5 Transforming Healthcare Through Nursing Implications for Practice and Education2015
6 Our New Market Reality Care Delivery Transformation Implications for Nursing Practice and Education
7 ” What Business Are We In? Businesses Displaced by Focusing on the Means Rather than the EndsTimeline for Eastman Kodak Business”Providing Health, Not Health Care1990sDigital 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.”197690% market share of commercial film business2012Kodak files for bankruptcyStudy 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 imagesDraws parallels to the challenges that provider organizations face in shifting activities from delivering health services to a broader spectrum of tactics for healthSource: 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.
8 Traditional Hospital Cross-Subsidy 8Our Existing Business ModelStaying Afloat Through Cross-SubsidizationTraditional Hospital Cross-SubsidyBelow CostAbove CostCommercial InsurancePublic PayersAbove-cost pricingRobust fee-for-service volume growthSteady price growthOnly one component of our total business149%86%Hospital Payment-to-Cost Ratio, Private Payer, 2012Hospital Payment-to-Cost Ratio, Medicare, 2012Source: American Hospital Association, “Trendwatch Chartbook 2014,” available at: Health Care Advisory Board interviews and analysis.
9 Payer Cross-Subsidy Eroding 9Payer Cross-Subsidy ErodingProjected Discharges by Payer, 2021Annualized Commercial Price Growth6-7%CommercialMedicareInpatient Contribution IncomeWeighted Per-Case AverageMedicaidSource: American Hospital Association Chartbook, available at: http:accessed on April 29, 2011; Advisory Board Company interviews and analysis.
10 $260B $56B $151B Public-Payer Reimbursement Still in the Crosshairs 10Public-Payer Reimbursement Still in the CrosshairsMedicare Payment Cuts Becoming the NormACA’s Medicare Fee-for-Service Payment CutsNot the End of the StoryReductions 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$151BHospital payment rate cuts,Reduced Medicare and Medicaid DSH2 payments,Reduced Medicare payments due to sequestration and 2013 budget billOffice of the Actuary, CMSIncludes 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.
11 Coverage Expansion and the Rise of Individualized Insurance 11ACA (and Recovery) Making a Dent in UninsuranceBut Every Silver Lining Has Its CloudPercentage of U.S. Adults Without Health Insurance2013 Q32014 Q318.0%Insurance exchanges launchMedicaid expansion beginsEmployer-sponsored coverage grows13.4%(highest on record)(lowest on record)A Bargain Still Unbalanced$5.7B$14BReduction in uncompensated care, 2014vs.ACA-related reductions in Medicare fee-for-service payment, 2014Source: 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.
12 9.6M 6.7% 2.4% Medicaid Expansion Contentious—and Consequential 1228 States + DC Have Opted for ExpansionState Participation in Medicaid ExpansionFinancial ImpactAs 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”PricewaterhouseCoopersExpansion by WaiverNot Currently ParticipatingParticipating9.6M6.7%2.4%Increase in Medicaid, CHIP1 enrollment, July-Sept OctAverage Medicaid enrollment increase across non-expansion statesAdvisory Board estimate of impact of Medicaid expansion on typical hospital’s 10-year operating margin projectionChildren’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.
13 Another Year, Another Lawsuit 13Another Year, Another LawsuitChallenge to Subsidies Making Its Way Through the CourtsThe Question:Potential ImpactDoes the language of the ACA allow subsidies in states that do not set up their own exchanges?UnsubsidizedSupreme Court Stepping InSubsidized on Federally-Run ExchangesHalbig v. BurwellD.C. Circuit panel strikes down subsidies on federal exchangesSubsidized on State-Run ExchangesKing v. BurwellFourth Circuit rules subsidies legal on Virginia’s federally-run exchangeOver half of all enrollees collecting potentially unallowable subsidiesSupreme Court agreed to hear King v. Burwell in November 2014; final ruling expected by June 2015
14 6% Increasing Competition for Medicare Dollars No More A’s for Effort 14Increasing Competition for Medicare DollarsNo More A’s for EffortMedicare Value-Based Purchasing Program Performance CriteriaOther Mandatory Risk ProgramsWeight in Total Performance ScoreHospital-Acquired Condition PenaltiesClinical ProcessPatient ExperienceReadmission PenaltiesOutcomes of CareNo Trivial ThingEfficiencyMedicare revenue at risk from mandatory pay-for-performance programs1, FY 20176%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.
