Environmental factors largely determine the health of a community. A nurse and advocate for population health says nurses are the healthcare providers best-suited to affect positive change.
Food insecurity, neighborhood violence, homelessness, unemployment, and underemployment are not abstract ideas.
To many they are everyday realities.
These burdens are specific, and too-familiar examples of what the World Health Organization has as defined as social determinants of health: The "conditions in which people are born, grow, work, live, and age" as well as political and economic systems that affect day-to-day life.
SDH are also specific, actionable problems that can be solved or alleviated.
Increasingly healthcare providers are coming to understand their role.
"Social determinants are things that are not biomedical, but more psychological or social," says Ellen Olshansky, RN, PhD, chair of the School of Social Work Department of Nursing at the University of Southern California.
"Social context, behavioral [context], and economics [are parts] of it. It's what's in the environment in which we live that affects our health," she says.
Social determinants strongly influence population health, which is a key component of the Affordable Care Act. The Centers for Disease Control and Prevention says they account for 75% of population health while genes, biology, and health behaviors like smoking and drug use comprise the rest.
Because of nursing's history delving into SDH—think of Lillian Wald providing care for the poor and sick in New York's Lower East Side in the early 1900s—Olshansky see nurses as natural leaders in addressing social determinants and their effects on population health.
"Social determinants have been part of nursing for a long time, as opposed to in medicine. That's why I think nursing can really take a strong leadership role," she says.
Which is why, when it launches this fall, USC's new online family nurse practitioner program will make SDH a key component in its curriculum.
"We (nurses) come from a perspective of valuing the social determinants of health," Olshansky says. "What is missing is that the typical curriculum for nursing, while it includes social determinants, needs to include them more."
Improve SDH, Improve Costs
Olshansky, who earned a degree in social work before she became a nurse, is passionate about SDH because health is a social justice issue for her. She also understands that tackling SDH can affect another important piece of healthcare delivery—costs.
"Ultimately, what we're all trying to do in the work we do in healthcare is to improve the health of populations," she says.
"We also want to cut costs. From the business person's perspective it may not be obvious to look at what we're talking about—improving the neighborhood. That may not look like a direct link between saving money. It may look like we have to put money into it. If you look over time and if we can do things to optimize health and prevent illness, in the long run we're going to save money."
Olshansky says SDH also affect the acute care realm.
"When someone's in the ICU, we don't think about [SDH]. We just think about 'Do they have to be intubated?' Those are the priorities and of course," she says.
"But these are still people who have lives and who knows what their social context is?
When they're discharged where are they going and what are they going to do? We need to bring this consciousness about it to all aspects of healthcare."
Olshansky hopes that one day, the importance of social determinants of health are fully understood in the healthcare system.
Ideally, "We would give in our system of health and human services equal weight to the social determinants and the biomedical," she says. "We should look at them as integrated with one another."
Physicians may balk at full-practice authority for APRNs, but medical doctors have more in common with Clinical Nurse Specialists than they realize.
When it comes to advanced practice nurses, what's old is news again.
In May, the Department of Veterans Affairs proposed amending its medical regulations to permit full practice authority of all VA advanced practice registered nurses when they are acting within the scope of their VA employment.
And in keeping with recent history, the American Medical Association, the American Association of Anesthesiologists, and the American College of Radiology are against the proposal.
The AMA asserts that "all patients deserve access to physician expertise, whether for primary care, chronic health management, anesthesia, or pain medicine," and "physician-led team-based care results in improved access to high-quality, cost-effective health care."
The ACR's position is that allowing the VA's APRNs to "practice independently of a physician's clinical oversight, regardless of individual state law, could seriously undermine the quality of care that our nation's heroes receive."
The ASA calls the VA's proposed policy change "untested and ill-advised for the Veterans population."
What these statements overlook is that APRNs are not trying to take over physicians' roles.
APRNs, and in particular, clinical nurse specialists, share some of the same goals as physicians, says Sharon Horner, RN, PhD, FAAN, president of the National Association of Clinical Nurse Specialists.
"They [physicians] have their own lens or blinders on, too, with how they approach certain things," she told me in March, soon after she assumed the role as the organization's 2016-2017 president.
"And yet, if you're talking about improving care, they're right on board with you. Just give them the evidence and tell them what you're about."
What the role of the CNS is about, says Horner, is providing safe, high-quality, cost-effective care, that improves both the health of populations and patient outcomes.
The NACNS, she says, sees the CNS role functioning within three spheres of influence in order to achieve these goals.
1.The Patient
This sphere encompasses things that improve patient outcomes and patient care and can take place in multiple settings, Horner says.
"The CNS really shines in this complex chronic illness management and self-management. They're doing management of [the problems] and they're helping the patients learn to be good self-managers of really complex health problems," she says.
Rather than being strictly hospital unit-based as CNSs often were in the past, Horner now sees them focusing on patient populations.
"Patients are going to be seen more and more in the community and so these specialists are helping with the transition so that you don't drop people. It's this huge continuity of care piece that's so important," she says.
2.The Nurse and Nursing Practice
The CNS works with other healthcare staff, including physicians, to educate them on organizational processes and policies, disease processes, and evidence-care practices.
"They bring staff people up to speed, correcting anything that needs to be corrected, enhancing what they know," Horner says.
"It's the staff development piece that fits into what's going on in the whole system so that we improve what we're doing at as a group."
3.The Health System
The CNS looks at policies and procedures and makes corrections to avoid any deficiencies in the delivery system. To help prevent medication errors, a CNS would play the role of detective, assessing a system for areas that could contribute to an error.
The CNS proactively makes adjustments and institutes safety measures to avert the occurrence of any errors. "You go through the steps for catching and correcting [the problem] before it's a real error," Horner says.
The director of the Nurses on Boards Coalition urges nurse leaders to elevate their presence on corporate, health-related, and other boards and offers tips on how to get there.
"Until there's a nurse serving on every board where it makes strategic sense to do so, our work is not done," says Laurie Benson, BSN.
She'd like to get to a point "where very naturally nurses are sought out to serve on boards and policy-setting and strategy-setting bodies because of the valuable perspective they provide."
Benson has been executive director of the Nurses on Boards Coalition for two short months, but her decades of experience as a corporate executive, founder, CEO, C-suite advisor, and multi-sector board member have left her well-versed on issues such as board governance, innovation, strategy, and high-performance teams.
Her experience and knowledge align with the NOBC's mission to build healthier communities across the nation by increasing nurses' presence on corporate, health-related, and other boards, panels and commissions with a goal of at least 10,000 nurses on boards by 2020.
More than 2,000 nurses who are on boards have registered with the NOBC's database. Benson encourages all nurses who are already working on boards to register with the coalition so they can be counted towards the 10,000-nurse goal.
Benson has some practical advice for nurses who aspire to serving in board positions:
1.Find an organization you're interested in.
Nurses need not limit their participation to boards that are obviously health-related. A local food pantry could benefit from the input of a nurse on its board because of the role it plays in community health, Benson says.
"There's an element of health in almost everything," she points out.
2.Know your strengths.
"Have a talk with yourself about how can you contribute," Benson advises.
Then create a one-page bio and supporting resume that will show a nominating committee how you stand out from the rest of the candidates and how you'll be able to contribute to their mission.
"Make it easy for them to see how your light can shine in their environment," she says.
3.Express your interest.
Benson encourages nurses to pick an organization that has a mission they feel passionate about and to connect with the organization's executive director or chairman of the board.
"Tell people you want to serve on a board because they're not going to assume that," she says.
