Transforming Healthcare Through Nursing

Transforming Healthcare Through Nursing
Nursing Executive Center Transforming Healthcare Through Nursing Implications for Practice and Education 2015

Nursing Executive Center
Practice Manager Jennifer Stewart Design Consultant Pascale Chehade Executive Director Steven Berkow

Transforming Healthcare Through Nursing
Implications for Practice and Education 2015

Our New Market Reality Care Delivery Transformation
Implications for Nursing Practice and Education

” What Business Are We In?
Businesses Displaced by Focusing on the Means Rather than the Ends Timeline for Eastman Kodak Business ” Providing Health, Not Health Care 1990s Digital cameras enter mainstream market “…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.” 1976 90% market share of commercial film business 2012 Kodak files for bankruptcy 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 Source: Asch D., "What Business Are We In? The Emergence of Health as the Business of Health Care,” NEJM, 367,2012: ; Nursing Executive Center interviews and analysis.

Traditional Hospital Cross-Subsidy
8 Our Existing Business Model Staying Afloat Through Cross-Subsidization Traditional Hospital Cross-Subsidy Below Cost Above Cost Commercial Insurance Public Payers Above-cost pricing Robust fee-for-service volume growth Steady price growth Only one component of our total business 149% 86% Hospital Payment-to-Cost Ratio, Private Payer, 2012 Hospital Payment-to-Cost Ratio, Medicare, 2012 Source: American Hospital Association, “Trendwatch Chartbook 2014,” available at: Health Care Advisory Board interviews and analysis.

Payer Cross-Subsidy Eroding
9 Payer Cross-Subsidy Eroding Projected Discharges by Payer, 2021 Annualized Commercial Price Growth 6-7% Commercial Medicare Inpatient Contribution Income Weighted Per-Case Average Medicaid Source: American Hospital Association Chartbook, available at: http: accessed on April 29, 2011; Advisory Board Company interviews and analysis.

$260B $56B $151B Public-Payer Reimbursement Still in the Crosshairs
10 Public-Payer Reimbursement Still in the Crosshairs Medicare Payment Cuts Becoming the Norm ACA’s Medicare Fee-for-Service Payment Cuts Not the End of the Story Reductions to Annual Payment Rate Increases1 “Notwithstanding recent favorable developments… Medicare still faces a substantial financial shortfall that will need to be addressed with further legislation.” $260B $56B $151B Hospital payment rate cuts, Reduced Medicare and Medicaid DSH2 payments, Reduced Medicare payments due to sequestration and 2013 budget bill Office of the Actuary, CMS Includes hospital, skilled nursing facility, hospice, and home health services; excludes physician services. Disproportionate Share Hospital. 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 Health Care Advisory Board interviews and analysis.

Coverage Expansion and the Rise of Individualized Insurance
11 ACA (and Recovery) Making a Dent in Uninsurance But Every Silver Lining Has Its Cloud Percentage of U.S. Adults Without Health Insurance 2013 Q3 2014 Q3 18.0% Insurance exchanges launch Medicaid expansion begins Employer-sponsored coverage grows 13.4% (highest on record) (lowest on record) A Bargain Still Unbalanced $5.7B $14B Reduction in uncompensated care, 2014 vs. ACA-related reductions in Medicare fee-for-service payment, 2014 Source: Gallup, “In U.S., Uninsured Rate Holds at 13.4%,” Department of Health and Human Services, “Impact of Insurance Expansion on Hospital Uncompensated Care Costs in 2014,” Health Care Advisory Board interviews and analysis.

9.6M 6.7% 2.4% Medicaid Expansion Contentious—and Consequential
12 28 States + DC Have Opted for Expansion State Participation in Medicaid Expansion Financial Impact As of February 2015 “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” PricewaterhouseCoopers Expansion by Waiver Not Currently Participating Participating 9.6M 6.7% 2.4% Increase in Medicaid, CHIP1 enrollment, July-Sept Oct Average Medicaid enrollment increase across non-expansion states Advisory Board estimate of impact of Medicaid expansion on typical hospital’s 10-year operating margin projection Children’s Health Insurance Program. Estimate does not include CT or ME. Source: Kaiser Family Foundation, “Current Status of State Medicaid Expansion Decisions,” January 27, 2015, available at: 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.