15 Many Facilities Receiving Multiple Penalties Few Escaping Penalties Altogether, Almost Half Facing Two or MoreHospitals Receiving FY 2015 P4P Penalties1ReadmissionsPenalty1,071 (32%)NoPenalties423 (13%)48%Hospitals receiving multiple P4P penalties961 (29%)288 (9%)318 (9%)VBPPenalty152 (5%)HACPenalty112 (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.
16 Overview of Risk-Based Payment Models Key AttributesBundledPaymentsShared Savings Programs(ACOs)CapitationDefinitionPurchaser 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 savedNetwork 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 capitationProvider receives a flat per-member, per-month payment for providing all necessary care for a defined populationPurposeIncent multiple types of providers to coordinate care, reduce expenses associated with care episodesReward providers for reducing total cost of care for patients through prevention, disease management, coordinationCenter for Medicare and Medicaid Innovation.Source: Health Care Advisory Board interviews and analysis.
17 The Market Force Course 17The Market Force Course12 Tools for Translating Market Forces into Frontline TermsSample Toolkit ResourcesNurse Manager “Cheat sheets”Plug-and-Play VideosReady-to-Use PostersCustomizable PresentationsInteractive ExercisesOne-page primers on market forces impacting organizational strategyShort, easy-to- digest videos for frontline staff on current market forcesVisuals that distill complex concepts into concrete actions for frontline staffPowerPoint slides and scripting for leaders to brief staff on tough messagesGames for frontline staff and managers aimed at conveying budget constraintsTo access The Market Force Course, visit advisory.com/nec/publications.Source: Nursing Executive Center, The Market Force Course, 2014.
18 Operational Economics on the Brink of Failure Margin Improvement Analysis ResultsFive-Year Margin ProjectionsTen-Year Margin Projections0-5% Decline5-10% Decline5-10% Decline0-5% DeclineGreater than 10% DeclineImprovementGreater than 10% DeclineImprovementHCAB Service in Brief: The Margin Improvement IntensiveCombines 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 performanceAvailable to all Health Care Advisory Board members at no extra costVisit to participateSource: Health Care Advisory Board interviews and analysis.
19 Care Delivery Transformation Our New Market RealityCare Delivery TransformationImplications for Nursing Practice and Education
20 How Much Avoidable Cost Is There in Health Care? $75Source: Institute of Medicine, “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America”, 2012; Nursing Executive Center analysis.
21 A Clear Mandate for Meaningful Change? Select Studies Analyzing Opportunities for Reducing Health Care CostsEstimated Magnitude of Avoidable Cost OpportunitiesAreas of OpportunityAvoidable CostsUnnecessary Care$210 BAdministrative Inefficiencies$190 BInefficiently Delivered Services$130 BMissed Prevention Opportunities$55 BFraud and Abuse$75 BHigh Prices$105 B30Cents of every health care dollar an unnecessary expenseSource: 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).
22 4.4M 18% Huge Opportunity for Improvement 22Huge Opportunity for ImprovementPercentage of ED Visits that are Avoidable in the US1Estimated number of preventable trips to US hospitals each year4.4M18%30-day all-cause readmission rate2Based 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.
23 Unnecessarily Crowded Many Medical Admissions PreventableAmbulatory-Sensitive1Inpatient 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.”SurgicalMedicalCFOMedicare Revenue per CasePercent of Medicare discharges considered sensitive to better ambulatory care17%Inpatient admissions associated with Agency for Healthcare Research and Quality (AHRQ) Preventable Quality Indicator conditions.Source: MedPAR FY2009; Nursing Executive Center interviews and analysis.
24 Toward an Economics of Value Adapting to New Rules of CompetitionHealth System Strategy, c. 2003“Extractive Growth”Health System Strategy,“Value-Based Growth”Grow by being bigger: Leverage market dominance to secure prime pricing, network statusGrow by being better: Leverage cost, quality, service advantage to attract key decision makersDischargesService line shareFee-for-service revenuePricing growthOccupancy rateProcess qualityShare of livesGeographic reachRisk-based revenueShare of walletOutcomes qualityTotal cost of careInpatient capacityOutpatient imaging centersClinical technologyAmbulatory surgery centersPrimary care capacityCare management staff and systemsIT analyticsPost-acute care networkDescriptionPerformance MetricsCritical InfrastructureSource: Advisory Board interviews and analysis.
