AAACN AAACN

April 2008April 2008

Mary Ramos, PhD, RNMary Ramos, PhD, RN

The Role of Military The Role of Military Ambulatory Care Nurses Ambulatory Care Nurses in Facilitating the Best in Facilitating the Best Evidence-based CareEvidence-based Care

Military Health System New to Military Health System New to Provision of Broad-based CareProvision of Broad-based Care

Until 1880s cared only for SoldiersUntil 1880s cared only for Soldiers After 1884 Medical Officers and After 1884 Medical Officers and

Contract Surgeons cared for families Contract Surgeons cared for families free of charge as possiblefree of charge as possible

World War II presented huge burden World War II presented huge burden of obstetrical careof obstetrical care

December 7, 1956: Dependents December 7, 1956: Dependents Medical Care ActMedical Care Act

CHAMPUS: 1967CHAMPUS: 1967

The 1960sThe 1960s

CHAMPUS provided ambulatory and CHAMPUS provided ambulatory and psychiatric care for all family psychiatric care for all family members and retirees by 1967: members and retirees by 1967: Modified HMO/PPOModified HMO/PPO

About 30 HMOs in commercial sectorAbout 30 HMOs in commercial sector Beginning awareness of financial risk Beginning awareness of financial risk

in provision of health carein provision of health care– Utilization ReviewUtilization Review– Cost ContainmentCost Containment

1980s1980s

Fee for Service Decreasingly Feasible Fee for Service Decreasingly Feasible in Community-based Carein Community-based Care

Growth of Managed Care Growth of Managed Care EnvironmentEnvironment

CHAMPUS Reform Initiative in MilitaryCHAMPUS Reform Initiative in Military TRICARETRICARE

Military Health Care in 2008Military Health Care in 2008

TRICARE-contractedTRICARE-contracted Network-dependentNetwork-dependent AmbulatoryAmbulatory Cost-focusedCost-focused Resource-strainedResource-strained Complex SystemsComplex Systems High TechnologyHigh Technology High ExpectationsHigh Expectations Outcomes Measured and ComparedOutcomes Measured and Compared

Key to Maximizing Quality of Key to Maximizing Quality of CareCare

Attention to ProcessesAttention to Processes Balanced Team ApproachBalanced Team Approach Patient FocusPatient Focus Data-based Decision-makingData-based Decision-making

– Evidence-based PracticesEvidence-based Practices– Clinical Practice GuidelinesClinical Practice Guidelines– Using Available DataUsing Available Data

The Best Position to Facilitate The Best Position to Facilitate Change: NursesChange: Nurses

Providers Look at One Patient at a Providers Look at One Patient at a TimeTime

Providers Should be Seeing PatientsProviders Should be Seeing Patients Providers Need System SupportProviders Need System Support

Nurses Can Be System ThinkersNurses Can Be System Thinkers Nurses Can Provide DataNurses Can Provide Data Nurses Can Support Providers in Nurses Can Support Providers in

Improving Population Health Through Improving Population Health Through Data-based Decision-makingData-based Decision-making

Clinical Practice GuidelinesClinical Practice Guidelines

Evidence-basedEvidence-based Algorithmic: Decision MatricesAlgorithmic: Decision Matrices Outcomes-focusedOutcomes-focused Bring Best Practices to the PatientBring Best Practices to the Patient Decrease Unwanted VariationDecrease Unwanted Variation Free Providers to Concentrate on Free Providers to Concentrate on

What Cannot be “Automatic”What Cannot be “Automatic”

https://qmo.amedd.army.mil/pguide.htm

https://qmo.amedd.army.mil/CPGShoppingCart/entry.aspx?link=/CPGShoppingCart/default.aspx

Diabetes Clinical Practice Diabetes Clinical Practice Guideline RecommendationsGuideline Recommendations

A1C At Least AnnuallyA1C At Least Annually Foot Exam AnnuallyFoot Exam Annually Dilated Eye Exam AnnuallyDilated Eye Exam Annually Track LipidsTrack Lipids Influenza/PNX VaccineInfluenza/PNX Vaccine Microalbumin CheckMicroalbumin Check

Provider Decisions?Provider Decisions?