"On some of the non-profit boards I've served on over the years, they need more board candidates, and there's no waiting list… so get your name on the list."
4.Don't let your calendar talk you out of getting involved.
Benson acknowledges that different boards will take different amounts of time commitments, but in general, she says board work does not take an overwhelming amount of time.
"Remember that boards are strategic," she points out. Many boards meet for about four to five times a year for a few hours. "You're not doing the work every day."
"But don't opt out of being considered because you wonder about your ability to have the time," she says.
"Nurses manage much more in their schedules that is more difficult than finding the time to serve on a board. And the rewards are so meaningful."
The NOBC grew out of an Institute of Medicine's (now the National Academy of Medicine) 2010 report which calls for nurses to play larger decision making roles on boards in order to improve the health of all Americans.
Nurses can cope with challenging situations better if they've developed the ability to sustain or restore their integrity in the midst of moral complexity. But they can't do it alone.
Those within the nursing profession are well-aware of the presence of moral distress among nurses.
The reality of healthcare is that the difficult situations that challenge nurses' ethical and moral integrity are part of the job and they are not going away.
"The idea of moral resilience is pointing to this capacity, that I think we all have in varying degrees, to sustain or restore our integrity in the midst of moral complexity, confusion, moral distress, or setbacks that we experience when we really feel like we can't do the right thing," says Cynda H. Rushton, PhD, RN, FAAN.
She is the Anne and George L. Bunting Professor of Clinical Ethics in the Berman Institute of Bioethics and the School of Nursing at Johns Hopkins University.
Don't discount those gut feelings you may have about something, Rushton advises. "Our bodies have a lot of wisdom," she says.
"If you think about what happens in your gut, 'You know it in your gut.' The body is a great sort resource to help us detect there's something here that's challenging or threatening my integrity."
Notice your emotions
Rushton says nurses should identify what emotions occur when they're in a challenging situation. "There's a whole range of emotions. They can be anger and frustration or people could be depressed and totally shut-down in response to these type of situations," she says.
Identify your assumptions and biases
Jumping to conclusions—for example, saying, "I've been here before," or "I know how this ends,"—can limit creative solutions to a problem.
"Immediately, there's a set of assumptions about the people involved and the context of the situation that can lead us down a path where it obscures other possibilities of what might happen in that situation," Rushton explains.
These techniques all contribute to what Rushton calls self-regulation.
"The importance of regulating our nervous system is so we can recognize what's happening. We can pause and reflect and think clearly," she says. "We can't do that if our nervous system has gone bonkers."
Supportive Practice Environments Required
Nurses can't be expected to develop moral resilience without organizational support, says Rushton.
"Being morally resilient individually requires individual capacities, and it requires an ethical practice environment," she says.
Chief nursing officers can support an ethical practice environment by ensuring that decisions are being made and priorities are being set, that reflect the organization's values.
Also, the organization should have mechanisms in place to make it possible for others to speak up about practices that are challenging their sense of integrity without fear of retaliation.
"Another piece of this culture would be to have accountability norms to prevent or remediate instances of reprisal, disrespect, or dismissal of ethical concerns," Rushton says.
"This links to the whole idea of disruptive behavior and creating a culture of civility where everybody's viewpoint is respected and honored. And when it's communicated, it's received in a way that allows people to feel heard and that their concerns are taken seriously."
The bottom line when it comes to developing a culture of ethical practice, Rushton says, is that preserving or restoring integrity is vital for the sustainability of the nursing workforce.
"It is really an urgent issue for us to address as a profession and as a healthcare community because our healthcare system is unsustainable without a healthy nursing workforce," she says.
"I think this has got to be a priority and something that we're all willing to invest in to try to find some really effective solutions at both the individual and the system level."
For more on moral resilience and ethical practice environments, joinCynda H. Rushton, PhD, RN, FAAN, the Anne and George L. Bunting Professor of Clinical Ethics in the Berman Institute of Bioethics and the School of Nursing at Johns Hopkins University for the HealthLeaders Media webcast, "Creating a Culture of Ethical Practice to Foster Moral Resilience" on June 9 from 1:00 to 2:00pm ET.
Nurse practitioners can improve outcomes, lower healthcare costs, and expand patient access to care. But only if their practice environments let them.
It's not news that the US is facing a shortage of primary care physicians.
According to estimates by the U.S. Department of Health and Human Service's Health Resources and Services Administration, by 2020 the nation will by facing a shortage of 20,400 primary care physicians.
The good news is that the organizationpredicts this gap in primary care could potentially be filled by nurse practitioners and physician's assistants.
The number of primary care NPs is expected to increase by 30% (from 55,400 in 2010 to 72,100 in 2020) and the primary care PAs is projected to increase by 58% (from 27,700 in 2010 to 43,900 in 2020).
Annual Number of Graduates from NP Programs: Master's and Post-Master's Graduates, 2002 Through 2012
As Cindy Cooke, DNP, FNP-C, FAANP, president of the American Association of Nurse Practitioners points out there's more to solving the primary care provider shortage equation than simply balancing less with more.
Scope of practice and licensing issues also need to be addressed. The AANP (source of map below) tracks practice environments.
"Alabama is a collaborative state and I actually worked for the military, so it's a federal property where I can practice to the full scope of my education and training. But as soon as I drive outside of those states, I'm not smart-enough, apparently, to do it again," Cooke says.
"To me it's a terrible waste of people. We have the expertise and let's utilize it. The patients are suffering. Access to care is huge."
Cooke believes there are three major reasons that healthcare leaders should support full practice environments for NPs.
1. NPs Can Improve Patient Outcomes
As an example of how NP's can impact patient outcomes, Cooke points to the results Judith Kutzleb, RN, DNP, CCRN, CCA, APN-C, vice president of advanced practice professionals at Holy Name Medical Center, in Teaneck, NJ, has seen with her model of care delivery, The NP Care Model.
After implementing the model, Kutzleb saw a drop in heart failure patient's 30-day readmission rates. They fell to 8% from 26% over a 12-month period.
"To me that is a perfect of example of how we can really, truly effect change, how can we improve outcomes, how can we decrease admissions, and how can we really attack a problem before it becomes big," Cooke says.
"In hospitals across the nation, whether they have heart failure clinics or whether it's a critical access hospital, I see NPs in those roles because they're there to meet the needs of the patients."
2. NPs Can Expand Access to Care
Recent research from nurse economist and Montana State University professor Peter Buerhaus
has found that NPs are more likely than medical doctors to work in rural areas.
But in order to meet the needs of these underserved patients, NPs need to be allowed full practice.
"If it's a collaborative or supervisory state, and let's say a physician decides to retire or gets sick or dies or tries to leave the practice urgently... Then that NP cannot practice period," Cooke says.
"And so to me, the patients are left without, they're hung out to dry, and they've got to find a new provider, especially in underserved areas."
3. NPs Help Contain Costs
Because they're trained to "partner" with patients to improve their health, NPs have the ability to help contain healthcare costs, says Cooke.
"What we have now is a sick care model of health care," she says.
"We always say we're our patients' partner in health. How do we motivate our patients to be active participants in their own healthcare? To me that is a collaboration, a working together in promoting health and that to me is a way to help in hospital costs and to help in so many ways."
Once on track to be a CNO, Amy Rosa took an unexpected detour to becoming a nurse leader and now uses her clinical experience, collaboration skills, and knowledge of informatics to affect patient outcomes as a CNIO.
"So you used to be a nurse?" I can't tell you how many times I've been asked this after explaining my non-traditional career path to someone.