Another Year, Another Lawsuit
13 Another Year, Another Lawsuit Challenge to Subsidies Making Its Way Through the Courts The Question: Potential Impact Does the language of the ACA allow subsidies in states that do not set up their own exchanges? Unsubsidized Supreme Court Stepping In Subsidized on Federally-Run Exchanges Halbig v. Burwell D.C. Circuit panel strikes down subsidies on federal exchanges Subsidized on State-Run Exchanges King v. Burwell Fourth Circuit rules subsidies legal on Virginia’s federally-run exchange Over half of all enrollees collecting potentially unallowable subsidies Supreme Court agreed to hear King v. Burwell in November 2014; final ruling expected by June 2015

6% Increasing Competition for Medicare Dollars No More A’s for Effort
14 Increasing Competition for Medicare Dollars No More A’s for Effort Medicare Value-Based Purchasing Program Performance Criteria Other Mandatory Risk Programs Weight in Total Performance Score Hospital-Acquired Condition Penalties Clinical Process Patient Experience Readmission Penalties Outcomes of Care No Trivial Thing Efficiency Medicare revenue at risk from mandatory pay-for-performance programs1, FY 2017 6% Includes Value-Based Purchasing Program, Hospital Readmissions Reduction Program, and Hospital-Acquired Conditions Program. Source: The Advisory Board Company, “Mortality Rates Are Only One of Many VBP Changes to Come,” December 4, 2013, CMS, “Request for Information on Specialty Practitioner Payment Model Opportunities,” February 2014, available at Health Care Advisory Board interviews and analysis.

Many Facilities Receiving Multiple Penalties
Few Escaping Penalties Altogether, Almost Half Facing Two or More Hospitals Receiving FY 2015 P4P Penalties1 Readmissions Penalty 1,071 (32%) No Penalties 423 (13%) 48% Hospitals receiving multiple P4P penalties 961 (29%) 288 (9%) 318 (9%) VBP Penalty 152 (5%) HAC Penalty 112 (3%) 43 (1%) Based on Readmissions and VBP proxy adjustment factors from FY 2015 IPPS Final Rule, proxy HAC adjustments from FY 2015 IPPS Proposed Rule. Source: CMS, Advisory Board Analysis.

Overview of Risk-Based Payment Models
Key Attributes Bundled 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 Center for Medicare and Medicaid Innovation. Source: Health Care Advisory Board interviews and analysis.

The Market Force Course
17 The Market Force Course 12 Tools for Translating Market Forces into Frontline Terms Sample Toolkit Resources Nurse Manager “Cheat sheets” Plug-and-Play Videos Ready-to-Use Posters Customizable Presentations Interactive Exercises One-page primers on market forces impacting organizational strategy Short, easy-to- digest videos for frontline staff on current market forces Visuals that distill complex concepts into concrete actions for frontline staff PowerPoint slides and scripting for leaders to brief staff on tough messages Games for frontline staff and managers aimed at conveying budget constraints To access The Market Force Course, visit advisory.com/nec/publications. Source: Nursing Executive Center, The Market Force Course, 2014.

Operational Economics on the Brink of Failure
Margin Improvement Analysis Results Five-Year Margin Projections Ten-Year Margin Projections 0-5% Decline 5-10% Decline 5-10% Decline 0-5% Decline Greater than 10% Decline Improvement Greater than 10% Decline Improvement HCAB Service in Brief: The Margin Improvement Intensive 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 to participate Source: Health Care Advisory Board interviews and analysis.

Care Delivery Transformation
Our New Market Reality Care Delivery Transformation Implications for Nursing Practice and Education

How Much Avoidable Cost Is There in Health Care?
$ 7 5 Source: Institute of Medicine, “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America”, 2012; Nursing Executive Center analysis.

A Clear Mandate for Meaningful Change?
Select Studies Analyzing Opportunities for Reducing Health Care Costs Estimated Magnitude of Avoidable Cost Opportunities Areas of Opportunity Avoidable 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 30 Cents of every health care dollar an unnecessary expense 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. Thomson Reuters: McKinsey Global Institute: Institute of Medicine: But where can we get actionable information on cost and utilization patterns? Certainly not from policy-focused papers. The IOM view o.f the world is not actionable/provides no value to hospitals for a few reasons. One of which is that the IOM view makes it appear as if there is opportunity everywhere (e.g. waste, fraud & abuse; administrative waste).

