avoidable fall
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Opportunity Lies in Underleveraged Hours
Source: Storfjell J, Omoike O, and Ohlson S, “The Balancing Act: Patient Care Time Versus Cost,” JONA 38 (2008): 244-249; Nursing Executive Center analysis.
Imperative: Top of License Practice
1) Based on three-year study of nursing activities on 14 med/surg units in three hospitals.2) Assessing, teaching, providing hands-on care, providing psychosocial support, coordinating care, and documenting care.3) Waiting, disruptions, delays, work-arounds, and rework.
Current Distribution of Med/Surg Nursing Time1
36%64%
$756,724RN wages spent on non-value-added time per med/surg unit
“Most attention has been focused on increasing nursing staffing levels rather than on increasing patient care time.”
Judith Lloyd Storfjell, PhD, RNOsei Omoike, MS, MBA, RN
Susan Ohlson, MSA, RNC
”“Non-Value-Added” Time3
“Value-Added” Time2
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Impeding Effective Patient CareStaff Often Feeling Unsupported by Interprofessional Colleagues
Source: Advisory Board Survey Solutions Data Cohort, 2012.
Imperative: Interprofessional Collaboration
Staff Strongly Agreeing with the Following Statements:
RNs APRNs PCAs Pharmacists Physical Therapists
Social Workers
29%
33%31%
24%
35%
39%
17%
22% 23%
17% 18%
28%
“I receive the necessary support from employees in other units/departments to help me succeed in my work.”
“I receive the necessary support from employees in my unit/department to help me succeed in my work.”
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Poor Collaboration Leading to Poor Patient Outcomes
Source: Baggs J, et al., “Association Between Nurse-Physician Collaboration and Patient Outcomes in Three Intensive Care Units,” Critical Care Medicine, 27 (1999):1991-1998; Nursing Executive Center analysis.
Imperative: Interprofessional Collaboration
Association Between Nurse-Physician Collaboration and Negative Patient Outcomes in the ICU
Negative Outcome to Predicted Mortality Unit
Collaboration Score, 1 (Poor) to 7 (High)
Medical ICU Surgical ICU Med-Surg ICU
3.5
2.5
1.0
0.470.77
0.860000000000001
The lower the nurse-physician collaboration score, the higher the risk of a negative patient outcome
Medical ICU Surgical ICU Med/Surg ICU
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Estimating the Costs InnInefficientollabortaionEstimating the Cost of Inefficient CoCollabommunicationInefficient collaboration and communication….
Source: Agarwal R, et al., “Quantifying the Economic Impact of Communication Inefficiencies in U.S. Hospitals,” Journal of Healthcare Management, 55 (2010): 265-281; Nursing Executive Center analysis.
Imperative: Interprofessional Collaboration
Annual Economic Burden of Communication Inefficiencies
Average 500-Bed Hospital
$0.3 M
$1.8 M $2.5 M
Cost of Wasted Physician Time
Cost of Wasted Nurse Time
Cost of Increased LOS
$4.6M Total annual costs attributed to inefficient communication for average 500-bed hospital
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Renewed Emphasis on Interprofessional Education
Source: Institute of Medicine, “Educating for the Health Team,” National Academy of Sciences, October 1972, available at http://www.ipe.umn.edu/prod/groups/ahc/@pub/@ahc/@cipe/documents/asset/ahc_asset_350123.pdf, accessed November 12, 2012; Interprofessional Education Collaborative, “Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel,” 2011, available at http://www.aacn.nche.edu/education-resources/IPECReport.pdf, accessed November 12, 2012; Nursing Executive Center interviews and analysis.
Imperative: Interprofessional Collaboration
Factors Reinforcing the Need for Improved Interprofessional
Collaboration
New payment models rewarding effective primary care and population management
Impending health care workforce shortages
Aging population with multiple chronic conditions
1972 Institute of Medicine Report
“Educating for the Health Team”
“We face, in the next decade, a national challenge to redeploy the functions of health professions in new ways, extending the roles of some, perhaps eliminating others, but more closely meshing the functions of each than ever before.”
Educating for the Health Team
Institute of Medicine1972
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Is This All We Aspire to Do?
Source: HCAHPS, available at: http://www.hcahpsonline.org/home.aspx, accessed November 11, 2011; Nursing Executive Center interviews and analysis.
Imperative: The Patient Experience
Summary of Eight HCAHPS Domains
1. Communication with nurses
2. Communication with doctors
3. Responsiveness of hospital staff
4. Pain management
5. Communication about medicines
6. Discharge information
7. Hospital environment (quiet, noise)
8. Overall hospital rating
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Broadening Our Ambition
Imperative: The Patient Experience
• Ongoing Emotional Support• Family Involvement and
Care Team Integration• Avoidable Disruptions
Minimized• Compassionate,
Empathetic Caregivers
• Clear, Actionable Patient Education
• Up-to-Date andThorough Information
• Physical and Emotional Needs Anticipated
Patient Experience
• Communication• Quiet at Night• Information About
Medications• Discharge Information• Cleanliness• Responsiveness• Pain Management
HCAHPS
Source: HCAHPS, available at: http://www.hcahpsonline.org/home.aspx, accessed November 11, 2011; Nursing Executive Center interviews and analysis.