When I started my career at the bedside in a large, urban teaching hospital, no one ever questioned whether I was a "real" nurse or not. I wore scrubs, passed out medications, and worked weekends. It was clear in the minds of many that I was a nurse, because that's what people believe nurses do.
But now that I'm working in the media industry again—I've moved between publishing and clinical care throughout my 17-year career—I'm back to having the "used to be a nurse" discussion.
Even though I spend the bulk of my day thinking about, talking to, or writing about nurses and healthcare, there always seems to be some question about whether I'm a nurse or not.
I've seen this happen to other nurses as well. I once heard a radio piece where the reporter referred to Marilyn Tavenner, who was CMS administrator at the time, as a former nurse even though she still held an active RN license.
I've also heard nurses who are COOs, chief patient experience officers, vice presidents of various services lines referred to in this "used to be a nurse," manner despite the fact that skills in collaboration, planning, implementing evidence-based policies and procedures, are the cornerstones of nursing practice.
A few months back, I talked about this phenomenon with Amy M. Rosa, RN, DNP, MSMI, chief nursing information officer, Baptist Health, Jacksonville, FL.
I brought it up because the more I talk with people about health information technology, the more I feel that nurses who work in the IT realm, are also getting that "used to be a nurse" label.
Below, she shares her thoughts on how RNs who have chosen IT as a specialty use their nursing skills on a daily basis and how she functions as a nurse leader rather than strictly a technology expert. The transcript has been lightly edited.
On the path to nursing leadership:
I was on a CNO track. I was being directly mentored by a CNO at a hospital I worked at for 14 years to eventually be in that position.
I was very much looking forward to it, but then life happened. The vice president of IT for that same organization had acquired a job [elsewhere] as CIO for a large health system in the same county.
It was at the same time that EMR implementations were firing up, and she had the foresight to realize she needed a clinical person on that leadership team to lead that change.
She offered me the job of manager of clinical applications. I had never done anything in IT before—ever. So I jumped into this and I was overseeing clinical applications for a health system of 8,000 people and learning it very fast.
The first thing I did was build relationships with the nursing executives at the facilities. I so much enjoyed [it] that I got my masters of science in medical informatics.
On becoming a CNIO:
I really wanted to pursue informatics leadership in a much greater, more strategic way. I wanted to be at the table, rather than just leading teams in a management role.
The CIO here at Baptist Health, Roland Garcia, has a great vision for that and they had listed a position for director of clinical informatics. When I interviewed, I realized that position would allow me the path to be involved [in that] manner.
They developed the CNIO position for me in the last eight months. It's really thrilling and very flattering. The senior leaders went to bat and developed this position, so I'm the first CNIO here at Baptist.
This is a combination of my passion of nursing and the quality of information and seeing redundancies in healthcare—so all this stuff is really rocking my boat. I just love it.
On the value of clinicians in IT:
When I got here, the team was—and this is a phenomenon across the country—very implementation-oriented.
Even though they were clinicians, they had never been coached that once we get past implementation phase, your real value as a clinician is to understand how you can help design systems to affect patient outcomes.
There was a lot of coaching and encouraging them, that when they're sitting with their colleagues and designing systems, to keep in mind the whole tapestry, the whole long-term result, and [to think about] where that information flows across the system and [whether] we can design it a little bit differently so we can start making a difference with outcomes.
We're another department that is functioning as nurses affecting care, just in a different way.
You have analysts, you've got people that are familiar with designing systems, but not many people can take that information and design it to affect patient outcomes. You have to know clinical practice and be able to bring that to the table.
On how to collaborate with CNOs:
Being able to have collaborative strategic planning with the nursing executive team, I've worked very hard to educate them on IT. I feel that my role as their colleague is to sit at the table and tell them about what happens in IT so they're comfortable.
Any CNO needs to be aware of how IT runs and what the expectations are, so I've been trying to impart that information to them. [I also try] and bring more of the industry information, the health IT information to our executive meetings so they understand what is going on there as well.
I have a dotted line to [the system CNO] Diane Raines, RN and I meet with her monthly, and 60% of my time is spent in clinical operations meetings.
I meet with my nurse execs individually, once a month, and I sit on the nurse executive team. Then I'm coming back and translating that with IT.
I do all that footwork and analysis and then recommend the approach that I think we should take for whatever has become, in my observation, priority for the clinical end user. We round, we do tracers, and every Wednesday I'm out there in scrubs.
Our support specialists wear scrubs. Our clinical informatics specialists wear lab coats so that we are seen as being part of the clinical team.
Happiness researcher Shawn Achor shares five evidence-based methods for nurses to raise their levels of happiness and rational optimism.
Starting May 6, the annual wishes of "Happy Nurses Week," will begin as National Nurses Week gets underway once again.
Last year, I wrote about intangible gifts such as thoughtfulness, compassion, or mentoring that nurses have given and received throughout their careers. This year I'd like to talk about a gift nurses can give themselves—happiness.
Back in March, I attended happiness researcher Shawn Achor's opening keynote session at the American Organization of Nurse Executives' 2016 conference in Fort Worth, TX. It was a not a Pollyanna speech about putting on a smile no matter what and [Beyoncé notwithstanding] making lemons out of lemonade.
Instead Achor, whose research is rooted in positive psychology, focused on the science behind happiness, how it influences many aspects of our lives, and the steps we can take to cultivate it. It's a topic that's been getting a lot of attention over the last few days. Last week, the Harvard School of Public Health announced it will launch an academic Center for Health and Happiness.
"All this research comes down to three conclusions," Achor told the crowd. "Scientifically, happiness is a choice. Scientifically, happiness is an advantage, improving every single one of our business and educational outcomes and many of our health outcomes, and happiness is extraordinarily contagious."
More Than a Feeling
To be clear, Achor points out, happiness is not synonymous with pleasure.
"As soon as I start talking about happiness, most people actually get the wrong idea," he says. "They immediately start thinking we're talking about pleasure—like you have to have a smile all the time or work always has to be fun."
Rather, he says, we should define happiness as the ancient Greeks did. "They defined happiness as the joy you feel moving toward our potential together," Achor explains.
And joy, he says, is something we can experience even when life is not pleasurable. "In the midst of working long hours, trying to care for other people, [is] not going to be pleasurable, but you can actually feel joy that you are helping them reach their health potential," he says.
I'm happy—well, maybe appreciative is a better word—he made this distinction. There are many aspects of nursing that are not so pleasurable, like when a patient dies or gets a difficult diagnosis, or when you have to miss out on holiday celebrations because you have to work. But, if you follow some of Achor's principles, you can find joy and positivity in those situations.
For example, you can feel honored that you were able to be part of something as intimate as the dying process. You can have pride that you were there to help guide someone in understanding a frightening diagnosis. You can feel connection to your fellow nurses when you all bring dishes to share with each other during the inevitable holiday shift.
Even those prone to pessimism can recalibrate their brains to achieve what Achor describes as "rational optimism."
"Rational optimism doesn't start with rose-colored glasses. Rational optimism starts with a realistic assessment of the present, but throughout that process you maintain the belief that your behavior matters," he says.
In other words, rather than pretending a problem doesn't exist or, alternatively, assuming a problem is permanent, a rational optimist acknowledges a problem and takes steps to fix it.
Cultivating the Happiness Habit
A person's optimism or pessimism hinges more on the lens through which they view the world versus external circumstances or genes, Achor says.
If you train your brain to look for mistakes and errors, then that is what your brain scans the world for first.