4.4M 18% Huge Opportunity for Improvement
22 Huge Opportunity for Improvement Percentage of ED Visits that are Avoidable in the US1 Estimated number of preventable trips to US hospitals each year 4.4M 18% 30-day all-cause readmission rate2 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. CMS, 2012. Source: Truven Health Analytics, “Avoidable Emergency Department Usage Analysis,” 2013, Web/TruvenHealthAnalytics/EMP_12260_0113_AvoidableERAdmissionsRB_WEB_2868.pdf; Robert Wood Johnson Foundation, Reform in Action: Reducing Avoidable Hospital Readmissions,” 2013, 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.

Unnecessarily Crowded
Many Medical Admissions Preventable Ambulatory-Sensitive1 Inpatient Admissions ” An Ounce of Prevention… “It’s a lot easier to prevent people from needing a service than it is to eliminate the service once you offer it.” Surgical Medical CFO Medicare Revenue per Case Percent of Medicare discharges considered sensitive to better ambulatory care 17% Inpatient admissions associated with Agency for Healthcare Research and Quality (AHRQ) Preventable Quality Indicator conditions. Source: MedPAR FY2009; Nursing Executive Center interviews and analysis.

Toward an Economics of Value
Adapting to New Rules of Competition Health System Strategy, c. 2003 “Extractive Growth” Health System Strategy, “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 Description Performance Metrics Critical Infrastructure Source: Advisory Board interviews and analysis.

Disaggregating Health Care Reform
Financing Coverage Expansion Delivery System Reform Source: Nursing Executive Center analysis.

Economics Aligning with Mission
Evolving Market Demand Building Long-Term Patient Relationships for Ongoing, Coordinated Care Managing Chronic Care for High-Risk Patients Improving Overall Health and Wellness of the Population Centering Hospital Care on the Patient Source: Nursing Executive Center interviews and analysis.

Establishing the Medical Perimeter
The New Reality Establishing the Medical Perimeter Extensive Ambulatory Care Network Addresses Medical Demand Medical Management Investments Patient Activation Post-Acute Alignment Medical Home Infrastructure Disease Management Programs Primary Care Access Population Health Analytics Electronic Medical Records Health Information Exchanges Source: Nursing Executive Center interviews and analysis. How do you see yourself? Is this exciting or depressing?

If We Were Building from Scratch…
Governing Principles of the Transformed Care Enterprise Personalized Management Accessible Primary Care Care management appropriately matched to individual patient, population need Oriented toward patient-centered goals that will drive clinical metric improvement Team available to patient for access, education, decision support Accessible when, where patient needs care Aligned Across the Continuum Outcomes-Driven System Multidisciplinary team works together to maintain unified care plan across patient needs Data transparency, sharing to ensure streamlined patient care Dashboard aligned to key cost, quality goals for improving population health Information available across the continuum to track utilization Source: Nursing Executive Center interviews and analysis.

Retail consumer behavior at the point of…
Key Factor Driving The Change Today: The Rise of The Retail Triple-Threat 29 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 Purchase High deductibles and narrow networks make us price sensitive with a high demand for value Spend Lifestyle Integration 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

7.0M (Original CBO Projection)
30 One Year In, Insurance Exchanges Generally on Track Aggregate Numbers in Line With Expectations; Enrollee Mix Older Initial Public Exchange Enrollment1 91% 7.0M (Original CBO Projection) Of enrollees still enrolled as of September 2014 25M Projected exchange enrollment by 2018 28% Enrollees aged 18-34 Numbers do not add precisely due to rounding. 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, Cheney K and Norman B, “Insurers See Brighter Obamacare Skies,” Politico, April 15, 2014, Health Care Advisory Board interviews and analysis.

Early Year Two Enrollment Outpacing First Round
31 Fewer Glitches, Greater Awareness Driving Increased Enrollment A Solid Start for Both Federal, State Exchanges First Round Enrollment Second Round Enrollment Federal Exchange 106K Enrollment during first month 462K Enrollment during first week 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 California Exchange 11K Enrollment during first fifteen days 11K Enrollment during first four days Source: CNBC, ‘'Solid' Obamacare start: More than 1M apply in first week,” Baltimore Sun, “Md. health exchange enrolls 16,700 in first week,” Colorado Public Radio, “Colorado health exchange: Enrollment rate outpacing last year,” Los Angeles Times, “California enrolls 11,357 in first 4 days of Obamacare open enrollment,” Health Care Advisory Board interviews and analysis.