25 Disaggregating Health Care Reform FinancingCoverage ExpansionDelivery System ReformSource: Nursing Executive Center analysis.
26 Economics Aligning with Mission Evolving Market DemandBuilding Long-Term Patient Relationships for Ongoing, Coordinated CareManaging Chronic Care for High-Risk PatientsImproving Overall Health and Wellness of the PopulationCentering Hospital Care on the PatientSource: Nursing Executive Center interviews and analysis.
27 Establishing the Medical Perimeter The New RealityEstablishing the Medical PerimeterExtensive Ambulatory Care Network Addresses Medical DemandMedical Management InvestmentsPatient ActivationPost-Acute AlignmentMedical Home InfrastructureDisease Management ProgramsPrimary Care AccessPopulation Health AnalyticsElectronic Medical RecordsHealth Information ExchangesSource: Nursing Executive Center interviews and analysis.How do you see yourself? Is this exciting or depressing?
28 If We Were Building from Scratch… Governing Principles of the Transformed Care EnterprisePersonalized ManagementAccessible Primary CareCare management appropriately matched to individual patient, population needOriented toward patient-centered goals that will drive clinical metric improvementTeam available to patient for access, education, decision supportAccessible when, where patient needs careAligned Across the ContinuumOutcomes-Driven SystemMultidisciplinary team works together to maintain unified care plan across patient needsData transparency, sharing to ensure streamlined patient careDashboard aligned to key cost, quality goals for improving population healthInformation available across the continuum to track utilizationSource: Nursing Executive Center interviews and analysis.
29 Retail consumer behavior at the point of… Key Factor Driving The Change Today:The Rise of The Retail Triple-Threat29Unleashing 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 decisionsPurchaseHigh deductibles and narrow networks make us price sensitive with a high demand for valueSpendLifestyleIntegrationHealth 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
30 7.0M (Original CBO Projection) 30One Year In, Insurance Exchanges Generally on TrackAggregate Numbers in Line With Expectations; Enrollee Mix OlderInitial Public Exchange Enrollment191%7.0M (Original CBO Projection)Of enrollees still enrolled as of September 201425MProjected exchange enrollment by 201828%Enrollees aged 18-34Numbers 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.
31 Early Year Two Enrollment Outpacing First Round 31Fewer Glitches, Greater Awareness Driving Increased EnrollmentA Solid Start for Both Federal, State ExchangesFirst Round EnrollmentSecond Round EnrollmentFederal Exchange106KEnrollment during first month462KEnrollment during first weekMaryland Exchange16KEnrollment during first two months16KEnrollment during first weekColorado Exchange204Enrollment during first week6KEnrollment during first weekCalifornia Exchange11KEnrollment during first fifteen days11KEnrollment during first four daysSource: 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.
32 Individuals Gravitating Toward Leaner Plans 32Individuals Gravitating Toward Leaner PlansPeople Choosing Cheaper Premiums and Higher DeductiblesLevel 1: Choice of Metal TierLevel 2: Plan Choice Within Metal TierAll Metal Levels1GoldPlatinumCatastrophicLowest-Cost PlanAny Other PlanBronzeSilverSecond-Lowest-Cost PlanFactors Influencing Metal LevelPremium Levers Beyond Benefit DesignDeductibleNon-Essential Services CoveredScope of Non-Essential BenefitsCopaysNetwork CompositionNegotiated Payment Rates to ProvidersOut-of-Pocket MaximumNegotiated RatesUtilization Patterns, TrendsData 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.
33 $2,500 $6,250 High Deductibles Accelerating Consumerism 33High Deductibles Accelerating ConsumerismAggressive Cost Sharing Troublesome for Provider StrategyIndividual Deductibles Offered On Public ExchangesChallenges for Providers2014High out-of-pocket costs discourage appropriate utilization$2,500$6,250MedianMaximumIndividual Deductibles Chosen on eHealth Individual MarketplaceLarge patient obligations lead to more bad debt, charity care<$1,000$6,000+$1,000-$2,999Price-sensitive patients more likely to seek lower- cost options$3,000-$5,999Source: 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.