And yes, nurses must be on alert for potential errors because catching them before they happen can mean the difference between life and death. But they need to take care that this vigilance in spotting the negative doesn't ooze out into the rest of their lives to negatively shape interactions friends, colleagues, and loved ones.
"Our brains become whatever we practice," he says. "If we can find some way of helping people become more positive… it takes the cap off our potential for happiness but also human potential at every level—our creativity, our energy levels, our resilience."
By doing at least one of these five simple habits—most of which take less than two minutes—for 21 days in a row, you can develop a sense of optimism and happiness, Achor says.
1.Three Gratitudes
Write down three new things you are grateful for each day and be specific about why you are grateful for them. If you simply say you're grateful for work, family, and health the habit won't have an effect. But Achor says, "If I say I'm grateful for my son Leo, he gave me a hug last night which means I'm worth love," that will raise optimism levels.
After employees at American Express implemented this habit for 21 days, Achor found that by day 22, those who originally tested as low-level pessimists began testing as low-level optimists.
2.The Doubler
Think of one positive experience you had over the past 24-hours and write four details about that experience. This helps your brain stamp the memory as meaningful and allows it to relive the positive experience a second time.
"This is the fastest and cheapest intervention we've found for raising engagement scores at companies worldwide," Achor says. Expressive writing, such as this can affect health outcomes, as well. Achor says research has found that when patients with chronic neuromuscular disease engaged in expressive writing, they were able to decrease the use of pain medication sometimes by as much as 50%.
3.Fun Fifteen
Do an enjoyable cardio-activity for 15 minutes. Achor says your brain records exercise as a victory and this feeling of accomplishment transfers to other tasks throughout the day. "People who exercise for 15 minutes a day in the morning, even briskly walking a dog, are better at dealing with their inbox in the middle of the day," he says.
4.Meditation
While at work, take your hands off the keyboard once a day and pay attention to your breath going in and out for two minutes, Achor suggests. When Google employees did this exercise, the company saw significant results.
"21 days later, their accuracy rates improved by 10%, their levels of happiness rose, and their engagement scores rose significantly," he says. Though the perks of free food and exercise equipment may attract employees to work there, that's not what keeps them at Google for the long haul.
"Once they're there, [the external environment] doesn't sustain engagement after the first six weeks," Achor says. "What they find sustains engagement better than anything is their mindfulness training."
5.Conscious Act of Kindness
Take two minutes to write an email, praising or thanking one person you know. Much like the gratitude exercise, it must be a different person each day and the email must be authentic and specific about why you appreciate them.
"Social connection is the greatest predictor of long-term happiness we have," he says. "It trumps everything else we do."
And, as an added bonus, you'll get "people writing back about how great they think you are," Achor says.
I encourage you to celebrate Nurses Week by starting one of these habits on May 6 and continuing it for 21 days, as Achor recommends. Make it a happy Nurses Week by become a happy nurse.
As the industry turns toward value-based care and population health management, leaders are recognizing that physical healthcare alone is not sufficient.
This article first appeared in the May 2016 issue of HealthLeaders magazine.
Clarence E. Jordan, MBA, has dealt with a diagnosis of co-occurring mental health issues and substance abuse for the past 30 years of his adult life. It may come as a surprise to some that a person with behavioral health issues could be successful as a business and healthcare leader. The stereotype that those with behavioral health problems are violent, unemployable, strange, or erratic still exists. In fact, before he received a behavioral health diagnosis, Jordan had a similar image of those dealing with mental illness.
"Like many people, I probably saw mental illness as a homeless individual with a shopping cart with all their belongings loaded into it, pushing it down the street," says Jordan, the vice president of wellness and recovery for Boston-based Beacon Health Options, a behavioral health management company that serves 48 million people in the United States and the United Kingdom. "When I was given my original diagnosis, it came as a real shock to me because I did not ever feel that I had a mental illness. Life to me was normal."
For many Americans, living with behavioral health issues is the norm. According to the National Institute of Mental Health, in 2014 an estimated 43.6 million—or 18.1% of U.S. adults age 18 or older—experienced any form of mental illness (AMI, which includes mental, behavioral, or emotional disorders, but excludes developmental and substance use disorders). That same year, about 4% of U.S. adults, nearly 10 million, had serious mental illness (SMI, which results in serious functional impairment that substantially interferes with or limits one or more major life activities).
That's a significant portion of the population, and the challenges surrounding delivery of behavioral healthcare—stigma, access to care, utilization of resources, funding, cost, and reimbursement—are significant as well.
These issues have dogged behavioral healthcare for decades, but now, with the Patient Protection and Affordable Care Act's emphasis on population health, quality outcomes, and value-based payment models, industry leaders are recognizing the integral role that behavioral healthcare must have in patient care, and they are developing solutions.
Why now?
"I think CEOs and healthcare leaders across the country are realizing, as they move toward value-based contracting, behavioral health is a unique variable that can help accomplish the Triple Aim," says David Deopere, PhD, corporate vice president for behavioral health development at Des Moines, Iowa-based UnityPoint Health, a system with 3,788 licensed beds, 185 physician clinics, and total operating revenue of $3.8 billion in 2014.
It's hard to deny that behavioral healthcare is a key component to achieving the Institute for Healthcare Improvement's Triple Aim goals of improving the patient experience of care, improving the health of populations, and reducing the per capita cost of healthcare.
"When you start to look at value-based contracting, capitated-type contracting, we know that people with behavioral comorbidity go to their primary care doctor more often with depression—comorbid depression—than if they don't have comorbid depression," Deopere says. "They also go to the emergency rooms more frequently. They get readmitted to the hospital more frequently."
To Deopere's point, according to the Medicaid and CHIP Payment Access Commission, total spending for an enrollee with a behavioral health diagnosis was almost four times greater than for an enrollee without a behavioral health diagnosis. The World Health Organization reports that mental health issues and substance abuse are the leading cause of disability worldwide, and according to a fact sheet from the National Alliance on Mental Illness, some $193 billion per year in workplace earnings is lost due to untreated mental illness. Plus, individuals living with serious mental illness face an increased risk of having chronic medical conditions, and adults living with serious mental illness die, on average, 25 years earlier than other Americans, largely due to treatable medical conditions.
"The real drive around this, and the real conversation around this starting now is because of population health and accountable care organizations," says Martha Whitecotton, MSN, FACHE, senior vice president of behavioral health services at Carolinas HealthCare System in Charlotte, North Carolina, a nonprofit organization with more than 900 locations and 7,395 licensed beds throughout North and South Carolina.
"If you ever hope to see progress in health outcomes for diabetics or patients with congestive heart failure, you have to address both behavioral and physical health. The way people are going to be paid, placing their payment at risk for overall health and overall cost, it's forcing the conversation around what do we do about mental illness."
Treatment works—if you can get it
The way behavioral health needs have been addressed in this country has not been stellar—something Jordan has experienced.
Before receiving a behavioral health diagnosis, Jordan found that mental illness and substance abuse can strain productivity. Though he did well during his naval career, becoming a commander and attaining a master's degree, after retirement from the military, he found it difficult to maintain a job as a civilian.
"After leaving the service, I had one of those experiences that took me from job to job, town to town, in search of some stability, in search of something to root myself to," Jordan recalls. "It never happened for me, at least during the course of the first 10 years out of the Navy, which I would classify as the period of my darkest time."
"The way people are going to be paid, placing their payment at risk for overall health and overall cost, it's forcing the conversation around what do we do about mental illness."