Individuals Gravitating Toward Leaner Plans
32 Individuals Gravitating Toward Leaner Plans People Choosing Cheaper Premiums and Higher Deductibles Level 1: Choice of Metal Tier Level 2: Plan Choice Within Metal Tier All Metal Levels1 Gold Platinum Catastrophic Lowest-Cost Plan Any Other Plan Bronze Silver Second-Lowest-Cost Plan Factors Influencing Metal Level Premium Levers Beyond Benefit Design Deductible Non-Essential Services Covered Scope of Non-Essential Benefits Copays Network Composition Negotiated Payment Rates to Providers Out-of-Pocket Maximum Negotiated Rates Utilization Patterns, Trends Data from federally-facilitated exchanges only. 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.

$2,500 $6,250 High Deductibles Accelerating Consumerism
33 High Deductibles Accelerating Consumerism Aggressive Cost Sharing Troublesome for Provider Strategy Individual Deductibles Offered On Public Exchanges Challenges for Providers 2014 High out-of-pocket costs discourage appropriate utilization $2,500 $6,250 Median Maximum Individual Deductibles Chosen on eHealth Individual Marketplace Large patient obligations lead to more bad debt, charity care <$1,000 $6,000+ $1,000-$2,999 Price-sensitive patients more likely to seek lower- cost options $3,000-$5,999 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.

Convenience Consistently a Top Consumer Priority
Convenience Outranking Service and Cost Top Preferences for On-Demand Care How Convenient Is Convenient? Consumers Want Virtual, 24/7 Access #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” Clinic located near the home Increasing Consumer Preference Access, Convenience ing provider with symptoms 6 OF TOP 10 FEATURES RELATED TO ACCESS, CONVENIENCE Cost Clinic located near errands Service Clinic location near work Source: The Advisory Board Company, 2014 Primary Care Consumer Choice Survey, Marketing and Planning Leadership Council; Health Care Advisory Board interviews and analysis. Of chronically ill patients feel they lack control over their health data This results in about 11 percent of Americans seeing and using provider quality information. - See more at: doctors.aspx#sthash.3IpXBtxm.dpuf 68 percent say that, given equal out-of-pocket costs between two health care providers, the providers’ quality ratings would be an important factor in their choice. - See more at: doctors.aspx#sthash.3IpXBtxm.dpuf

Price Sensitivity at the Point of Care
35 Price Sensitivity at the Point of Care Cost-Conscious Behavior Affecting Pillars of Profitability Consumers Paying More Out-of-Pocket MRI Price Variation Across Washington, DC Fall within HDHP deductible2 $2,183 $730 Fall within PPO deductible3 $411 $900 $1,269 Price-sensitive shoppers will be acutely aware of price variation MRI prices range from $400 to $2,183 High-deductible health plan. $2,086; based on KFF report of average HDHP deductible. $733; based on KFF report of average PPO deductible. Source: KFF, “2012 Employer Health Benefits Survey,” available at: New Choice Health, “New Choice Health Medical Cost Comparison,” available at: Healthcare Blue Book, “Healthcare Pricing,” available at: Kliff S, “How much does an MRI cost? In D.C., anywhere from $400 to $1,861,” Washington Post, March 13, 2013, available at: Health Care Advisory Board interviews and analysis.

Meet Our New Competitors
Retail Clinics Meet Our New Competitors Walgreens Aims to Become the Premier Health Destination 2013: Launches three ACOs; begins diagnosing and managing chronic disease 2009: Launches flu vaccine campaign Simple Acute Services Vaccinations and Physicals Chronic Disease Monitoring Chronic Disease Diagnosis and Management 2007: Acquires Take Care Health Systems 2012: Offers three new chronic disease tests Case in Brief: Walgreen Co. ” Not Just a Drugstore 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 “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 Source: Japsen B, “How Flu Shorts Became Big Sales Booster for Walgreen, CVS,” Forbes, February 8, 2013, available at: “Take Care Clinics at Select Walgreens Expand Service Offerings,” Reuters, May 31, 2012, available at: Murphy T, “Drugstore Clinics Expand Care into Chronic Illness,” The Salt Lake Tribune, April 4, 2013, available at: Walgreens, “Company Overview,” available at: Health Care Advisory Board interviews and analysis.

