2018 moln fall leadership conference building trust ... · more rns need to understand and choose...

2018 MOLN Fall Leadership Conference Building Trust & Innovation in Nursing: Current Trends

and Resources to Inspire Change

Oct. 18-19

Nurses' Role in Transforming Our Health Care System Kelly Kruse Nelles RN, APRN‐BCMS; Mary Jo Borden RN, APRN‐BC, CCM Friday, Oct. 19 8:30 AM to 9:30 AM

Session Outcomes:

1. Describe the link between health systems policies and payment reform that impact nursing prac ce.

2. Discuss the rela onship between RN care management and improved health outcomes.

3. Explain the ra onale care coordina on/care management by RNs across all health care se ngs.

Presenters’ slides a ached.

National RN Case Manager Training Center Emerging Role for Registered Nurses in Our Changing Health Care System

Content may not be used without the written permission of the National RN Case Manager Training Center. 1

Emerging Roles for Nurses in Our Changing Health Care System

Mary Jo Borden RN, WHNP-BC, CCM, MSNKelly Kruse Nelles RN, WHNP-BC, MS

Minnesota Organization of Leaders in NursingOctober, 2018

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Fast Facts• The U.S. spends nearly twice as much as 10 high-income countries on medical care and performs less well

on most population health outcomes. (OECD, 2016) We spend about $3.2 trillion on health care annually. (CMS, 2018)

• 1st in obesity. 27th in Life Expectancy. 31st out of 40 in Infant Mortality and Premature Birth. (OECD, 2016)

• 37st in Health Coverage – about 81% of Americans are covered by private or government health insurance, placing the country ahead of only Turkey, Mexico and Chile.

• Our current health care delivery system has resulted in expensive, fragmented, inefficient and ineffective care.

• 10,000 a day turn 65. By 2030 the about 73 million of the US population will be over 65. Chronic illness and disease rates for the older population are increasing at an alarming rate.

• Average age of working RN is about 50 years old. Average age of nursing faculty member 58. Average Age of an RN entering practice is 30. Over 1/3 of U.S. physicians are over 55.

• Healthcare reform is intended to change the landscape of acute care, long term care and primary care -from a medical model to a holistic model of care.

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Every other developed nation starts at the base of the pyramid with primary care and works their way up until the money runs out

Acute

Care

Primary Care

Secondary Care

Acute Care

Secondary Care

Primary

Care

We started at the top of the pyramid, and work our way down …

…while prioritizing medical specialty care, pharmaceuticals and acute care.

The U.S.Every Other Nation

We have to flip the pyramid

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Health Delivery System Change

Triple Aim:

Better Population Health

Better Care Experiences

Slower Cost Growth

THE COMMONWEALTHFUND

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How Payment Reform Leads To Improved Performance

“Recent Progress In The Value Journey: Growth Of ACOs And Value-Based Payment Models In 2018”, Health Affairs Blog, August 14, 2018. DOI: 10.1377/hblog20180810.481968

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, 2017

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The health challenges of the 21st Century cannot be overcome

without strengthening nursing.

It's time to give nurses more recognition,

investment and influence.

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“… begins with the assumption that nursing

can fill new and expanded roles in a

redesigned health care system.” p. xi

“The report calls on nurses, individually and as a profession,

to embrace changes needed to promote health, prevent illness,

and care for all people in all settings across their lifespan.” p. ix

Institute of Medicine, Future of Nursing Report, 2011

The Future of Nursing Report

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The future for nurses requires a major change in acquired knowledge

• Effective communication with patients and other professionals.

• Leadership ability across settings

• Leadership ability in teams and organizations

• Emotional intelligence (so called ‘soft skills’).

• Resilience, flexibility and adaptability to change.

• Commitment to advanced education

• Mindset of continuous learning

• Technology proficiency

• Relationship building and collaboration

• Performance-driven business acumen –value, quality, outcomes

• Use of evidence that leads to quality outcomes.

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Major changes in the U.S. health care system and practice environment will require profound changes in the education of nurses both before and after they receive their licenses.