34 Convenience Consistently a Top Consumer Priority Convenience Outranking Service and CostTop Preferences for On-Demand CareHow 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 homeIncreasing Consumer PreferenceAccess, Convenienceing provider with symptoms6 OF TOP 10 FEATURES RELATED TO ACCESS, CONVENIENCECostClinic located near errandsServiceClinic location near workSource: 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 dataThis results in about 11 percent of Americans seeing and using provider quality information. - See more at: doctors.aspx#sthash.3IpXBtxm.dpuf68 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
35 Price Sensitivity at the Point of Care 35Price Sensitivity at the Point of CareCost-Conscious Behavior Affecting Pillars of ProfitabilityConsumers Paying More Out-of-PocketMRI Price Variation Across Washington, DCFall within HDHP deductible2$2,183$730Fall within PPO deductible3$411$900$1,269Price-sensitive shoppers will be acutely aware of price variationMRI prices range from $400 to $2,183High-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.
36 Meet Our New Competitors Retail ClinicsMeet Our New CompetitorsWalgreens Aims to Become the Premier Health Destination2013: Launches three ACOs; begins diagnosing and managing chronic disease2009: Launches flu vaccine campaignSimple Acute ServicesVaccinations and PhysicalsChronic Disease MonitoringChronic Disease Diagnosis and Management2007: Acquires Take Care Health Systems2012: Offers three new chronic disease testsCase in Brief: Walgreen Co.”Not Just a DrugstoreLargest drug retail chain in the United States, with 372 Take Care ClinicsIn 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. OverviewSource: 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.
37 Walmart Care Clinic Model 37Walmart Enters Full Primary CareSaving Money—For Its Associates and CustomersWalmart Care Clinic ModelWalmart associate or customer visits Care ClinicCare Clinic staffed by two NPs from QuadMed, an employer onsite clinic providerNP provides primary care services, refers to external specialists and hospitalsThe Largest “Activated Employer” YetVisit 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$40Labeed DiabPresident of Health and Wellness, Wal-MartSource: Canales MW, “Wal-Mart Opening Clinic in Cove,” Killeen Daily Herald, April 18, 2014, Health Care Advisory Board interviews and analysis.
38 Retail Clinics Expected to Continue Growing Estimated Total Number of Retail Clinics in the USGrowth trajectory depends on preferred payer relations, PCP capacity, and health system partnershipsRetailerOperational Retail Clinics1900+400+1351475+As of OctSource: 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.
39 Differentiating Effective Population Health Managing Three Distinct Patient PopulationsHigh Risk PatientsRising-Risk PatientsLow-Risk PatientsTrade high-cost services for low-cost management5% of patients; usually with complex disease(s), comorbiditiesAvoid unnecessary higher-acuity, higher-cost spending15-35% of patients; may have conditions not under controlKeep patient healthy, loyal to the system60-80% of patients; any minor conditions are easily managedSource: Health Care Advisory Board interviews and analysis.
40 Chronic Disease Growth Outpacing Population Population Growth Projected Increase in Chronic Disease Cases19%: Projected population growth,Source: Milken Institute, available at: pdf/chronic_disease_report.pdf, accessed April 27, 2011; Nursing Executive Center interviews and analysis.
41 Plenty of Room for Improvement in Managing Care Difference Between “Loosely-Managed” and “Well-Managed” PMPM1 Spending2011MedicaidCommercialMedicare$100.48$131.84$449.79Loosely ManagedWell ManagedLoosely ManagedWell ManagedLoosely ManagedWell ManagedSource: Milliman; Nursing Executive Center interviews and analysis.
42 Building a System that Never Discharges the Patient 42Building a System that Never Discharges the PatientEvolution of Patient Care PerspectivePerfecting Individual TransitionsAchieving Care ContinuityAcute CareSNFEDHomePCPRetail ClinicRehabHome HealthSource: Nursing Executive Center interviews and analysis.
43 43Finding the 80/20Key Root Causes of Patients Receiving Fragmented, Episodic CarePatients receive fragmented, episodic careClinicians not equipped to provide continuous careClinicians only feel accountable for their immediate settingPatients and families don’t manage their care effectivelyClinicians don’t have necessary patient informationClinicians have a siloed, setting- specific perspectivePatients lack motivationPatients don’t know howClinicians don’t know howClinicians’ incentives focus on site-specific carePatients face economic roadblocksClinicians don’t have timeTo access Achieving Top-of-License Nursing Practice, visit advisory.com/nec/publications.Source: Nursing Executive Center interviews and analysis.