Walmart Care Clinic Model
37 Walmart Enters Full Primary Care Saving Money—For Its Associates and Customers 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 The Largest “Activated Employer” Yet Visit fee for Walmart associates $4 “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.” Visit fee for Walmart customers $40 Labeed Diab President of Health and Wellness, Wal-Mart Source: Canales MW, “Wal-Mart Opening Clinic in Cove,” Killeen Daily Herald, April 18, 2014, Health Care Advisory Board interviews and analysis.

Retail Clinics Expected to Continue Growing
Estimated Total Number of Retail Clinics in the US Growth trajectory depends on preferred payer relations, PCP capacity, and health system partnerships Retailer Operational Retail Clinics1 900+ 400+ 135 14 75+ As of Oct 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.

Differentiating Effective Population Health
Managing Three Distinct Patient Populations High Risk Patients Rising-Risk Patients Low-Risk Patients Trade high-cost services for low-cost management 5% of patients; usually with complex disease(s), comorbidities Avoid unnecessary higher-acuity, higher-cost spending 15-35% of patients; may have conditions not under control Keep patient healthy, loyal to the system 60-80% of patients; any minor conditions are easily managed Source: Health Care Advisory Board interviews and analysis.

Chronic Disease Growth Outpacing Population Population Growth
Projected Increase in Chronic Disease Cases 19%: Projected population growth, Source: Milken Institute, available at: pdf/chronic_disease_report.pdf, accessed April 27, 2011; Nursing Executive Center interviews and analysis.

Plenty of Room for Improvement in Managing Care
Difference Between “Loosely-Managed” and “Well-Managed” PMPM1 Spending 2011 Medicaid Commercial Medicare $100.48 $131.84 $449.79 Loosely Managed Well Managed Loosely Managed Well Managed Loosely Managed Well Managed Source: Milliman; Nursing Executive Center interviews and analysis.

Building a System that Never Discharges the Patient
42 Building a System that Never Discharges the Patient Evolution of Patient Care Perspective Perfecting Individual Transitions Achieving Care Continuity Acute Care SNF ED Home PCP Retail Clinic Rehab Home Health Source: Nursing Executive Center interviews and analysis.

43 Finding the 80/20 Key Root Causes of Patients Receiving Fragmented, Episodic Care Patients receive fragmented, episodic care Clinicians not equipped to provide continuous care Clinicians only feel accountable for their immediate setting Patients and families don’t manage their care effectively Clinicians don’t have necessary patient information Clinicians have a siloed, setting- specific perspective Patients lack motivation Patients don’t know how Clinicians don’t know how Clinicians’ incentives focus on site-specific care Patients face economic roadblocks Clinicians don’t have time To access Achieving Top-of-License Nursing Practice, visit advisory.com/nec/publications. Source: Nursing Executive Center interviews and analysis.

Investing in Nursing with Good Reason
Patient Complexity Increasing Mounting Evidence Linking Nursing to Patient Outcomes Average Medicare Case Mix1 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 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): ; Aiken L, et al., “Educational Levels of Hospital Nurses and Surgical Patient Mortality,” JAMA, 290 (2003): ; Kane RL, et al., “The Association of Registered Nurse Staffing Levels and Patient Outcomes: Systematic Review and Meta-Analysis,” Medical Care 45 (2007): ; McHugh M, et al., “Hospitals with Higher Nurse Staffing Had Lower Odds of Readmissions Penalties than Hospitals with Lower Staffing,” Health Affairs, 32(2013): ; Nursing Executive Center analysis. Case Mix Index (CMI) in short-stay hospitals participating in Medicare’s Inpatient Prospective Payment System; excludes Medicare Advantage patients.

