Supporting nurses' education might be key to solving the staffing crisis.
Recruitment and retention are particularly difficult right now in healthcare, especially in nursing.
Health systems are struggling to find new nurses who will stay at their hospitals permanently. Many veteran nurses are retiring and taking their knowledge and experience with them. This combined with the overall shortage of staff leaves new nurses feeling overworked and without the guidance and mentorship of their predecessors.
Here's what you need to know about building academic partnerships to improve recruitment and retention, according to Maribeth McLaughlin, VP and CNE at UPMC.
This leader outlines the dissatisfaction of nurses across the industry.
On this week’s episode of HL Shorts, we hear from Katie Boston-Leary, Director of Nursing Programs at the American Nurses Association, about the factors leading to nurse dissatisfaction and the increase in union and strike activity across the country.
What are the underlying causes of the recent union and strike activity happening in the U.S?
There's a generalized dissatisfaction of the current state of [nursing] from nurses. There are a number of things that nurses that have historically [and] traditionally struggled with, and I think that the phenomenon that's happening right now is nurses are really saying “no more.” There was dissatisfaction, but it was a dull roar, and now a lot of what's bubbling is manifesting in a lot of this organized activity. That is a big concern for a lot of administrators and hospital executives, but in some respects, nurses are using this as a last resort. [Some are having a] “tried everything and this is where we are” kind of approach to this, and then there's some that are saying, “you know, maybe this is the way for us to have a voice, so getting unionized is probably the way to go.”
There is a lot under the surface that's causing this, starting with the staffing and the crisis that we're in. Then you have the well-being piece where [the] nurses’ overall health and well-being is compromised because of everything that's happening, and we have data that actually links those two, staffing and well-being, together for nurses. Then there's everything else after that, that's a close second, third and 4th and 5th. There's workplace violence, there's unmanageable workloads, there's [the] hierarchical structure of healthcare systems. There's the feeling of not being heard, the feeling of exhaustion and not being able to do what you figure patients deserve, and leaving everyday feeling that moral distress. All those things have brought us to this point, unfortunately.
With version 2.0 now supporting FHIR-based exchange, Mariann Yeager of the Sequoia Project says the final draft of standards for nationwide interoperability should be unveiled by the end of March.
Healthcare organizations with a vested interest in interoperability should be taking a close look at version 2.0 of the Trusted Exchange Framework and Common Agreement (TEFCA), which now supports FHIR-based exchange.
The government-supported effort to create nationwide interoperability standards has been more than two years in the making, coming out of the 21st Century Cures Act. This past December, five healthcare organizations were the first to be certified as Qualified Health Information Networks (QHINs), giving them the standing to support data exchange.
Yeager says the biggest take-away from version 2.0 is federal recognition of FHIR (Fast Healthcare Interoperability Resources), the HL7 standard that defines how healthcare information can be moved between disparate platforms.
“The most important thing for people to understand is that version 2.0 was revised to support FHIR-based exchange,” she told HealthLeaders. “There are new use cases to support healthcare operations and public health. The other thing is it does permit health systems that participate in TEFCA-based exchange to connect to multiple QHINS, to the extent that they support multiple data sources.”
Yeager also said she expects more conversation around health systems that appoint another entity to exchange healthcare data.
Writing in the HealthITbuzz blog earlier this month, Chris Muir and Alan Swenson of the Health and Human Services Department’s Office of the National Coordinator for Health IT (ONC) said the unveiling of five QHINs and the release of TEFCA version 2.0 “continue the momentum” toward a nationwide interoperability platform this year.
“In the short-term, ONC and the TEFCA RCE anticipate ‘facilitated FHIR’ exchange beginning to be implemented as part of TEFCA exchange as early as the first quarter of calendar year 2024 connected to the release of Common Agreement Version 2,” they said. “As in Version 1, Version 2 of the Roadmap describes facilitated FHIR exchange in which Qualified Health Information Networks (QHINs) provide the network infrastructure to support FHIR API-based exchange between TEFCA Participants and Subparticipants from different QHINs.”