Jordan says he had many problems maintaining healthy relationships and had significant conflict with authority. It wasn't until he landed in front of Judge Seth Norman in a Davidson County, Tennessee, drug court that things began to change for him and he received a behavioral health diagnosis.
"It was through the courts, as a matter of fact, that I received mandated treatment," Jordan says. "I was given the option of going to jail or getting treatment. That was not a hard decision to make."
Unlike Jordan, many people in need of behavioral healthcare never receive necessary services.
"Because our system is so broken, only 40% of people who actively have mental health issues are getting treatment," says John Santopietro, MD, FAPA, DFAPA, chief clinical officer of behavioral health at Carolinas HealthCare System. However, with proper diagnosis and treatment, he says, 60%–80% of those with behavioral health issues can experience recovery. "Success rates are very high with the treatment we have today, but people have no clue about that. They don't know it because what they see day to day is people not getting treatment."
Over the years, a major barrier to treatment has been reimbursement for and funding of services. Medicaid is the single largest payer source for behavioral health in the United States, but it has typically had low reimbursement rates.
"It's heavily Medicaid and lower socioeconomic populations that we serve," says Greg Pagliuzza, vice president of finance and CFO at UnityPoint Health-Trinity, a 584-licensed-bed integrated delivery system based in Rock Island, Illinois. "We are dependent so heavily on grants from the state, and the Medicaid payment rates, which have not been increased, I believe, in at least 20 years. Our reimbursement rate is the same as it was 20 years ago, and we've had a reduction in grants."
"Success rates are very high with the treatment we have today, but people have no clue about that. They don't know it because what they see day to day is people not getting treatment."
Funding for behavioral health services varies from state to state, and in many areas of the country, dollars for behavioral health have been subjected to the chopping block.
"Basically, there are 50 different departments of mental health. There's no real federal driver for quality and consistency and programming in mental healthcare in the country," Santopietro says. "There's SAMSHA [the Substance Abuse and Mental Health Services Administration within the U.S. Department of Health and Human Services], but they have a tiny budget compared to the Centers for Medicare & Medicaid Services, so it's state by state."
For example, according to 2013 data from the National Association of State Mental Health Program Directors Research Institute, the U.S. average mental health spending per capita was $119.62, with a high of $345.36 in Maine, and a low of $32.77 in Idaho. But there has been some movement toward improving behavioral health benefit coverage through parity laws and the PPACA.
"Policy change is often a combination of philosophy and money," says Linda Rosenberg, MSW, president and CEO of the National Council for Behavioral Health in Washington, D.C., a nonprofit association representing 2,700 mental health and addiction treatment member organizations. "The end of the state hospitals was philosophy. People could live well in the community, but Medicaid also drove it. I think we're having the same thing now—a combination of philosophy but also money. I think parity and the ACA introduced more money into behavioral health."
Prior to the passage of parity laws, behavioral health benefits were often not covered by insurance plans, or if they were, the number of treatments or provider visits a patient could receive were limited and hefty copayments were attached. The Mental Health Parity and Addiction Equity Act of 2008 attempted to break down those barriers to care by requiring health plans to provide mental health and substance abuse benefits that are on par with medical/surgical health benefits.
For example, if a patient has a $30 copayment for an orthopedist, then the copayment for a behavioral health specialist cannot exceed $30. In addition, there are stipulations in the PPACA that require all new small-group and individual plans to cover mental health and substance abuse benefits. And, while it holds much promise, the logistics of parity are still a work in progress.
"It's a complex law to implement, and I think it's still a process. It's so complex that case law will actually, I think, clarify it, because some of it is simple and other parts of it are not so simple," Rosenberg says. "The copay is simple. It becomes more complex when you're talking about services where there isn't necessarily an equivalent on the medical side and it becomes an issue of utilization management, or it becomes an issue of medical necessity. That's often subjective and harder to sort out."
The emergency department safety net
What's not hard to sort out is where behavioral health patients end up seeking care when they lack community and outpatient resources—the emergency department.
"Acute care emergency rooms are being overrun with patients that have psychiatric illnesses because they have nowhere else to go."
According to data from the CDC, 5% of ED visits were made by patients with a primary mental health diagnosis during 2007–2008. During the period 2008–2010, the CDC reported, nearly 10% of ED visits had one or more MHD-DCs assigned to the visit and the rate of MHD-DC-related ED visits increased seven times as much as the overall rate of ED visits in North Carolina during the study period.
"Acute care emergency rooms are being overrun with patients that have psychiatric illnesses because they have nowhere else to go," Whitecotton says. "There are no resources. There's no place for them to seek care so they show up in emergency rooms."
There are many reasons an ED is not the optimal place to seek behavioral healthcare, expense being one. A 2012 study titled "The Impact of Psychiatric Patient Boarding in the Emergency Department" and published in Emergency Medicine International found that from 2007 to 2008, psychiatric patient boarding cost the department $2,250 per patient in lost payments due to slower turnover.
With two- and three-day wait times for placement, a behavioral health patient occupying an emergency room bed can be an obstacle to ED flow and throughput for patients with medical issues.
"Their focus in the ED is get the patient through the system so you can get the next patient in," Whitecotton says. "Even if we were still in the volume world, in an emergency room, a patient that occupies a bed for 40 hours—think of the lost revenue opportunity from having that bed tied up."
Plus, being trapped in the limbo of a chaotic ED is not conducive to good mental hygiene.
One organization that witnessed what can happen when state and local funding for behavioral healthcare gets cut is Swedish Covenant Hospital in Chicago, a 279-bed nonprofit teaching hospital with a total patient revenue of nearly $1.4 billion. Between 2009 and 2012, Illinois cut $113.7 million in general funds from the state's mental health budget. In April 2012, Chicago closed six of its 12 city-run mental health clinics. It was around that time that Ajimol Lukose, DNP, RN-BC, nursing director at the hospital, noticed more patients with behavioral health issues seeking treatment in the ED.
"There was a reduction in mental health clinics, so the follow-up or outpatient programs were limited. That resulted in patients showing up in the emergency department," Lukose says.
On any given day, there could be as many as six or seven behavioral health patients in the ED. "Our emergency department was struggling with patients with mental health issues staying there for three and four days and waiting for state transfer, especially unfunded patients," she says.
To address this problem, Lukose launched a safe care delivery model to improve patient outcomes among behavioral health patients in the ED. Long term, she wants to see a decrease in several metrics, including ED length of stay, the use of sitters and behavioral restraints, elopement events, and labor costs.
To accomplish these goals, Lukose hired a nurse practitioner to round on behavioral health patients in the ED, established a dedicated area for behavioral health patients in the department, and created new policies, procedures, and timelines regarding assessment of behavioral health patients and implementation of interventions. A walk-in "bridge" program for patients waiting to connect with community resources was also created.
Designating the nurse practitioner as the ED behavioral health liaison helps meet the new expectation that an initial behavioral health assessment in the ED will occur within one hour of its order time with a member of the crisis team and that behavioral health interventions will be initiated with the nurse practitioner within two hours of the consultation order time being set. The NP works eight-hour shifts, Monday through Friday, rounding on behavioral health patients in the ED, completing psychiatric evaluations, initiating appropriate interventions, and coordinating discharge planning.
Lukose and the ED director developed policies, procedures, and guidelines using the Four S Model, which calls for focus on safety, support, structure, and symptom management. For example, giving behavioral health patients a different color gown so they can be easily identified if they are trying to elope, placing all patient belongings into a locked cabinet, and ensuring that metal objects such as soda cans or silverware are not brought into the room.