An Alarming Dichotomy Health System Economics Care Team Economics
Expenses per Adjusted Admission Percentage of Hospital Costs2 Comprising Wages and Benefits $10,533 2012 $6,980 2001 2011 Affordable Care Act’s Medicare Fee-for-Service Payment Cuts1 Total RN Compensation per Hour Worked Reductions to annual payment rate increases; includes hospital, skilled nursing facility, hospice, and home health services; excludes physician services. Does not include capital. Source: American Hospital Association, “Trendwatch Chartbook 2013: Trends Affecting Hospitals and Health Systems,” available at: 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: 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.

Population Health Efforts Shaping Volume Outlook
Utilization Patterns Difficult to Predict Inpatient Volume Under Different Population Health Assumptions Quite a Difference 7.6% Total inpatient volume growth, , with no additional population health management effort 1.1% Total inpatient volume growth, , with aggressive population health management efforts Source: Health Care Advisory Board interviews and analysis.

Designing the Care Team for Accountable Care
Two Dimensions of Care Team Design 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 Nursing Team Efficiency Inefficient, Siloed Care Team Nurses do not practice to the full extent of their training and skills; caregivers work in professional silos Inefficient, Interprofessional Care Team Nurses and other caregivers collaborate to provide care, but nurses do not practice at top of license Interprofessional Team Integration Source: Nursing Executive Center interviews and analysis.

A Unique Moment in Time to Build a Different Kind of Care Team
Age Distribution of Practicing Registered Nurses in the US Opportunities to Redefine the Care Team 2008 Fill vacant positions with a different skill set Instill a new care team philosophy in new hires Use attrition (rather than cuts) to eliminate positions ~1,000,000 Number of RNs reaching retirement age in the next years Source: US Department of Health and Human Services, Health Resources and Services Administration, The Registered Nurse Population: Findings from the National Sample Survey of Registered Nurses, 2010, available at: 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: accessed on May 7, 2013; Nursing Executive Center interviews and analysis.

A Nurse Isn’t a Nurse Isn’t a Nurse
Estimated Rate of Adverse Outcomes per 1,000 Patients by Hospital-Wide Level of Nurse Education1 Failure to Rescue Patient Mortality 90.4 Percentage of hospital staff nurses with BSN degree. Source: Aiken L, et al., “Educational Levels of Hospital Nurses and Surgical Patient Mortality,” JAMA, 290 (2003): ; Nursing Executive Center analysis. TP: Studies show the positive impact of more BSN nurses on patient outcomes. One example study here—as the percentage of BSNs increase, patient mortality and failure to rescue rates decrease. Transition: And, accordingly, we’re striving to increase our percentage of BSNs.

Three Paths for Building the High-Value Care Team
Root Cause of Inefficiency Overreliance on Bedside RNs Uncoordinated Interprofessional Care A “One-Size-Fits-All” Care Team 1 2 3 Path to Higher Value Change the Nursing Skill Mix Align Interprofessional Goals and Work Deploy the Minimum Core Team and Selectively Scale Up Support Achieve Top-of-License Nursing Practice Right-Size the Proportion of RNs in the Skill Mix Trade a Nursing Position for an Expert RN Role to Improve Unit Performance Give All Care Team Members the Same Set of Goals Transfer Work to Specialized Team Members Gather Physicians and Staff at the Bedside at the Same Time Keep Teams as Consistent as Possible Select Your Patient Population of Focus Identify Patients Needing Additional Support Define the Core and Expanded Care Teams Layer Additional Support onto the Core Team Regularly Reassess Patient Need for Support Source: Nursing Executive Center interviews and analysis.

Implications For Nursing Practice and Education
Our New Market Reality Care Delivery Transformation Implications For Nursing Practice and Education

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 creation of the Medicare and Medicaid programs. Institute of Medicine Source: Institute of Medicine, “The Future of Nursing: Leading Change, Advancing Health,” available at: accessed November 11, 2011; Nursing Executive Center analysis.

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

Imperatives for Nursing and Nursing Practice
Top of License Practice Inter-Professional Collaboration Non-valued added work eliminated Core responsibilities clear Professional practice model as foundation Care team as core in all settings Roles clearly defined, supported, aligned with patient needs Enhancing the Patient Experience Frontline Accountability Beyond satisfaction Processes and systems patient-’centered’ Patient as partner Value-based care Activity ‘completion’ not enough Ownership of outcomes the key

Endorsing “Top-of-License” Nursing Practice
Imperative: Top of License Practice Endorsing “Top-of-License” Nursing Practice The Future of Nursing: Leading Change, Advancing Health ” “Nurses should practice to the full extent of their education and training.” Institute of Medicine ” Broadening the Scope of Nursing Practice “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.” Julie A. Fairman, PhD, RN John W. Rowe, MD Susan Hasmiller, PhD, RN, FAAN Donna Shahala, PhD Source: Institute of Medicine, “The Future of Nursing: Leading Change, Advancing Health,” available at /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): ; Nursing Executive Center analysis.