“Specifically, if a TEFCA Participant or Subparticipant wants to obtain a patient’s data using FHIR, they will go to their QHINs to determine who has the patient information,” Muir and Swenson continued. “Patient discovery will take place through the QHIN-to-QHIN interaction, including discovery of the FHIR endpoints for those that have the patient data. The initiating Participant or Subparticipant will then directly (i.e., without going through the QHIN) and securely query each of those endpoints.”
Yeager says she’s excited to see data exchange scaled up to a national level.
“There are different ways in which FHIR is being used,” she said, noting that TEFA had support content exchange and is now embracing native FHIR. “We’re talking about … facilitating FHIR-based exchange with each other. What that enables is nationwide scale. This is an unprecedented opportunity in the US to support FHIR-based exchange at such scale.”
The five QHINs, MedAllies, the eHealth Exchange, Epic Nexus, Health Gorilla, and the KONZA National Network, have been exchanging data since TEFCA officially went live in December. Yeager says “several others” are going through the process to become designated QHINs and other healthcare organizations are preparing to take that route as well.
“They really see FHIR as an important functionality,” she said of the first QHINS.
Aside from gathering information through the public comment period, Yeager says the Sequoia Project will be scheduling public information webinars as well as targeted feedback sessions over the next several weeks to prepare the final version.
Muri and Swenson of the ONC said there are more goals ahead.
“Looking forward, the updated Roadmap describes two more phases of FHIR implementation beyond facilitated FHIR exchange,” they wrote in the blog. “The next phase, QHIN-to-QHIN FHIR Exchange, [will] enable QHINs to leverage FHIR-based exchange for exchange between QHINs while continuing to support non-FHIR approaches within the QHINs’ internal networks.”
“The last phase, End-to-End exchange, would permit a Participant/Subparticipant to seamlessly exchange FHIR data between themselves and other network members through the QHINs and multiple other intermediaries both within a QHINs’ network and through the TEFCA-governed network,” they added.
Yeager expects interoperability to be an ever-evolving process.
“TEFCA is really going to be evolutionary,” she said. “We will definitely be learning as we go, learning and adjusting. … You learn by putting things into practice.”
Recruitment and retention are particularly difficult right now in healthcare, especially in nursing.
Health systems are struggling to find new nurses who will stay at their hospitals permanently. Many veteran nurses are retiring and taking their knowledge and experience with them. This combined with the overall shortage of staff leaves new nurses feeling overworked and without the guidance and mentorship of their predecessors.
Maribeth McLaughlin, vice president and chief nurse executive at UPMC, says the COVID-19 pandemic also contributed to this issue.
“During the pandemic, if you think about back in the beginning in 2020,” McLaughlin says, “for many of us, our pipelines with the schools of nursing, our academic partners…really kind of fell apart.”
Students moved to remote settings, relationships were strained, and curriculums changed, she says. And it affected academic partnerships all across the healthcare industry.
Establishing partnerships
A crucial first step for CNOs dealing with this issue is to reestablish academic partnerships with nursing schools to help create clear pathways into the industry for students who are working to become nurses.
McLaughlin says UPMC partners with about 140 different schools, and a senior nurse leader runs point with each of those relationships. UPMC also created an academic affairs office, with oversight from a CNO, that helps with finding placements for students, building relationships, and partnering on new and innovative programs.
Additionally, health systems can take certain measures to support their own employees going back to school.
McLaughlin says UPMC expanded the diploma at its schools of nursing, and partnered with other universities so their students can become nurses and continue to work towards bachelor’s degrees. UPMC also has a tuition reimbursement program, in which many of the participating students are UPMC employees who are in entry level positions and want to become nurses.
“There are an overwhelming number of people who want to still become nurses,” McLaughlin says. “The challenge is helping them, not just with tuition, [but also with] going back to school, and with trying to work and go to nursing school.”