44 Investing in Nursing with Good Reason Patient Complexity IncreasingMounting Evidence Linking Nursing to Patient OutcomesAverage Medicare Case Mix1Representative Studies on the Impact of Nurse StaffingPrimary AuthorTop-Level FindingsNeedleman et al., 2002An 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 patientsAiken et al., 2003An 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 rescueKane et al., 2007A review of the literature finds consistent associations between increased RN staffing and lower odds of hospital-related mortality and adverse patient eventsMcHugh et al., 2013Hospitals with higher nurse staffing had 25% lower odds of incurring Medicare readmissions penalties than similar hospitals with lower nurse staffingSource: 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.
45 An Alarming Dichotomy Health System Economics Care Team Economics Expenses per Adjusted AdmissionPercentage of Hospital Costs2 Comprising Wages and Benefits$10,5332012$6,98020012011Affordable Care Act’s Medicare Fee-for-Service Payment Cuts1Total RN Compensation per Hour WorkedReductions 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.
46 Population Health Efforts Shaping Volume Outlook Utilization Patterns Difficult to PredictInpatient Volume Under Different Population Health AssumptionsQuite a Difference7.6%Total inpatient volume growth, , with no additional population health management effort1.1%Total inpatient volume growth, , with aggressive population health management effortsSource: Health Care Advisory Board interviews and analysis.
47 Designing the Care Team for Accountable Care Two Dimensions of Care Team DesignEfficient, Siloed Care TeamNurses practice to the full extent of their training and skills but within professional siloEfficient, Interprofessional Care TeamInterprofessional care team collaborates efficiently and effectively, providing high-quality, low-cost careNursing Team EfficiencyInefficient, Siloed Care TeamNurses do not practice to the full extent of their training and skills; caregivers work in professional silosInefficient, Interprofessional Care TeamNurses and other caregivers collaborate to provide care, but nurses do not practice at top of licenseInterprofessional Team IntegrationSource: Nursing Executive Center interviews and analysis.
48 A Unique Moment in Time to Build a Different Kind of Care Team Age Distribution of Practicing Registered Nurses in the USOpportunities to Redefine the Care Team2008Fill vacant positions with a different skill setInstill a new care team philosophy in new hiresUse attrition (rather than cuts) to eliminate positions~1,000,000Number of RNs reaching retirement age in the next yearsSource: 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.
49 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 Education1Failure to RescuePatient Mortality90.4Percentage 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.
50 Three Paths for Building the High-Value Care Team Root Cause of InefficiencyOverreliance on Bedside RNsUncoordinated Interprofessional CareA “One-Size-Fits-All” Care Team123Path to Higher ValueChange the Nursing Skill MixAlign Interprofessional Goals and WorkDeploy the Minimum Core Team and Selectively Scale Up SupportAchieve Top-of-License Nursing PracticeRight-Size the Proportion of RNs in the Skill MixTrade a Nursing Position for an Expert RN Role to Improve Unit PerformanceGive All Care Team Members the Same Set of GoalsTransfer Work to Specialized Team MembersGather Physicians and Staff at the Bedside at the Same TimeKeep Teams as Consistent as PossibleSelect Your Patient Population of FocusIdentify Patients Needing Additional SupportDefine the Core and Expanded Care TeamsLayer Additional Support onto the Core TeamRegularly Reassess Patient Need for SupportSource: Nursing Executive Center interviews and analysis.
51 Implications For Nursing Practice and Education Our New Market RealityCare Delivery TransformationImplications For Nursing Practice and Education
52 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 MedicineSource: Institute of Medicine, “The Future of Nursing: Leading Change, Advancing Health,” available at: accessed November 11, 2011; Nursing Executive Center analysis.
53 Then and Now…. Single-needs patient an endangered species Mr. Jones; 1975Mr. Jones; 2015AMIAMI, HF, diabetes, obesePCPPCP, cardiologist, endocrinologist, hospitalist, geriatric NP2 meds15 medsLives at homeLives in assisted livingWife is caregiverMultiple family members, no one designatedLOS: 10 daysLOS: 2.5 daysOne admission in 1973Third admission in 2013
54 Imperatives for Nursing and Nursing Practice Top of License PracticeInter-Professional CollaborationNon-valued added work eliminatedCore responsibilities clearProfessional practice model as foundationCare team as core in all settingsRoles clearly defined, supported, aligned with patient needsEnhancing the Patient ExperienceFrontline AccountabilityBeyond satisfactionProcesses and systems patient-’centered’Patient as partnerValue-based careActivity ‘completion’ not enoughOwnership of outcomes the key
55 Endorsing “Top-of-License” Nursing Practice Imperative: Top of License PracticeEndorsing “Top-of-License” Nursing PracticeThe 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, PhDSource: Institute of Medicine, “The Future of Nursing: Leading Change, Advancing Health,” available at 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): ; Nursing Executive Center analysis.