New Competencies at all levels of nursing education

• Systems thinking

• Quality improvement

• Care management

• Understanding of health policy and research

• Lifelong learning

• Demonstrated mastery of clinical skills and managerial competencies

• Inter-professional team training throughout career

Future of Nursing Report, IOM, p. 1-10, 2011

“Many members of the nursing profession lack the education and preparation necessary to adapt to new roles quickly in response to rapidly changing health care

settings and an evolving health care system.”

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In the area of primary preventive care

• 22% of patients said their PCP had recommended an increase in exercise.

• 90% of PCPs said they had done so.

• 19% of patients said they had been advised to improve their diet.

• 90% of doctors said they'd recommended that to patients.

• 14% of patients said they were generally reminded about preventive screenings.

• 89% of physicians said they provided those reminders.

• Only about 1/3 of obese patients said they were advised to exercise more and eat better.

Progress Remains Slow on Physician/Patient Care Coordination.(sponsored by Council of Accountable Physician Practices (CAPP). Medscape. Jun 23, 2016.

From 2015 to 2016 the % of patients who said their doctors had told them to exercise more, eat better, get preventive screenings, or enroll in a weight-loss program dropped by a few

percentage points in each category.

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Nursing’s Big Opportunity in this Era of Change

The focus of health care reform on disease prevention, chronic illness management and health promotion is a most promising redirection for nurses.

Diagnosis and treatment of disease can be standardized.

Prevention and health promotion are highly individualized.

They are related to predisposing biological factors, culture, beliefs, lifestyle, environment, health literacy and educational/change readiness.

Nurses are the health care experts with the professional history, philosophy and expertise to accomplish this shift from a medical model to a holistic healthcare system.

M.J. Borden

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Where is primary care headed?

• RN Case Management will be required and reimbursable in primary care and in most community based settings.

• Hospital based systems will shift to primary care as the foundational for all care.

• Home-based Primary Care with need to visit determined by the RN and the patient/family caregiver.

• RNs and APRNs presence and scope will continue to grow.

• Increasing reliance on health aides and Community Health Workers for care of diverse populations.

• RNs will routinely work with technology to identify patient population health needs, evaluate quality measures and to provide direct nursing care.

• RNs will be working with patients in groups to address similar health concerns.

• More RN Home visiting for patient care for non-medical, holistic patient care management.

• Nurse Managed Health Centers and FQHCs

More RNs need to understand and choose specialization in primary care if the goal of patient centered care and RNs working to their full potential is to succeed.

RNs in primary care practice autonomously to their full scope as important members of the inter-professional care team

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RN Primary Care Management includes the following:

• Generating a holistic nursing care plan in partnership with the patient.

• Providing compassionate, patient-centered care.

• Involving the whole care team in planning, carrying out, and following up patient visits.

• Planning patient visits that focus on health promotion, prevention and care coordination rather than medical management only (with both individuals and groups).

• Involving the patient in goal setting and intervention design.

• Providing customized education and skills training for individuals or groups, while using materials appropriate for different cultures and health literacy levels.

• Making referrals to community-based resources, such as programs that help patients quit smoking or follow an exercise plan.

• Following up with patients through office or home visits, email, phone, text messaging, or mailings to support them taking good care of themselves.

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Many areas where hospitals have focused a great deal of their efforts have a relatively small

impact on population/community health.

Socioeconomic factors and transitioning individuals to healthier behaviors hold the most promise for "achieving the potential of health

system transformation.“

What does this mean for health systems?

The most successful future health systems will function essentially as

“a private public health department” within the larger integrated organization.

Community-wide health impact pyramid

“The Real Reason American Healthcare Struggles, And What to Do About It”, Lindsey Dunn, March 2014, Becker Hospital Review

Increasing population

impact

Increasing individual effort

needed

Counseling and

education

Clinical interventions

Long lasting protective

interventions

Changing the context to make individuals default decisions healthy

Social and economic factors

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What will Hospitals of the Future Look like?