CNOs should focus on pipelines and targeted recruitment, and ensure that there are good student experiences in the health system. McLaughlin says UPMC created student ambassadors in all of the units across all the hospitals, as well as the student nurse internship program. Both programs allow students to get clinical experience before they graduate, making them better candidates for recruitment.
The education of future nurses can go far beyond university and collegiate experience as well.
“[We have started] to think about how to get into the middle schools and high schools,” McLaughlin says. “Not just for nursing, but for all of our patient care roles in a hospital, to be able to really grow our professions for the future.”
Support from outside agencies can also make these pipelines possible. For instance, the Vanderbilt School of Nursing was recently granted funds from the Health Resources and Services Administration’s (HRSA) Bureau of Health Workforce to help build the new Nurse Education, Practice, Quality, and Retention Simulation Education Training Program. The $1.5 million grant is intended to help expand offerings for students, faculty, and other health professionals and to provide them with more learning and career-building opportunities.
The grant is funded by the Department of Health and Human Services and is part of the HRSA’s Nurse Education, Practice, Quality and Retention (NEPQR) grant program. The goal behind the grant program, according to the HRSA, is to forge a pathway for students to enter the clinical environment by creating and implementing Licensed Practical Nurse (LPN) or Licensed Vocational Nurse (LVN) to Registered Nurse (RN) bridge programs, and the employment of clinical nurse faculty. The funds can be used for program development, direct LPN/LVN to RN student support, curriculum and partnership development, and for recruiting faculty and clinical preceptors.
Support after recruitment
How can CNOs build upon this progress?
Creating the pipelines is only half the battle. CNOs must provide support for incoming nurses and make sure they feel valued and have opportunities for advancement in their careers.
“Rotating shifts is not easy,” McLaughlin says. “Being a nurse in a hospital, you’re going to work off shifts, you’re going to work weekends, [and] you’re going to work holidays.”
The support needs to go beyond just the clinical.
McLaughlin says UPMC is restructuring the onboarding and education processes to be more supportive at the bedside, and to consider what nurses need in a residency beyond the support that is typically provided. New nurses need help learning how to rotate shifts and how to take care of themselves throughout their shifts. They should be given advice on how to sleep in different patterns, eat properly, wear the right shoes and clothing, look at their schedules, and know how many shifts they should be working.
“We have a wellbeing committee of frontline staff and we’ve been working with our own health plan to develop a tool kit,” McLaughlin says. “That’s where we’re now very focused, trying to support those nurses.”
There are other kinds of support as well that must be made available to new nurses. Nurses need to have the right teaching skills and know how to deescalate situations, delegate, work in teams, and process what they are going through on an emotional level, McLaughlin states.
She says UPMC created “condition support,” which is a resource that nurses can use to get help with deescalating situations.
“Those are all things that are really important for all our staff,” McLauglin says, “so that we can help them as they transition to the workforce, [and] learn the skills they need. …We’re trying to give them as many of those tools and support as we can.”
CNOs should focus on academic partners and making sure student experiences are positive, and then focus on first year turnover. McLaughin recommends checking in with employees and asking more targeted questions to find out how they are doing.
“Try to create mechanisms for identifying people who are beginning to be at risk or are struggling [with] anything from the work to emotions or situations,” McLaughlin says. “And then [look] at scheduling, and [look] at the ability to be as flexible as you possibly can be, so that people feel like they have that work-life harmony.”
A new law allows Garden State health systems to expand their Hospital at Home programs to include Medicaid patients and those on private insurance
Health systems in New Jersey are now able to expand their Hospital at Home programs to patients in Medicaid and private insurance, thanks to a new state law.
The Hospital at Home Act, which was passed by the state Legislature and signed by Governor Phil Murphy in September 2023 and enacted into law on January 23, establishes a state Hospital at Home permitting process through the New Jersey Department of Health that is consistent with the Centers for Medicare & Medicaid Services’ Acute Hospital Care at Home Program.