56 Defining “Top-of-License” Practice by Patient Needs Imperative: Top of License PracticeDefining “Top-of-License” Practice by Patient NeedsEstablishing Consensus on Core ResponsibilitiesCore Nursing Responsibilities Across SettingsAssess Clinical and Psychosocial Patient Needs1Manage Key Components of the Clinical Record5Establish Patient Goals and Track Progress2Coordinate Care with Interprofessional Caregivers6Provide Patient-Centered, Outcomes-Focused Care3Facilitate Safe Patient Transitions to the Next Care Setting7Educate and Engage Patients and Their Families4Assess and Incorporate New Technologies and Evidence-Based Practice8Source: Nursing Executive Center interviews and analysis.
57 An All-Too-Common Reality Imperative: Top of License PracticeAn All-Too-Common RealityReal Nurses’ Stories from the Front LinePrimary Care OfficeEmergency DepartmentInpatientSkilled Nursing FacilityHome Health10 minutes looking for patient’s suicide risk in the EMRHunted down catheter because no one else available and care time-sensitiveWheeled patient to radiology so wouldn’t miss scheduled ultrasoundCalled hospital charge nurse to decipher hand- written discharge instructionsDrove 20 miles to agency office to document care in the electronic recordPhysician kept referring to the medical assistants as “nurses”Stuck waiting for physician’s order to administer pain medication20 minutes cleaning up large spill to prevent an avoidable fallTransported resident to dining room and stayed for the entire meal to assist him with feedingMade four calls to physician to have patient’s medication adjustedSource: Nursing Executive Center interviews and analysis.
58 Opportunity Lies in Underleveraged Hours Imperative: Top of License PracticeOpportunity Lies in Underleveraged HoursCurrent Distribution of Med/Surg Nursing Time1$756,724RN 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, RNOsei Omoike, MS, MBA, RNSusan Ohlson, MSA, RNCBased 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.
59 Impeding Effective Patient Care Imperative: Interprofessional CollaborationImpeding Effective Patient CareStaff Often Feeling Unsupported by Interprofessional ColleaguesStaff 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.
60 Poor Collaboration Leading to Poor Patient Outcomes Imperative: Interprofessional CollaborationPoor Collaboration Leading to Poor Patient OutcomesAssociation Between Nurse-Physician Collaboration and Negative Patient Outcomes in the ICUThe lower the nurse-physician collaboration score, the higher the risk of a negative patient outcomeMedical ICUSurgical ICUMed/Surg ICUNegative Outcome to Predicted Mortality UnitCollaboration 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.
61 Annual Economic Burden of Communication Inefficiencies Imperative: Interprofessional CollaborationEstimating the Costs InnInefficientollabortaionEstimating the Cost of Inefficient CoCollabommunicationInefficient collaboration and communication….Annual Economic Burden of Communication InefficienciesAverage 500-Bed HospitalCost of Wasted Physician Time$0.3 M$1.8 M$2.5 MCost of Wasted Nurse TimeCost of Increased LOS$4.6MTotal annual costs attributed to inefficient communication for average 500-bed hospitalSource: 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.
62 Renewed Emphasis on Interprofessional Education Imperative: Interprofessional CollaborationRenewed Emphasis on Interprofessional Education1972 Institute of Medicine Report “Educating for the Health Team”Factors Reinforcing the Need for Improved Interprofessional CollaborationAging population with multiple chronic conditionsEducating for the Health TeamInstitute of Medicine1972New 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 shortagesSource: 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.
63 Is This All We Aspire to Do? Imperative: The Patient ExperienceIs This All We Aspire to Do?Summary of Eight HCAHPS DomainsCommunication with nursesCommunication about medicinesCommunication with doctorsDischarge informationResponsiveness of hospital staffHospital environment (quiet, noise)Pain managementOverall hospital ratingSource: HCAHPS, available at: accessed November 11, 2011; Nursing Executive Center interviews and analysis.