Defining “Top-of-License” Practice by Patient Needs
Imperative: Top of License Practice Defining “Top-of-License” Practice by Patient Needs Establishing Consensus on Core Responsibilities Core Nursing Responsibilities Across Settings Assess Clinical and Psychosocial Patient Needs 1 Manage Key Components of the Clinical Record 5 Establish Patient Goals and Track Progress 2 Coordinate Care with Interprofessional Caregivers 6 Provide Patient-Centered, Outcomes-Focused Care 3 Facilitate Safe Patient Transitions to the Next Care Setting 7 Educate and Engage Patients and Their Families 4 Assess and Incorporate New Technologies and Evidence-Based Practice 8 Source: Nursing Executive Center interviews and analysis.

An All-Too-Common Reality
Imperative: Top of License Practice An All-Too-Common Reality Real Nurses’ Stories from the Front Line 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 Called hospital charge nurse to decipher hand- written discharge instructions Drove 20 miles to agency office to document care in the electronic record Physician kept referring to the medical assistants as “nurses” Stuck waiting for physician’s order to administer pain medication 20 minutes cleaning up large spill to prevent an avoidable fall Transported resident to dining room and stayed for the entire meal to assist him with feeding Made four calls to physician to have patient’s medication adjusted Source: Nursing Executive Center interviews and analysis.

Opportunity Lies in Underleveraged Hours
Imperative: Top of License Practice Opportunity Lies in Underleveraged Hours Current Distribution of Med/Surg Nursing Time1 $756,724 RN wages spent on non-value-added time per med/surg unit “Value-Added” Time2 “Non-Value- Added” Time3 ” “Most attention has been focused on increasing nursing staffing levels rather than on increasing patient care time.” Judith Lloyd Storfjell, PhD, RN Osei Omoike, MS, MBA, RN Susan Ohlson, MSA, RNC Based on three-year study of nursing activities on 14 med/surg units in three hospitals. Assessing, teaching, providing hands-on care, providing psychosocial support, coordinating care, and documenting care. Waiting, disruptions, delays, work-arounds, and rework. Source: Storfjell J, Omoike O, and Ohlson S, “The Balancing Act: Patient Care Time Versus Cost,” JONA 38 (2008): ; Nursing Executive Center analysis.

Impeding Effective Patient Care
Imperative: Interprofessional Collaboration Impeding Effective Patient Care Staff Often Feeling Unsupported by Interprofessional Colleagues Staff Strongly Agreeing with the Following Statements: “I receive the necessary support from employees in my unit/department to help me succeed in my work.” “I receive the necessary support from employees in other units/departments to help me succeed in my work.” Source: Advisory Board Survey Solutions Data Cohort, 2012.

Poor Collaboration Leading to Poor Patient Outcomes
Imperative: Interprofessional Collaboration Poor Collaboration Leading to Poor Patient Outcomes Association Between Nurse-Physician Collaboration and Negative Patient Outcomes in the ICU The lower the nurse-physician collaboration score, the higher the risk of a negative patient outcome Medical ICU Surgical ICU Med/Surg ICU Negative Outcome to Predicted Mortality Unit Collaboration Score, 1 (Poor) to 7 (High) Source: Baggs J, et al., “Association Between Nurse-Physician Collaboration and Patient Outcomes in Three Intensive Care Units,” Critical Care Medicine, 27 (1999): ; Nursing Executive Center analysis.