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Still Ample Room for Growth
Imperative: The Patient Experience
Percentage of Physicians and Patients Agreeing With the Following Statements
About Compassionate Care
n=800 patients, 510 physicians
Source: Health Affairs, “An Agenda For Improving Compassionate Care: A Survey Shows About Half Of Patients Say Such Care Is Missing,” available at: http://content.healthaffairs.org/content/30/9/1772.full, accessed November 10, 2011.
76% 78%85%
54%
Physicians Patients
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Advancing Multiple Aims
Imperative: Patient Experience
Source: Boulding W, et al., “Relationship Between Patient Satisfaction With Inpatient Care and Hospital Readmission Within 30 Days,” American Journal of Managed Care, 2011, 17:41-48; Glickman S, et al., “Patient Satisfaction and Its Relationship With Clinical Quality and Inpatient Mortality in Acute Myocardial Infarction,” Circulation: Cardiovascular Quality and Outcomes, 2010; 3:188-195; Bertakis K, et al., “Patient-Centered Care is Associated with Decreased Health Care Utilization,” Journal of the American Board of Family Medicine, 2011, 24:229-239; Nursing Executive Center interviews and analysis.
Representative Studies About the Relationship Between Patient Experience and Outcomes
Journal of the American Board of Family Medicine
Patient-Centered Care is Associated With Decreased Health Care Utilization
American Journal of Managed Care
Relationship Between Patient Satisfaction With Inpatient Care and Hospital Readmission Within 30 Days
Circulation: Cardiovascular Quality and Outcomes
Patient Satisfaction and Its Relationship With Clinical Quality and Inpatient Mortality in Acute Myocardial Infarction
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Growing Number of Metrics Linked to Reimbursement
Imperative: Accountability
Source: Centers for Medicare & Medicaid Services; Nursing Executive Center interviews and analysis.
HCAHPS Survey Measures During this hospital stay, how often did nurses treat you with
courtesy and respect?” During this hospital stay, how often did nurses
listen carefully to you? During this hospital stay, how often did nurses explain things in a
way you could understand? During this hospital stay, after you pressed the call button, how
often did you get help as soon as you wanted it? During this hospital stay, how often were your room and bathroom
kept clean? During this hospital stay, how often was the area around your room
quiet at night? During this hospital stay, did you need help from nurses or other
hospital staff in getting to the bathroom or in using a bedpan? How often did you get help in getting to the bathroom or in using a
bedpan as soon as you wanted? During this hospital stay, how often was your pain well controlled? During this hospital stay, how often did the hospital staff do
everything they could to help you with your pain? Before giving you any new medicine, how often did hospital staff tell
you what the medicine was for? Before giving you any new medicine, how often did hospital staff
describe possible side effects in a way you could understand? During this hospital stay, did doctors, nurses or other hospital staff
talk with you about whether you would have the help you needed when you left the hospital?
During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital?
Core Process MeasuresAcute Myocardial Infarction Aspirin prescribed at discharge Fibrinolytic agent received within 30 minutes of hospital arrival Time of receipt of primary percutaneous coronary intervention Statin prescribed at dischargeHeart Failure Discharge instructions Evaluation of left ventricular systolic function Angiotensin converting enzyme inhibitorPneumonia Blood culture performed in the ED prior to first antibiotic received Appropriate initial antibiotic selectionSurgical Care Improvement Project Prophylactic antibiotic received within 1 hour prior to surgical
incision Prophylactic antibiotic selection for surgical patients Prophylactic antibiotic discontinued within 24 hours after surgery
end time Cardiac surgery patients with controlled 6AM postoperative serum
glucose Postoperative urinary catheter remoaval on post operative day 1 or 2 Surgery patients on a Beta Blocker prior to arrival who received a
Beta Blocker during the perioperative period Surgery patients with recommended VTE prophylaxis ordered Surgery patients who received appropriate VTE prophylaxis within
24 hours pre/post surgery
Patient Safety and Quality MeasuresMortality Measures Acute Myocardial Infarction 30-day mortality rate Heart Failure 30-day mortality rate Pneumonia 30-day mortality rateReadmission Measures Acute Myocardial Infarction 30-day risk standardized readmission
measure Heart Failure 30-day risk standardized readmission measure Pneumonia 30-day risk standardized readmission measure Healthcare-Associated Infections Central line associated bloodstream infection Surgical site infection Catheter-associated urinary tract infectionHospital-Acquired Condition Measures Foreign object retained after surgery Air embolism Blood incompatibility Pressure ulcer stages III & IV Falls and trauma Vascular catheter-associated infection Catheter-associated urinary tract infection Manifestation of poor glycemic controlPrevention: Global Immunization Measures Immunization for influenza Immunization for pneumonia
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Frontline Accountability Foundational to Success
Imperative: Accountability
Practice Strategy Hierarchy
PeakPerformance
Frontline Accountability for Organizational Goals
Innovation Standardization
Source: Nursing Executive Center interviews and analysis.
Protocol adherence clearly important…
…Ownership of protocol/standard of practice outcomes supported by critical thinking essential
Critical thinking essential to addressing
needs
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Strategies for Nursing to Influence, Shape, Own, and Lead…..
What Lies Ahead?
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Holistic Care Transformation …An Opportunity to Design the Future Together
Population Health Management
Care Transitions
Care Model
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