• Shift away from traditional inpatient facilities

• Hospital at Home Programs that monitor people 24/7 in their own homes

• Same-day surgery centers

• Free-standing emergency rooms

• Micro hospitals that offer as few as eight beds for overnight stays

• Involve community members in redesigning hospitals as public health plus acute

• Employed physicians and a priority shift to primary care services

• Digital technology to treat and keep tabs on patients remotely from a high-tech hub

Laura Landro, Feb. 25, 2018, The Wall Street Journal

David Feinberg, president and chief executive of Geisinger Health System

“We should be investing in people and processes, not hospitals”His goal: To put his own hospitals “out of business” by keeping patients

healthier and engaging patients in improving their own well-being.

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Emerging RN Care Manager Roles in Hospital Settings

Effective, case management must occur along the

entire acute care episode beginning with access to

care, through care management, and ending with

transition to primary care or discharge back to the

community.

This requires the expertise of nurse specialists.

CEOs and CNOs now recognize that traditional utilization review activities

are no longer adequate to new care management roles.

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Transform RN Care Management in a Hospital or In-patient Setting

• Leverage RN Care Manager skills to support patients with complex discharge needs.

• Increase the focus on appropriate use of inpatient and observation status to assure efficient progression of care and appropriate referral to Transitional Care.

• Expand CM services for Emergency Department and same day surgery patients.

• Provide care management coverage 7 days per week.

Ensure that all RNs understand their role in care coordination, and are encouraged and supported to practice to their full potential.

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Are Nurses Ready for Real Health Care Reform?

“If RNs are provided with strong clinical leadership, participate in developing an

achievable vision of the future, and if supported to take risks and innovate to improve

the quality and efficiency of care delivery, then the profession is likely to thrive rather

than struggle during the health reform years that lie ahead.

The quality and content of education and preparation of nurses will be increasingly vital for nursing to prosper in the future.”

Breuhaus, P., 2013, Executive Summary, Nursing Economics

http://www.medscape.com/viewarticle/778502?nlid=28323_785&src=wnl_edit_medp_nurs&uac=92362CJ&spon=24

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“My view is that the ultimate destination is nursing of the sick in their

own homes. I look to the abolition of all hospitals, but it is of no use

to talk about the year 2000.”

Florence Nightingale, 1867

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To Change Outcomes Requires Fundamental Practice Change.

Integrate changes intended to:

• Influence physician full participation as team members.

• Make better use of nurses and other team members.

• Provide enhancements to information systems.

• Support all health care professionals working to their full potential.

• Develop and implement all health system, financial reform and practice change from a patient centric perspective.

• Ensure nation wide coordination of systems and case management for high need patients.

• Educate the direct care workforce about new practice expectations.

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Reorganizing for Complexity

• It is becoming increasingly clear that today’s 20th Century organizational model is a major obstacle to meeting patients’ needs and supporting innovation.

• Service delivery is organized around clinicians with results defined by how often particular discrete services are delivered, NOT in terms of how well patients’ overall needs are met.

• Poor coordination, inefficiency, and ineffectiveness are making organizational change essential.

• Financial pressures are making the current fee-for-service model unsustainable, but the real driver of the need to reorganize care is not cost alone — it is value for patients.

What 21st Century Health Care Should Learn from 20th Century Business, September 5, 2018

Michael E. Porter, PhD, MBA & Thomas H. Lee, MD, MSc

Harvard Business School; International Consortium of Health Outcomes Measurement, Press Ganey Associates, Inc.

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Building a culture of innovation Clipper and Dawson, ANA, 2018.

To innovate is to put new ideas into practice or existing ideas into practice in new ways.

The five innovation competencies that all nurses should be proficient in include:

1. Creativity: Brainstorming is a catalyst for creative solutions

Innovative solutions are the product of divergent thinking and creative problem solving. Nurses can demonstrate divergent thinking by identifying problems and developing a broad set of solutions.

2. Spanning boundaries: Innovation happens when silos are broken down.

Teams, departments, or organizations find creative solutions when they look outside of their own walls and across a broad scope of stakeholders. Cross-functional, inter-professional teams attain a better-balanced outcome that represents a variety of areas, making solutions more likely to “stick.”