In addition to training to boost the staff's comfort and compliance with the new policies, a checklist—similar to a preoperative checklist—was created.
"If you give a nurse a three-page or four-page policy, they're not going to sit down and read the policy all the time," Lukose says. "So we made a one-page checklist, which is a summary of the entire policy, so the nurse can make sure everything is done."
The results of the project? Lukose says initial behavioral health assessments were completed in one hour 93% of the time and sitter use decreased by 46%. There was also a drop in ED length of stay.
For all uninsured behavioral health patients in the ED, the length of stay dropped to 29.1 hours in fiscal year 2014 from 48.5 hours in 2013—a 40% reduction. For uninsured patients waiting to be transferred to a different facility, the average length of stay was 37.2 hours in fiscal year 2014, down from 74.7 hours in fiscal year 2013.
"The interesting thing that we found was many of them did not need to be in an inpatient psych unit," says Lukose.
Integration improves outcomes
Though the Swedish Covenant program yielded good results, often the best way to improve outcomes and decrease healthcare costs is to keep behavioral health patients out of the ED entirely. Integrating behavioral healthcare into the primary care settings, which SAMSHA describes as "the systematic coordination of behavioral and general healthcare," is one proven way to do this.
"We know behavioral health integration in primary care works," Whitecotton says. "We've had 90 randomized controlled trials that have proven it."
One of the most well-known assessments of behavioral health integration into primary care is the IMPACT trial out of the University of Washington, which refers to Improving Mood Promoting Access to Collaborative Care Treatment. Over two years, researchers tracked about 1,800 depressed adults in 18 primary care clinics across the country. Half the patients received typical care from their primary healthcare providers (including medication regimes and referral to specialty mental health services), and half the patients received care based on a collaborative care model that includes training primary care providers and their embedded behavioral health colleagues in evidence-based medication or psychosocial treatments.
"We know behavioral health integration in primary care works. We've had 90 randomized controlled trials that have proven it."
After 12 months, about half of the patients in the collaborative care cohort reported a 50% or greater decrease in depressive symptoms. Only 19% of the patients in the standard care cohort reported a reduction in symptoms. There were major cost savings when behavioral healthcare was integrated with primary care. For each dollar spent on its collaborative care model, $6 in healthcare costs were saved.
For these reasons—better patient outcomes, cost savings, and improved use of healthcare resources—in 2012, leadership at Carolinas HealthCare System decided to "expand behavioral health, make some significant system investments, and build out an integrated system of care across our system," says Whitecotton. Included in this was integration of behavioral healthcare into the primary care setting.
She says behavioral health integration has taken place in upwards of 40 primary care practices across CHS.
In 2015, primary care providers began using a patient health questionnaire depression tool, PHQ-9, to screen patients on antidepressants, antipsychotics, or for those who had a new problem relative to psychiatric illness. If patients scored above 10, or if they said they had thoughts of harming themselves or others, the primary care provider contacted the call center to connect with a behavioral health specialist.
"Our call center gets a behavioral health specialist on video with the patient right there in real time, while they're in the physician's office," says Whitecotton. Specialists are either licensed professional counselors or master's-prepared social workers who can do diagnostic interviewing and recommend a course of action for the patient. A psychiatrist is also available to assist the primary care provider in developing a medication regimen using evidence-based drug algorithms in the EMR.
Once the primary care providers become more skilled in managing behavioral healthcare treatments, Whitecotton says, they may not need to contact the psychiatrist for as much guidance. Patients are also connected with a health coach.
"Our team reaches out to the patient and establishes a telephonic relationship with them, and keeps them in telephonic health coaching until their score is below a 10," says Whitecotton.
According to the literature, she says, it takes about two years to show overall health improvement, but CHS does have some promising preliminary outcomes data gathered on 442 patients for whom they have data for six months before and six months after integration.
"About 75% of the patients that we've seen have had an elevated depression score, 62% of the patients had anxiety symptoms, and then about 83% of the patients ended up on medication," she says. "We've seen a 49% decrease in the PHQ-9 score, a 38% decrease in anxiety symptoms, and a 67% decrease in suicidal ideation."
As for clinical outcomes, Whitecotton says there was no change in patients' weight, but there was a significant decrease in A1C levels. Patients' total cholesterol levels went down, but triglyceride levels increased while HDL levels dropped. Inpatient hospital stays also decreased.
"What we're measuring is not only the patients' response within the context of their mental illness but also the improvement of their physical health," she says. "If we can keep them out of the hospital, out of the emergency room, out of the doctor's office other than for things they really need to be there for, and if we can improve their cholesterol, improve their blood pressure, and decrease their weight, then our overall spend on each patient will go down. Patients will be healthier, so that will be where the return on investment is."
Early intervention
Behavioral healthcare can also be integrated in the pediatric setting, as Montefiore Medical Group in the Bronx, New York, has done since 2006 with the Healthy Steps for Young Children program, a national initiative focusing on early childhood growth and development. In addition to a pediatrician, children from birth to age 5 are seen by a Healthy Steps specialist who is trained in child development and behavior to focus on "the parent-child relationship, the attachment between the two, and developmental and behavioral outcomes for the child," says Rahil Briggs, PsyD, director of the Healthy Steps program and the director of pediatric behavioral health services at Montefiore Medical Group, which provides primary pediatric care to 90,000 children each year across 19 practices.
Briggs says one characteristic unique to Montefiore's Healthy Steps program is its emphasis on parental mental health. "While there's no health without mental health, there's probably not a whole lot of child mental health without parent mental health. And if we're really trying to do preventive work and ensure better outcomes for the next generation, [then] we have to treat the parents' mental health."
The program has had positive, measurable outcomes, says Briggs.
"With our behavior and development consults, the short-term consults, we're able to take a child from screening at-risk to screening not at-risk in an average of 1.4 consults," she says.
The program also appears to disrupt the development of poor outcomes in a child's social and emotional development at age 3 if the mother had experienced abuse or neglect in her own childhood.
In summer 2014, the medical group expanded behavioral health integration to school-aged and adolescent patients. Briggs says thus far the feasibility of the program looks promising, noting that "26% of children who came for well child visits were referred to our program, which is fantastic, and, of those 26%, if they had a warm handoff, 63% of the 26% came for the next visit. If they did not have a warm handoff, 53% came for the next visit." The warm handoff is when the primary care provider introduces the patient to the behavioral health provider during the medical visit.
Looking back on his life, Jordan says he may have been the type of child to benefit from such screening and early intervention. "I was one of those very energetic children, both intellectually and cognitively, and I had a lot of anxiety or anxious moments growing up," he says. "My stepfather was in the Air Force, so we tended to move around the country, so I grew up without what many people would refer to as childhood friends. I think it's safe to say there's a lot of loner behavior in my life, and that combined with this extraordinary amount of energy, without places to channel it, more times than not, is where some of my issues stem from."
What's old is new again
With the recent interest in behavioral healthcare, integration may seem like a new concept in care delivery when it has, in fact, been around for decades. Since 1985, The Robert Young Center for Community Mental Health in Rock Island, Illinois, has been integrated within UnityPoint Health-Trinity, and has managed to stay financially viable despite the state's budget woes.
"The Robert Young Center was the first comprehensive community mental health center in Illinois. It was one of the few that, nationwide, developed within a healthcare system," Deopere says. "It has had a positive contribution margin after overhead allocated expenses; it's been on a positive bottom line for 30 consecutive years."