Research-basedResearch-based Universally AcceptedUniversally Accepted Patient Should be Involved in PlanningPatient Should be Involved in Planning

– Timing for A1CTiming for A1C– Relationship of Diet and Exercise to A1CRelationship of Diet and Exercise to A1C– Patient Ability to Assess FeetPatient Ability to Assess Feet– Importance of Eye ExamImportance of Eye Exam– Diabetes and Kidney FunctionDiabetes and Kidney Function

Using Data in Clinical Using Data in Clinical SettingsSettings

AggregationAggregation AnalysisAnalysis ActionAction

AggregationAggregation

Aggregation is putting individual Aggregation is putting individual numbers into sets that “fit” questionsnumbers into sets that “fit” questions

The questions, then, must come firstThe questions, then, must come first

Know Your EnrolleesKnow Your Enrollees

How Many EnrolleesHow Many Enrollees By Benefit CategoryBy Benefit Category By Age Group and GenderBy Age Group and Gender By Function and ActivityBy Function and Activity By ConditionBy Condition

Know Your ProvidersKnow Your Providers

How Many ProvidersHow Many Providers By Category By Category

– Primary Care vs. SpecialtyPrimary Care vs. Specialty– Physician vs. NP and othersPhysician vs. NP and others

By Population Benefit CategoryBy Population Benefit Category By Population Age Group and Gender By Population Age Group and Gender By Deployment StatusBy Deployment Status By Population ConditionBy Population Condition

Formulate QuestionsFormulate Questions

How many patients with asthma?How many patients with asthma?How many of those have had ED How many of those have had ED visits for asthma?visits for asthma?How many of them are on inhaled How many of them are on inhaled steroid medication?steroid medication?

All answers readily available through All answers readily available through the MHSPHPthe MHSPHP

Patient-level DataPatient-level DataAge BenCat PCM

Name

Provider Group

Hosp OP Visits ER Disp Ctrl Rx Ctrl Drug Name

40 ADA QR PCMA 0 3 0 6 30-Oct-07 ADVAIR DISKUS

35 ADA QR PCMA 0 1 0 5 4-May-07 ADVAIR DISKUS

49 ADA QR PCMA 0 1 0 7 22-Oct-07 ADVAIR DISKUS

34 ADA QR PCMA 0 0 0 4 13-Sep-07 ADVAIR DISKUS

47 ADA QR PCMA 0 0 0 5 3-Sep-07 ADVAIR DISKUS

51 ADA QR PCMA 0 0 0 4 22-Oct-07 ADVAIR DISKUS

47 ADA QR PCMA 0 4 0 21 28-Sep-07 ADVAIR DISKUS

42 ADAF QR PCMA 0 1 0 11 31-Jul-07 ADVAIR DISKUS

39 ADAF QR PCMA 0 0 0 8 13-Aug-07 ADVAIR DISKUS

46 ADAF QR PCMA 0 1 0 4 19-Sep-07 ADVAIR DISKUS

51 ADAF QR PCMA 0 1 0 5 13-Sep-07 ADVAIR DISKUS

41 ADAF QR PCMA 0 1 0 13 11-Oct-07 FLOVENT HFA

36 ADAF QR PCMA 0 0 0 17 10-Sep-07 SINGULAIR

26 ADAF QR PCMA 0 14 0 7 26-Sep-07 SINGULAIR

https://pophealth.afms.mil/tsphp/login/login.cfm

MTF-level DataMTF-level Data

https://cms.mods.army.mil/cms/secured/stoplights_frameset.aspx?metricCategoryCd=POPH

AnalysisAnalysis

Without analysis, numbers are just Without analysis, numbers are just data – not informationdata – not information