Bonnie Clipper is vice president of Nursing Practice and Innovation at ANA. Jaime Murphy Dawson is director of program operations in Nursing Practice and Innovation at ANA.

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3. Change management: Nurses should be able to support and guide change within their organizations.

The ability to embrace what’s new and different and help it develop “roots” is an important role for nurses, especially in such a dynamic environment. At the same time, organizations need to be agile and flexible to successfully adapt and even thrive when the unexpected happens.

4. Considered risk-taking: Creative problem-solving results in bold, often risky ideas.

Considered risk-taking is an intentional and thoughtful process where both benefits and potential problems are taken into account before an action is pursued. Requires a shift from current thinking in healthcare which is focused on minimizing risks.

5. Failure tolerance: Taking calculated risks means accepting that failure is a possibility and proceeding anyway.

Innovative organizations embrace frequent failure as a learning opportunity. Leaders who role model failure as an opportunity for growth, build trust. The work of innovation continues, and success becomes more likely.

Clipper & Dawson, ANA 2018

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Examples of Creative Implementation of new RN roles

Geisinger’s Proven Nurse Navigator Discovery

“The nurses, who used to coordinate care and provide advice through the telephone center under Geisinger’s health plan, suspected that they would be more effective if they could build relationships with patients and meet them at least a few times face to face.

• Accordingly, some highly experienced general-practice nurses moved from the call centers to primary care sites to meet with patients and their families.

• The nurses used a predictive model to identify who might need to go to the hospital and worked with patients and their families on creating a care plan.

• Later, when patients or families received a call from a nurse, they knew who that person was.

The program has worked so well that nurse coordinators are now being used in both Geisinger’s Medicare plan and its commercial plan.”

Future of Nursing Report P. 3-7

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Example: Hackensack Alliance Medicare ACO Nurse Care Coordination Program

Established to participate in the Medicare Shared Savings Program (MSSP) to reduce Medicare expenditures through a patient centered care model that focuses on providing

high quality services and medical care

• Required that its primary care practices be certified as Patient Centered Medical Homes.

• Worked with physicians to prepare them for what was required within a value-based care system

• Implemented a nurse care coordination program in larger practices for patients at high risk for readmissions from the beginning of the ACO contract including home visiting and telehealth remote patient monitoring

Results:• Improved outcomes across the board for patients with chronic conditions – patient

experience, readmission rates and healthcare associated infections• Significant shared savings: Year 1 - $5.6 million, Year 2 - $2.8 million

See more at: http://www.ajmc.com/journals/AJAC/2016/2016-vol4-n2/The-Ingredients-of-Success-in-a-Medicare-Accountable-Care-Organization#sthash.0E2rNjLz.dpuf Hackensack Alliance, NJ ACO, June 2016

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Example: Diversified Nurse Consultants

• Innovative Nurse-led Model founded in 2011 by 3 registered nurses to ensure that patients and families receive the safest and highest quality of care

• Began as contractual arrangement with several health insurers and hospital organizations to provide care coordination and case management services

• Now employs >90 RNs and provides comprehensive care management services with a commitment to helping adults with chronic conditions and disabilities “age in place”

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Diversified Nurse Consultants, cont.

• Nurse led RN/NP Quality Care Management Model that includes:

• Home visiting and assessment of chronic conditions with a nurse generated plan of care and on-going management support

• Caregiver support services:• Day Center in their own facility for dementia patients• home safety and driving assessments

• Telehealth services:• Remote patient monitoring of weights, BPs, Blood sugars, etc.• The use of adaptive monitoring to assess movement, sleep/wake, medication reminders, etc..• 24 hour care management and crisis support

• Community Health Worker program in which workers are trained and supervised by the RN staff

• On-going nurse workforce development:• Ongoing, onsite continuing education for staff RNs • Clinical residency for RN Case Managers focused on role development

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Consider for a moment….

• Nursing in a world of health care reform and accountable care is uncertain. This creates apprehension for some and uncertainty for all RNs.