Dennis Duke, who succeeded Deopere and became president of the Robert Young Center last year, attributes this success not just to integration of behavioral healthcare into the clinical setting but also to integration of behavioral healthcare into organization's leadership. The position of president of the Robert Young Center has had a seat on Unity Point-Trinity's leadership team since the two organizations were integrated in the 1980s.
"There's very few that are configured like we are, as a comprehensive community mental health center that's actually part of a health system, so we have vertical integration in the sense of our leadership and horizontal integration in terms of all the services that we provide," Duke says.
This leadership structure has enabled the organization to be proactive, thoughtful, and flexible about how it operates, Pagliuzza says.
"RYC succeeds because it's creative and is paying attention to how it spends, where it brings monies in, where it needs to expand services, and where it needs to take services away," he says. "It reads the financial reimbursement world well and works within it, besides having a very good model that's very effective at delivery of care."
Part of the beauty of an integrated system is that it allows for what Deopere describes as "deflection," where only the acutely mentally ill—those in true need of inpatient services—are admitted, while other patients are connected with outpatient or community services.
"Our continuum is a full continuum, and it includes inpatient and outpatient services," says Duke. "We understand that there's a need for inpatient, but in this model we're looking to assess the patient appropriately and get them into a disposition that's the right level of care—and it might be inpatient, but it might be connecting them back with their community provider system."
This type of flexibility is essential to remaining viable in an ever-changing healthcare system, says Kurt Barwis, FACHE, president and CEO of Bristol (Connecticut) Hospital, a 115-staffed-bed facility.
"Ultimately, that business could be switched off in a second if somebody comes up and advances the way that you take care of these patients," he says. "You're here today but gone tomorrow if you don't really pay attention to new models."
"My job as a hospital CEO is to pay attention—not just to one aspect of the outcome but all of the outcomes."
In September 2013, the organization did a community health needs assessment and the results were somewhat surprising, says Barwis, considering the wide variety of behavioral health services the organization was already providing.
"The No. 1 identified need was mental health, substance, and alcohol abuse," he says. "We have expansive behavioral health services. So you get this community health needs report that is in your face, and you have to do something different. You need to try to rethink and reimagine this."
This new vision includes improving care coordination among community services, inpatient services, and outpatient services as well as reassessing the counseling center's fee-for-service business model. After making the decision to outsource some of the organization's crisis workers, Barwis challenged the counseling center's staff to think about how the program should evolve to meet the community's needs.
"The models around us that are emerging are much more value-based and much more home-based," Barwis says. "So I said the thing that I would like to see you do is develop a strategy for yourself, and for everyone to start to ask themselves: 'What do we need to do to morph our program so we adapt it and become better?' "
And though it's often tempting, cost of readmissions should not be the only influencing factor when redesigning care. Patient outcomes beyond the hospital walls need to be considered as well.
"If I've detoxed the same patient 17 times in 12 months, then I'm really not getting it done. I've really failed the community if I can't create a system that helps somebody achieve that continuum and not end up coming back 17 times. There's a huge cost to the system, but there's also a cost to the community," Barwis says. "My job as a hospital CEO is to pay attention—not just to one aspect of the outcome but all of the outcomes. In the old days, the outcome would be within my four walls. Not anymore. Now, the outcome is the whole experience for that person who lives in the community."
One organization that changed its care model to better meet the needs of patients in the community is Durango, Colorado–based Axis Health System (formerly Southwest Colorado Mental Health Center), a nonprofit provider of mental health services, substance abuse treatment, and primary care services with seven locations that include an emergency behavioral health site and two school-based health centers.
Once strictly a behavioral health provider, the organization flipped integration on its head and now also provides primary healthcare. "The early model was one of colocation," says Bern Heath, PhD, CEO at Axis Health System. "So we started out by screening only those folks who the medical staff suggested might have a behavioral health issue, but we began to realize that this wasn't the right approach and what we should be doing is population-based screening."
"You cannot have a separate physical healthcare and separate mental healthcare...and have them be equal. The only way we're going to have equal care is with one system that makes no distinction between the care."
Once they began screening all patients at clinics where their staff was embedded, it became apparent that depression was more prevalent than they initially thought.
"What we found was rather than 8% to 9% of folks with depression, we were getting into 23% to 24% of folks who had depression," he says. "We learned a lot of things in those settings that helped us refine our practice. We began to see the limitation of bringing one or two people into a primary care practice. It didn't lead to a higher level of integration; it just enhanced the referral. That led us to say, 'We need to establish a practice on our own.' "
And that is exactly what they have done by establishing two fully integrated healthcare clinics and two school-based health clinics where they provide primary care and behavioral healthcare.
"You cannot have a separate physical healthcare and separate mental healthcare and separate substance use care systems and have them be equal. The only way we're going to have equal care is with one system that makes no distinction between the care," says Heath. "We have pulled all that into one setting. Somebody walks into our door, they walk into one facility, and it's an integrated health clinic."
To ensure big data is used to influence outcomes that are meaningful to the nursing profession, nurse executives need to act as data visionaries and architects.
Have you ever found yourself poring over stacks of data, feeling more like a statistician than a nurse? If you have, welcome to the world of big data.
"You have all of these different data sources coming at you on a weekly, monthly, quarterly basis. The CFO has a stack of data for you, your productivity-management engineer people have a stack of data for you, HR has a stack of data for you, and then your quality director, your clinical folks, have a stack of data for you," says Jane Englebright, RN, PhD, CEBP, FAAN, chief nursing executive and senior vice president at Nashville, Tennessee-based HCA.
"And your job is to sort through all that data and synthesize it in some way and come up with brilliant conclusions about how to run the organization."
Big data "typically refers to a large complex data set that yields substantially more information when analyzed as a fully integrated data set as compared to the outputs achieved with smaller sets of the same data that are not integrated," according to the Online Journal of Nursing Informatics.
Dealing with big data can understandably be challenging for chief nurse executives.
During a session titled, "The CNE Role in the Big Data Revolution," at the American Organization of Nurse Executives last month in Fort Worth, TX, Englebright and healthcare management consultant Barbara Caspers, RN, MS, PHN, discussed importance of shared strategies to help CNEs ready their organizations for the "big data revolution."
Drowning in Data
When a CNE is analyzing and synthesizing data, it's typically done manually and is a very time- and labor- intensive process, in part, because technology systems have traditionally been built in silos. "Often they don't even call the units the same thing. They don't name them the same thing. They don't necessarily define them the same way," Englebright says.
For example, the definition of a day may vary from system to system and the way a month is calculated in the finance systems may differ from how it is calculated in the payroll system.
Trying to "figure out how to keep up with your agency hours and what the cost of your agency is in the finance system versus the scheduling system," Englebright says, is "just a nightmare, trying to make all of these different things sync."
The lack of data standardization can also make it challenging for a CNE to assess how the organization or a particular unit is performing and to make well-informed decisions about what to change. Having good data is key to making effective changes.
"For those of us who grew-up studying the biological sciences, we understand that we have taken a very linear, Newtonian-approach to data over something that's really much more like a biological system," she explains. "When you perturb one part of our system… it has ripple effects throughout the entire organization."
Failure to recognize how this data interacts throughout the system has been a limitation in the types of data analytics that have been put forth.
"The frustration that we often have as nurse leaders in looking at this data, is [that] some of the variables we care about the most, aren't even in the data," Englebright says. "We don't have something that measures nursing competence, for example. We don't have something that measures how committed the nurses are. We don't have something that measures if the patient really [is] going to do the stuff we just invested all this time in teaching them to do."