Without analysis, we DRIPWithout analysis, we DRIP Analysis is interpreting numbers to Analysis is interpreting numbers to

answer questionsanswer questions The questions, then, must come firstThe questions, then, must come first

AnalysisAnalysis

Analyze data sets separatelyAnalyze data sets separately– ORYXORYX– HEDISHEDIS– Other Applicable DataOther Applicable Data

Analyze data sets togetherAnalyze data sets together– ED Utilization against Portal Asthma ED Utilization against Portal Asthma

datadata– Inpatient days for diabetes patientsInpatient days for diabetes patients– Readmission for CHF and ORYX Readmission for CHF and ORYX

discharge education datadischarge education data

ORYX Analysis ToolsORYX Analysis Tools

www.mhs-cqm.infowww.mhs-cqm.info– MTF comparison chartsMTF comparison charts– Can be edited to address local issuesCan be edited to address local issues

www.hcdinc.comwww.hcdinc.com– Process Control Charts (Consistency)Process Control Charts (Consistency)– Comparison Charts (Observed vs. Comparison Charts (Observed vs.

Benchmark)Benchmark)– Quality Reports (TJC Quality Check)Quality Reports (TJC Quality Check)

ActionAction

Having data is not enoughHaving data is not enough Everyone is involved in incorporating Everyone is involved in incorporating

data into every day decision-making data into every day decision-making and strategic planning to modify and strategic planning to modify processes to enhance and optimize processes to enhance and optimize patient care and patient safetypatient care and patient safety

Get your findings out of the office Get your findings out of the office and into the fieldand into the field

Talk to the delivery teams about Talk to the delivery teams about creative ways to improve numberscreative ways to improve numbers

Use data to feed and nourish quality Use data to feed and nourish quality improvement effortsimprovement efforts

Cross-pollinateCross-pollinate

Ambulatory Nursing Ambulatory Nursing InterventionsInterventions

Design Systems to Support Care Design Systems to Support Care DeliveryDelivery– HuddlesHuddles– Order SetsOrder Sets– Availability of DataAvailability of Data

Integrated TeamsIntegrated Teams Patient PartnershipsPatient Partnerships Case Management and Continuity of Case Management and Continuity of

CareCare

Best PracticesBest Practices

Mammography Self-referralMammography Self-referral Integrated Diabetes CareIntegrated Diabetes Care

– Classes to Fit Patient PreferencesClasses to Fit Patient Preferences– Comprehensive Cardiac Risk ManagementComprehensive Cardiac Risk Management– Interdisciplinary ApproachesInterdisciplinary Approaches

Comprehensive Asthma CareComprehensive Asthma Care– Integration with School NursesIntegration with School Nurses– Involvement of ED Involvement of ED – Diagnostic and Coding Issues AddressedDiagnostic and Coding Issues Addressed

Expanded Roles for Nurses in Expanded Roles for Nurses in Ambulatory CareAmbulatory Care

Active Partnerships with Case and Active Partnerships with Case and Disease ManagersDisease Managers

Identifying and Eliminating “Silos” in Identifying and Eliminating “Silos” in Preventative Care ServicesPreventative Care Services

Richer Mix of Professional NursesRicher Mix of Professional Nurses Nurses More Involved in Direct Patient Nurses More Involved in Direct Patient

CareCare Larger Voice in Administrative Decision-Larger Voice in Administrative Decision-

making and Systems Designmaking and Systems Design

Golden Opportunities for Golden Opportunities for NursesNurses

Advocate for Patient-friendly SystemsAdvocate for Patient-friendly Systems Expand Responsibility and Expand Responsibility and

PartnershipsPartnerships Assume Responsibility for Optimal Assume Responsibility for Optimal

Patient WellnessPatient Wellness Assist Military in Designing Assist Military in Designing

Delivery Systems Delivery Systems for the 21for the 21stst Century Century