• As health care reform transforms the environment, so will the role and staffing of nurses be transformed.

• There isn’t one right answer or agreed upon practice model for emerging nursing roles.

• This leaves nurses free to imagine roles and staffing possibilities for the future across practice settings.

• Including all RNs in conversations, visioning, and problem solving for the future will best prepare the profession for our role in caring for our patients.

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What needs to happen?

• As the health professionals closest to the public, nurses should be empowered to use their knowledge, skills and expertise to the full extent of their potential. They should be valued and respected for their pivotal role at the heart of most health teams.

• Nurses should be supported to drive health promotion, disease prevention and treatment, through leveraging new technology, greater patient participation and an increasing focus on community and primary care.

• Health decision-making needs nurses to be more involved. Despite the invaluable insights their unique position in the health system gives them, nurses role in policy development and planning is too small.

• Health leaders should work to develop new models of care that maximize nursing’s contributions to achieving Universal Health Coverage and other health goals.

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“Nurses must remodel the way we practice & make clinical [and ethical] decisions

• We must rethink the ways in which we learn how to care for people.

• We must rise to the challenge of providing leadership in rapidly changing care settings and in an evolving health care system.

• We must expand our vision of what it means to be a nursing professional.Future of Nursing Report, 2011

Future of Nursing Report, 2011, p. S

“ to be effective in re-conceptualized roles,

nurses must see POLICY as something they can shape

……rather than something that happens to them.”

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Nurses must unify to express this message:

“We are the sole health discipline that approaches health, disease, illness and chronic

care management with knowledge drawn from a model of holistic care.

We make decisions, provide and orient treatments, and take other critical actions

based on independent observations and team-based plans. We are the sole discipline

that hardwires the perspective of the patient/client within the context of family and

community, and care is coordinated and managed according to this context.”

Michael R. Bleich PhD, RN, FAAN

Future of Nursing Campaign for Action Meeting

Wisconsin Dells - June 5th, 2012

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The Next Five to Ten Years will be challenging…

…as we straddle current and future changes.

Maintain a vision of what could be, what should be,

and turn your ideas for improving care into reality!

Stay together and stay the course

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To learn more about our work and our programs at the National RN Case Manager Training Center,

visit our website:

www.nationalRNCM.com

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Contemporary RN Case Manager Training Center 2018

Citations and Sources

Peer Reviewed Journal articles

Diversity and education of the nursing workforce 2006-2016., Kovner CT, Djukic M, Jun J, Fletcher J, Fatehi FK, Brewer CS. Nurs Outlook. 2017 Sep 21. [Epub ahead of print]

Defining and measuring a culture of health. Health Affairs, Weil, A.R., (2016). 35(11), p 1947.

Ethical Nursing Care Versus Cost Containment: Considerations to Enhance RN Practice, Online Journal of Issues in Nursing (OJIN) January 31, 2018. Paula Kelly, MScN, BScN, RN and Caroline Porr, PhD, MN, RN

http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-23-2018/No1-Jan-2018/Ethical-Nursing-Cost-Containment.html?

Four challenges facing the nursing workforce in the United States, Buerhaus PI, Skinner LE, Auerbach DI, Staiger DO. J Nurs Regul. 2017;8:40-46

Increasing racial/ethnic diversity in nursing to reduce health disparities and achieve health equity., Phillips JM, Malone B.Public Health Rep. 2014;129 Suppl 2:45-50.

Multiple chronic conditions among US adults: a 2012 update, Ward BW, Schiller JS, Goodman RA. Prev Chronic Dis. 2014;11:E62.