Executives at Virtua Health, which launched its Hospital at Home program two years ago and now offers services through five of its hospitals in the southern part of the state, hailed the new law. Aside from introducing patients in the state’s NJ Family Care and Medicaid programs to the service, the law enables the health system to work with private payers to cover the program.
“We are excited to see Hospital at Home expand in New Jersey through this legislation, and we believe our state can serve as a template for the rest of the country,” Michael Capriotti, MBA, senior vice president of integration and strategic operations for Virtua Health, told the Gloucester City News earlier this week. “It is important that we continually innovate to create the best possible experiences and outcomes for our patients.”
More than 300 health systems and hospitals across the country are following the guidelines set by the CMS program, which includes a waiver, put in place during the pandemic in 2020, that allows the healthcare organization to qualify for Medicare reimbursement. That waiver is due to expire at the end of this year, and supporters are lobbying both Congress and CMS to make that waiver permanent.
The program targets patients who would otherwise be admitted to the hospital, creating a home-based care management plan that includes often-multiple daily visits by care teams, virtual care services and remote patient monitoring. Some programs have added ancillary services to address social determinants of health, imaging and tests, and pharmacy and rehab needs.
New Jersey is one of the first state to establish specific state guidelines for the program.
According to Virtua Health, the health system has enrolled more than 900 patients, representing more than 60 different medical conditions, in the program.
According to a recent national study of the program by researchers at Mass General Brigham—one of the first health systems to launch the program—the Hospital at Home concept has reduced the mortality rate for patient who would otherwise be hospitalized; it has also reduced the escalation rate (returning to the hospital for at least 24 hours) and rehospitalization rate within 30 days of discharge.
“Home hospital care appears quite safe and of high quality from decades of research — you live longer, get readmitted less often, and have fewer adverse events.” David Levine, MD, MPH, MA, clinical director for research and development for Mass General Brigham’s Healthcare at Home, said in a press release. “If people had the opportunity to give this to their mom, their dad, their brother, their sister, they should.”
Here’s how CNOs should be preparing for nursing strikes, according to this CNO.
Nurses have been going on strike all throughout the United States.
The recent union activity is indicative of large, widespread problems in the nursing industry with staffing, work environment, and nurse wellbeing. While it is the CNO’s responsibility to address those issues and to facilitate those conversations, it can be quite difficult.
To learn how CNOs should handle these situations, we sat down with Dr. Chaudron Carter, Executive Vice President and Chief Nurse Executive at Temple Health, to hear how her health system avoided a strike, and how to build a plan for continuing operations during a strike.
Federally qualified health centers (FQHCs) are using telehealth and digital health tools to improve access and erase care siloes for millions of underserved Americans
Federally Qualified Health Centers (FQHCs) are often the first point of contact for underserved populations seeking access to care. And often that first impression can make all the difference in accessing care that improves outcomes.
At Kenosha Community Health Center, that first contact is now handled by a nurse who can quickly and efficiently funnel the patient to the right care provider.
“We’re seeing a higher volume of patients with more complex needs, so it’s important that we make this as efficient as possible,” says Mary Ouimet, the Wisconsin-based health center’s CEO. “When you have more than 450 calls a day, that can be a bottleneck.”
Kenosha, part of the Pillar Health network, is one of several FQHCs to collaborate with Conduit Health Partners on nurse triage services. And that’s part of an even larger trend of FQHCs, rural health centers (RHCs), and assorted community health clinics outsourcing some services and using telehealth and digital health technology to alleviate those bottlenecks that keep patients from accessing the care they need.
There are an estimated 1,400 FQHCs and more than 4,400 RHCs in the US, according to the Health and Human Services Department’s Health Resources and Services Administration (HRSA), which supervises funding for those providers. They, along with look-alike (LAL) organizations, provide care and resources for more than 30 million Americans, many of whom can’t afford or access care at a hospital, health systems, or primary care provider.
With the Centers for Medicare & Medicaid Services (CMS) loosening the purse strings on Medicare and Medicaid coverage, these providers are embracing new technologies to improve access to care and resources. At Kenosha, that means instituting a digital nurse triage service that channels the right patients to the right care.