64 Broadening Our Ambition Imperative: The Patient ExperienceBroadening Our AmbitionPatient ExperienceOngoing Emotional SupportFamily Involvement and Care Team IntegrationAvoidable Disruptions MinimizedCompassionate, Empathetic CaregiversClear, Actionable Patient EducationUp-to-Date and Thorough InformationPhysical and Emotional Needs AnticipatedHCAHPSCommunicationQuiet at NightInformation About MedicationsDischarge InformationCleanlinessResponsivenessPain ManagementSource: HCAHPS, available at: accessed November 11, 2011; Nursing Executive Center interviews and analysis.
65 Still Ample Room for Growth Imperative: The Patient ExperienceStill Ample Room for GrowthPercentage of Physicians and Patients Agreeing With the Following Statements About Compassionate Caren=800 patients, 510 physiciansSource: 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.
66 Advancing Multiple Aims Imperative: Patient ExperienceAdvancing Multiple AimsRepresentative Studies About the Relationship Between Patient Experience and OutcomesAmerican Journal of Managed CareRelationship Between Patient Satisfaction With Inpatient Care and Hospital Readmission Within 30 DaysCirculation: Cardiovascular Quality and OutcomesPatient Satisfaction and Its Relationship With Clinical Quality and Inpatient Mortality in Acute Myocardial InfarctionJournal of the American Board of Family MedicinePatient-Centered Care is Associated With Decreased Health Care UtilizationSource: 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.
67 Growing Number of Metrics Linked to Reimbursement Imperative: AccountabilityGrowing Number of Metrics Linked to ReimbursementHCAHPS Survey MeasuresDuring 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 InfarctionAspirin prescribed at dischargeFibrinolytic agent received within 30 minutes of hospital arrivalTime of receipt of primary percutaneous coronary interventionStatin prescribed at dischargeHeart FailureDischarge instructionsEvaluation of left ventricular systolic functionAngiotensin converting enzyme inhibitorPneumoniaBlood culture performed in the ED prior to first antibiotic receivedAppropriate initial antibiotic selectionSurgical Care Improvement ProjectProphylactic antibiotic received within 1 hour prior to surgical incisionProphylactic antibiotic selection for surgical patientsProphylactic antibiotic discontinued within 24 hours after surgery end timeCardiac surgery patients with controlled 6AM postoperative serum glucosePostoperative urinary catheter remoaval on post operative day 1 or 2Surgery patients on a Beta Blocker prior to arrival who received a Beta Blocker during the perioperative periodSurgery patients with recommended VTE prophylaxis orderedSurgery patients who received appropriate VTE prophylaxis within 24 hours pre/post surgeryPatient Safety and Quality MeasuresMortality MeasuresAcute Myocardial Infarction 30-day mortality rateHeart Failure 30-day mortality ratePneumonia 30-day mortality rateReadmission MeasuresAcute Myocardial Infarction 30-day risk standardized readmission measureHeart Failure 30-day risk standardized readmission measurePneumonia 30-day risk standardized readmission measureHealthcare-Associated InfectionsCentral line associated bloodstream infectionSurgical site infectionCatheter-associated urinary tract infectionHospital-Acquired Condition MeasuresForeign object retained after surgeryAir embolismBlood incompatibilityPressure ulcer stages III & IVFalls and traumaVascular catheter-associated infectionManifestation of poor glycemic controlPrevention: Global Immunization MeasuresImmunization for influenzaImmunization for pneumoniaSource: Centers for Medicare & Medicaid Services; Nursing Executive Center interviews and analysis.
68 Frontline Accountability Foundational to Success Imperative: AccountabilityFrontline Accountability Foundational to SuccessPractice Strategy HierarchyPeak PerformanceFrontline Accountability for Organizational GoalsCritical thinking essential to addressing needsProtocol adherence clearly important…InnovationStandardization…Ownership of protocol/standard of practice outcomes supported by critical thinking essentialSource: Nursing Executive Center interviews and analysis.
69 What Lies Ahead?Strategies for Nursing to Influence, Shape, Own, and Lead…..
70 Holistic Care Transformation … An Opportunity to Design the Future TogetherPopulation Health ManagementCare TransitionsCare Model