Nurse Led Reform: Is It Time to Rethink the Nursing Unit?, Mark McClelland, DNP, RN, CPHQ. Online J Issues Nursing. 2017;22(2)

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Peer Reviewed Journal articles P.2

New England Journal of Medicine Catalyst Article Compilation, 2017. Redefining Healthcare – Improvement, Innovation and Value. www.catalyst.nejm.org

Registered Nurses as Professionals: Accountability for Education and Practice. ANA periodicals, OJIN, Sept,2016, 21 (3).. Barbara Zittel, PhD, RN, Edtrina Moss, MSN, RN-BC, NE-BC, Ann O’Sullivan, MSN, RN, NE-BC, CNE, ANEF, Terry Siek, MSN, RN, NEA-BChttp://www.nursingworld.org/mainmenucategories/anamarketplace/anaperiodicals/ojin/tableofcontents/vol-21-2016/no3-sept-2016/registered-nurses-as-professionals.html.aspx

Registered Nurses as Professionals, Advocates, Innovators, and Collaborative Leaders: Executive Summary. 2016 OJIN: The Online Journal of Issues in Nursing, Article published September 30, 2016, Tracy E. Williams DNP, RN, FNAP, Kathy Baker, PhD, RN, NE-BC, Leda Evans, BSN, RN, OCN, Michelle A. Lucatorto DNP, RN, FNP-C, Edtrina Moss, MSN, RN-BC, NE-BC, Ann O’Sullivan, MSN, RN, NE-BC, CNE, ANEF, Patricia C. Seifert, MSN, RN, CNOR, FAAN, Terry Siek, MSN, RN, NEA-BC, Timothy W. Thomas, BSN, RN, Barbara Zittel, PhD, RN, http://www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Vol-21-2016/No3-Sept-2016/Registered-Nurses-Executive-Summ.html

Rethinking the primary care workforce – An expanded role for nurses. (2016). New England Journal of Medicine. Bodenheimer, T. and Bauer, L. 375(11), 1015-1017.

Social Determinants of Health: The Role of Nursing. American Journal of Nursing. December 2017. Vol. 117, (12)

What the CCMC Role and Function Study Tells You about Changes in Case Management. Professional Case Management. Sminkey, P. V., (2015). 20(6). 138-139

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Expert Source (book, article, website)

American Academy of Nursing. Raise the Voice. http://www.aannet.org/initiatives/edge-runners Accessed January 9, 2018. American Nurses Association, www.nursingworld.org/care-coordination ANA Principles for Health System Transformation 2016, http://www.nursingworld.org/MainMenuCategories/Policy-

Advocacy/HealthSystemReform As Demand for Case Managers Rises, Educators Meet the Need. AHC media. (2016) Training is crucial to the case manager role.

https://www.ahcmedia.com/articles/139365-as-demand-for-case-managers-rises-educators-meet-the-need Center for the Advancement of Healthcare Professionals, AMN Healthcare. 2017 survey of registered nurses. Viewpoints on leadership,

nursing shortages, and their profession. AMN Healthcare. https://www.amnhealthcare.com/uploadedFiles/MainSite/Content/Campaigns/AMN%20Healthcare%202017%20RN%20Survey%20-%20Full%20Report.pdf Accessed January 9, 2018.

Center for Medicare and Medicaid Services (CMS) https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/ChronicCareManagement.pdf

Consumer Protections in New Medicare Payment and Delivery Models: A Checklist. Research Report 2017-09, November 2017. AARP, www.aarp.org/ppi

Future of Nursing: Leading Change, Advancing Health, Institute of Medicine (2010), www.nap.edu/catalog.php?record_id=12956 Progress Remains Slow on Physician/Patient Care Coordination. Medscape. Jun 23, 2016. Registered Nurses: Partners in Transforming Primary Care. Josiah Macy Jr Foundation, June 2016 Preparing Registered Nurses for

Enhanced Roles in Primary Care Conference Recommendations. pdf Strategies for Hiring and Training Care Managers in Integrated Programs Serving Medicare-Medicaid Beneficiaries, Center for Healthcare

Strategies, Inc. (2015), www.chcs.org The Patient Protection and Affordable Care Act of 2010, www.unitedhealthgroup.com/hrm/Health-Care-Law.pdf The Tri-Council for Nursing, AACN, ANA, AONE, NLN. The Essential Role of the Registered Nurse and Integration of Community Health

Workers into Community-based Team Care. January 2017, pdf

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