Because of this, CNEs end up having to advocate for the things they care about in a person-on-person debate, than being able to make a persuasive business case based on data, she says.
The Big Data Checklist
For all its current stumbling blocks, big data holds the potential to change healthcare delivery for the better. But for that to happen, nurse executives need to act as data visionaries and architects, Caspers says.
To support CNEs in doing this, Englebright, Caspers, and a workgroup that grew out of the University of Minnesota's annual Nursing Knowledge: Big Data Science Conference in 2014, developed the CNE Big Data Checklist. It outlines three main areas where nurse executives should become leaders in driving the use of big data:
To create a culture that thrives on data
To develop big data competencies for the organization
To create an operation infrastructure to support big data use
"The promise with big data is that we will quickly be able to move towards prescriptive analytics where we will be able to provide information that will give us knowledge and suggest interventions, or the capability to do something about a predicted upcoming event," Caspers says.
Using big data in this way will be a boon to population health, in that it will help inform decisions about how to manage risk and disease states across the care continuum.
"Big data will help us manage the upcoming transformation into value-based care," Caspers says.
It will also support CNEs in being more nimble when it comes to making decisions. Rather than waiting for the end of the year or end of the month to get various reports, they will have access to near real-time data.
Englelbright says that by breaking down data silos, big data will also facilitate a balanced approach to assessing organizational and nursing performance.
"I'm not over here worrying about my volumes, and I'm not over here worrying about my quality and over here worrying about my cost," Englebright says. "I'm able to think about all of these things in relation to each other and success is when they all get better… and I'm able to move forward in all of these dimensions at once."
The future of big data could be very bright, but chief nurses must get involved to ensure nurses gets the full benefit.
"The big data revolution is here," Englebright says. "We are much further along this path than we think we are and it is time for the chief nurse executive community to jump in the middle of this and to claim our part in it, to guide it and direct so we end up with the tools we need for practice and for our work."
Strategies to help nurse leaders better support care coordination and transition care management efforts include knowing the patient population, leveraging the value of technology, and engaging staff as well as patients.
For better or for worse, this, shall we say, "unique" primary election season has caused me to do some deep thinking. Not so much about the candidates or their platforms, but rather about our society and way of life.
Do we want to run the country like a business where finances, bottom lines, and budgets are what's important? Do we want to function as a community where all entities—government, schools, and citizens—have a personal investment in achieving shared goals and outcomes? Does it have to be "either/or? Can it be "both/and?"
I don't have the answers, but, lately, when I've been thinking about healthcare, I've been mulling over the same questions.
Healthcare leaders have been doing the same.
In February when I hosted the HealthLeaders Media roundtable, "How Informatics Can Reshape Healthcare," panelist Kevin Myers, senior client director at GE Healthcare, made the following point, "There are a number of stake holders that are involved…They all have to put a little skin in the game. It can't just be the health system that carries the entire burden of improving outcomes."
This concept of collaborating across the care continuum to achieve mutual goals was discussed last month at the American Organization of Nurse Executives 2016 annual conference in Fort Worth TX. It came up during the concurrent session, "The Nurse Leader's Role in Care Coordination and Transition Management." Four nurse leader-panelists outlined the specifics of a joint statement on care coordination and transition management between AONE and the American Academy of Ambulatory Care Nursing.
"We will look at it not from the perspective of how do you begin, or how do you implement care coordination and transition management but… from the role of the nurse leader," says Susan Paschke, former senior director ambulatory nursing at the Cleveland Clinic in Ohio.
"What do you need to know and how do you need to work in order to make sure that you can implement it in your organization?"
Because care coordination and transition management are so integral in today's healthcare system, the two organizations felt it wise to further clarify the nurse leader's role in these areas. Together they developed six strategies that acute and postacute care nurse leaders could apply to care coordination and transition care management.
Strategy 1: Know How Care is Coordinated in Your Setting
The beginning of understanding how care is coordinated in the acute or post-acute setting is to know your patient population, says Claire Zangerle, RN, MSN, MBA, president and chief executive officer of the Visiting Nurses Association of Ohio. "Determine the needs and requirements and resources of the particular population. It's going to be different for one group of patients than the other," she says.
She recommends using a "tracer" to simulate a patient's journey through the healthcare system to discover the organization's barriers and best practices.
Identifying and becoming familiar with organizational care transition models is essential, says Zangerle.
"As a nurse leader, it's important for you to be very well-versed on that transition of care model and be integral in development and refinement of that [model]," she says.
"If there isn't a model in place, there are numerous resources to allow you to pull a model together that works for your organization."
Strategy 2: Know Who is Providing Care
Defining the roles and key job responsibilities of those providing transition care is important, Zangerle says. In their quest to improve transition care, many health systems have added formal care coordination and transition of care roles like transition coach, care coordinator, case manager, etc.
Unfortunately, these multiple roles have often left the patient confused about who does what. "Focus on eliminating the redundancy in roles and insure they're well-defined so those within the team and those outside the team can understand," she says.
Strategy 3: Establish Relationships that Will Support Care Coordination
Looking beyond the inside of an organization is a hallmark of good care coordination and transition care, says Beth Ann Swan, CRNP, PhD, FAAN, dean and professor Jefferson School of Nursing, Thomas Jefferson University in Philadelphia.
"Our organization has had a history of strong academic-practice partnership," she says.
The SON worked with Thomas Jefferson University Hospitals to develop the Communication Catalyst Program to provide better care transition experiences for patients by improving nurse-patient communication. The program is educating 300 nurses in the care coordination and transition management core curriculum.
It covers 12 topics including advocacy, education and engagement of patients and families, coaching and counseling of patients and families, patient-centered care planning, support for self-management, and teamwork and collaboration.
"The Communication Catalyst program enables and empowers nurses to deliver better care through the use of effective communication, emphasizing the use of empathy and developing a sense of partnership between clinical teams and patients," Swan says.
Strategy 4: Understand the Value of Technology
"As a nurse leader I really need to understand what's happening in my organization," says Mary Beth Kingston, RN, MSN, NEA-BC, system chief nursing officer at Milwaukee-based Aurora Health Care.
That's "because I'm often in the role of advocating, of translating and integrating, and decision-making regarding care coordination technology."
Kingston recommends that nurse leaders assess their organization's current technology to see how it affects care coordination and transition management, that they strategize and optimize technology, and that they collaborate with IT on data analytics.
Strategy 5: Engage the Patient and Family
Patients as passive participants in their care is becoming a thing of the past, Paschke says. "We want them to take an active role and be an active partner," she says. "So again, they need that knowledge and skill and to be able to develop that confidence to be able to manage their healthcare issues."
Rather than a paternalistic model where healthcare provides tell patients what to do, patients are now becoming participants who discuss their goals with their providers. "Nurses now are empowered to lead that healthcare team in engaging patients and families," says Paschke.
Strategy 6: Engage All Team Members in Care Coordination
The care team has grown beyond just the nurse/patient or physician/patient relationship, Paschke says. Anyone who has an impact on how patients manage their care—family members, pharmacists, nutritionists, community resources—should be engaged in the patient's care.
"One of the ways [to do this] is to identify stakeholder champions," she says. "Who are the people who are going to be specifically interested so that they can help you to champion your efforts?"
Collecting metrics that show the effectiveness of care coordination and transition management helps strengthen team member's engagement. This, in turn, heightens patient empowerment, staff and provider satisfaction, and enhances clinical quality and safety outcomes, Paschke says.