Annual Economic Burden of Communication Inefficiencies
Imperative: Interprofessional Collaboration Estimating the Costs InnInefficientollabortaionEstimating the Cost of Inefficient CoCollabommunication Inefficient collaboration and communication…. Annual Economic Burden of Communication Inefficiencies Average 500-Bed Hospital Cost of Wasted Physician Time $0.3 M $1.8 M $2.5 M Cost of Wasted Nurse Time Cost of Increased LOS $4.6M Total annual costs attributed to inefficient communication for average 500-bed hospital Source: Agarwal R, et al., “Quantifying the Economic Impact of Communication Inefficiencies in U.S. Hospitals,” Journal of Healthcare Management, 55 (2010): ; Nursing Executive Center analysis.

Renewed Emphasis on Interprofessional Education
Imperative: Interprofessional Collaboration Renewed Emphasis on Interprofessional Education 1972 Institute of Medicine Report “Educating for the Health Team” Factors Reinforcing the Need for Improved Interprofessional Collaboration Aging population with multiple chronic conditions Educating for the Health Team Institute of Medicine 1972 New payment models rewarding effective primary care and population management “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.” Impending health care workforce shortages Source: Institute of Medicine, “Educating for the Health Team,” National Academy of Sciences, October 1972, available at accessed November 12, 2012; Interprofessional Education Collaborative, “Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel,” 2011, available at accessed November 12, 2012; Nursing Executive Center interviews and analysis.

Is This All We Aspire to Do?
Imperative: The Patient Experience Is This All We Aspire to Do? Summary of Eight HCAHPS Domains Communication with nurses Communication about medicines Communication with doctors Discharge information Responsiveness of hospital staff Hospital environment (quiet, noise) Pain management Overall hospital rating Source: HCAHPS, available at: accessed November 11, 2011; Nursing Executive Center interviews and analysis.

Broadening Our Ambition
Imperative: The Patient Experience Broadening Our Ambition Patient Experience Ongoing Emotional Support Family Involvement and Care Team Integration Avoidable Disruptions Minimized Compassionate, Empathetic Caregivers Clear, Actionable Patient Education Up-to-Date and Thorough Information Physical and Emotional Needs Anticipated HCAHPS Communication Quiet at Night Information About Medications Discharge Information Cleanliness Responsiveness Pain Management Source: HCAHPS, available at: accessed November 11, 2011; Nursing Executive Center interviews and analysis.

Still Ample Room for Growth
Imperative: The Patient Experience Still Ample Room for Growth 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: accessed November 10, 2011.

Advancing Multiple Aims
Imperative: Patient Experience Advancing Multiple Aims Representative Studies About the Relationship Between Patient Experience and Outcomes 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 Journal of the American Board of Family Medicine Patient-Centered Care is Associated With Decreased Health Care Utilization 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: ; Bertakis K, et al., “Patient-Centered Care is Associated with Decreased Health Care Utilization,” Journal of the American Board of Family Medicine, 2011, 24: ; Nursing Executive Center interviews and analysis.

Growing Number of Metrics Linked to Reimbursement
Imperative: Accountability Growing Number of Metrics Linked to Reimbursement 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 Measures Acute 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 discharge Heart Failure Discharge instructions Evaluation of left ventricular systolic function Angiotensin converting enzyme inhibitor Pneumonia Blood culture performed in the ED prior to first antibiotic received Appropriate initial antibiotic selection Surgical 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 Measures Mortality Measures Acute Myocardial Infarction 30-day mortality rate Heart Failure 30-day mortality rate Pneumonia 30-day mortality rate Readmission 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 infection Hospital-Acquired Condition Measures Foreign object retained after surgery Air embolism Blood incompatibility Pressure ulcer stages III & IV Falls and trauma Vascular catheter-associated infection Manifestation of poor glycemic control Prevention: Global Immunization Measures Immunization for influenza Immunization for pneumonia Source: Centers for Medicare & Medicaid Services; Nursing Executive Center interviews and analysis.

Frontline Accountability Foundational to Success
Imperative: Accountability Frontline Accountability Foundational to Success Practice Strategy Hierarchy Peak Performance Frontline Accountability for Organizational Goals Critical thinking essential to addressing needs Protocol adherence clearly important… Innovation Standardization …Ownership of protocol/standard of practice outcomes supported by critical thinking essential Source: Nursing Executive Center interviews and analysis.

What Lies Ahead? Strategies for Nursing to Influence, Shape, Own, and Lead…..

Holistic Care Transformation …
An Opportunity to Design the Future Together Population Health Management Care Transitions Care Model

Transforming Healthcare Through Nursing

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