“This is an essential function of the health center,” says Ouimet, who estimates that 100-150 incoming calls a day are now connected to Conduit Health nurses. “These are nurses at the other end who can work with [patients] to coordinate care. The average call time is reduced, and we’re improving time to treatment and bed scheduling. It’s just better care.”
In Massachusetts, meanwhile, an organization serving the commonwealth’s 52 community health centers covering more than 300 sites and 1 million patients is using HRSA grant funding to maintain a technology platform that keeps track of when and where patients receive care. The platform, developed by Bamboo Health, sends real-time notifications to care teams when a patient visits another care provider outside the system, enabling the care team to access admission, discharge and transfer data.
Susan Adams, vice president of health informatics for the Massachusetts League of Community Health Centers, says the technology gives care teams instant digital access to information that would otherwise be siloed away, creating gaps in care that could affect outcomes. She said those care teams had to ask for paper printouts of those visits, then manually enter the data into the patient’s medical record.
“We could be at the printer all day long,” she says.
Thirteen of the Mass League’s CHCs were originally put on Bamboo Health’s platform to monitor some 400,000 patients. According to the organizations, those CHCs saw a 47% reduction in 30-day readmissions among ED patients, a 20% reduction in 30-day readmission among hospitalized patients, and a 33% increase in follow-ups within 30 days of discharge.
The Mass League is now expanding that platform to more CHCs.
“We aren’t getting all the data we need to manage these patients,” Adams says, noting care teams sometimes never learn that a patient has been hospitalized or visited an ED somewhere else unless it comes up in conversation with the patient. The more data we can put into [the patient record] the better chance we have of providing care.”
Having a complete patient record, she says, also helps with chronic care management and strategies to address social determinants of health (SDOH), key care programs that CHCs, FQHCs and other health clinics are being asked to take on.
“I think the challenge will come with managing all of these alerts,” Adams says. “But that’s a good challenge. This gives us a chance to address more care [management and] coordination goals. It’s something that we’ve been waiting a long time to do.”
The collaboration is one of several between health systems and Big Tech to develop and scale AI programs
A partnership between the Cleveland Clinic and IBM is applying AI to cancer care, with the goal of creating better and more effective treatments.
In a study recently published in Briefings in Bioinformatics, the research team reported that it was able to use both supervised and unsupervised AI technology to better understand the molecular details of peptide antigens, the first step in using them to attack cancer cells or cells infected with viruses. Researchers can use this data to tailor vaccines and engineered immune cells.
“In the past, all our data on cancer antigen targets came from trial and error,” Timothy Chan, MD, PhD, chair of Cleveland Clinic’s Center for Immunotherapy and Precision Immuno-Oncology and Sheikha Fatima Bint Mubarak Endowed Chair in Immunotherapy and Precision Immuno-Oncology, said in a press release. “Partnering with IBM allows us to push the boundaries of artificial intelligence and health sciences research to change the way we develop and evaluate targets for cancer therapy.”
The research proves the value of using AI to gather and analyze data faster and more accurately. According to the Cleveland Clinic team, antigen peptides interact with immune cells based on specific features on the surface of those cells.
“Research has been limited by the sheer number of variables that affect how immune systems recognize these targets,” Cleveland Clinic executives said in the press release. “Identifying these variables is difficult and time intensive with regular computing, so current models are limited and at times inaccurate.”
Using supervised and unsupervised algorithms “can highlight subtle but key determinants of peptide immunogenicity within the [atomistic molecular dynamics] trajectory data and can … provide significantly more predictive power over a baseline sequence architecture on peptide datasets,” the research team said in the study.
“These insights highlight how MD can help predict and foster understanding of immunogenicity, and the methods developed here lay a framework for broad HLA [ human leukocyte antigen] allele studies to further elucidate mechanisms of immune responses and inform T cell therapies,” they concluded.
The project was borne out of Discovery Accelerator, a collaboration launched in 2021 to match Cleveland Clinic’s biomedical research capabilities with IBM’s AI and quantum computing technology. It’s one of several partnerships forged between health systems and Big Tech to expand access to AI tools for research as well as administrative and clinical services.
The goal is to provide better patient care, say CNOs and CNIOs in the know.
With nursing tech disruption at a fever pitch, savvy CNOs and CNIOs are putting their heads together to ensure their investments make real impact. And there’s one place in particular where they’re setting their sights: virtual nursing.
Here's what CNOs should keep in mind when developing and integrating virtual nursing into their programs.
Health systems and hospitals are facing competition from disruptors offering personalized urgent and emergency care. But is that a bad thing?
A new disruptor is taking aim at the healthcare industry’s busiest site: The Emergency Department.
Concierge care programs designed specifically for urgent and emergency care are finding support from consumers who don’t want to wait several hours in an ED, along with primary care providers who don’t want to send their patients there. The service offers a cash-only alternative to the ED and could pull more patients away from hospitals and health systems.
“The experience [of an ED] is so challenging,” says Brad Olson, CEO of Sollis Health, which operates 11 clinics in New York City and the nearby Hamptons, as well as California and South Florida, and serves some 18,000 members. “What makes us different is we’re offering [patients] immediacy.”
Launched in 2016 in New York as Priority Private Care, Sollis is building a business model through partnerships with consumers, primary care providers, and businesses who want to avoid the traffic and time spent in an ED, which sees more than 130 million visits a year. The company offers a concierge care model that bypasses payers, and also offers a range of services that include diagnostics, labs and vaccines, virtual care, specialty care, even house calls.
The model adds another wrinkle to the crowded urgent care market, where hospitals and health systems are already competing with retail and stand-alone urgent care clinics that not only pull patients out of the ED, but offer additional resources and connections that pull a patient further outside the health system’s orbit of care.
Olson is quick to point out that Sollis Health is a disruptor, but not necessarily a competitor to health systems and hospitals—he notes the company has partnerships in place with more than 30 health systems for everything from ED services to specialty consults. He notes one clinic is located not far from Cedars-Sinai in Los Angeles and is partnering with the hospital even while giving consumers an alternative to Cedars-Sinai’s ED.
The ’disruptor’ moniker is important. Olson, a former executive with Peloton and Starwood Hotels & Resorts, brings a retail mentality to healthcare that is propelling companies like Amazon, Walmart, and Walgreens in the healthcare space. He notes that consumers are turning away from hospitals and health systems because of the complexity and cost of healthcare, and they certainly don’t want to wait several hours in a crowded hospital waiting room for fragmented care that leads to more scheduled visits in other locations.
Disruptors like Sollis Health and other concierge care companies are luring consumers away from traditional healthcare organizations with the promise of convenient, personalized care. And Olson says Sollis equips its clinics with ER-trained and boarded clinicians, many of whom also work at nearby health systems. Sollis also offers a range of services that stand-alone and retail urgent care clinics do not.
In the basic business model, Sollis Health partners with primary care providers and businesses who will refer their patients/employees to Sollis for urgent care, with those patients paying out of pocket for services. In some cases a PCP or business will purchase memberships for their patients or employees, figuring the cost of a membership will be much lower than costs associated with going to a hospital or urgent care clinic.
Olson says Sollis Health reaches out to health systems and hospitals to suggest partnerships, particularly in specialty care services, and those organizations haven’t sought out Sollis Health to help with crowded EDs. But the opportunity is there for healthcare executives to see disruptors like Sollis Health as a valuable resource, giving patients another option to access care.
“We definitely don’t compete with them,” he says.
Olson emphasizes that Sollis Health’s growth is in the consumer market, and in building out its concierge care to attract more primary care providers and businesses looking for alternatives to the ED or retail urgent care space. He says payers have expressed interest in this model of care, though the company currently isn’t working with any insurance companies and is focused on membership and cash-only payment plans.
“Our biggest challenge right now is explaining who we are and what we do,” he says. But once that connection is made, the value becomes evident.
