They're getting serious about wellness down on the bayou.
The Louisiana Hospital Association this month launched a workplace wellness initiative involving more than 100 hospitals across the Pelican State. The Smart Choices, Better Health Hospital Campaign will be implemented over the next three years, focusing first on promoting nutrition, exercise and weight loss, and then turning the emphasis toward smoking cessation.
The need is definitely there. The Trust for America's Health reports that Louisiana was the fifth-fattest state in 2011 because 31.6% of the adult population is obese, as are 20.7% of children. In addition, 10.7% of the population has diabetes. The Centers for Disease Control and Prevention ranks Louisiana No. 10 among states in tobacco use.
"The health status statistics in Louisiana are not wonderful. Some of us are tired of seeing our state close to the bottom of the lists on health status," LHA President and CEO John Matessino tells HealthLeaders Media.
"It doesn't take a rocket scientist to figure out that if we are going to try to improve health in this country we are going to have to do things to keep the costs of healthcare down. We are spending so much money on healthcare in this country that supports the costs of bad health practices of people," he says.
Matessino says healthcare workers must be role models in any effort to encourage Louisianans to take personal responsibility for improving and maintaining their health.
"If we are going to be leaders in the delivery of healthcare we have got to learn to walk the walk and talk the talk when it comes to healthy lifestyles," he says. "We want our hospitals to be examples to the community and hopefully through their efforts they can promote all businesses and schools to be aware of health and what it takes to eat healthy and not be sick," he says. "We are out there telling people 'look folks we are out here when you get sick but we don't want to take care of you prematurely.'"
Hospital CEOs throughout Louisiana sent "Campaign Champions" from their organizations to Baton Rouge last week for orientation. There they were given the training and resources to build a wellness team at their hospitals that will create hospital-specific worksite wellness action plans for their employees and communities, Matessino says.
LHA wants hospitals to design programs that fit their specific size and community rather than shoe-horning all hospitals into a one-size-fits-all program. The campaign has the backing of the Louisiana Department of Health and Hospitals and the Louisiana Business Group on Health.
"It's great to see hospitals leading the way to improve the health of Louisianans, not just for their patients but also for their employees who should serve as role models for their patients," DHH Secretary Bruce D. Greenstein said in a media release. "Hospitals are large employers, and I am happy they are taking the opportunity to set an example of how to help people take charge of their own health."
There are legitimate concerns about the wellness movement and its potential to infringe on the privacy of the people it is purportedly designed to benefit, particularly if more emphasis is placed on punishing unhealthy workers. However, those concerns should not cancel out efforts to promote personal responsibility for one's health. Safeguards can be built into any wellness program to ensure that they are not discriminatory toward age, sex, race, or income.
The fact is that the United States can no longer afford to ignore bulging waistlines. The cost is simply too dear. With that in mind, hospitals are the perfect places to build a culture of wellness. They are in every sizeable town in every state, and workers at these hospitals—from environmental staff to CEOs —represent a broad socioeconomic spectrum.
Successful wellness programs will not only improve the lives of hospital employees and the people they serve, but will also help the push to eliminate billions of dollars of preventable costs in hospitalizations associated with tobacco use and complications from overweight.
It's a win-win-win for hospitals, their employees, and the rest of us, too.
The economy is still too soft to change the negative outlook for not-for-profit healthcare providers in the United States in 2012, and that outlook may stay negative "for at least the next several years," says a report from Moody's Investors Service.
The bond rating agency's healthcare group is holding firm to the negative outlook it has maintained since 2008, based largely on issues that are beyond the control of providers.
The main reasons for the continued negative outlook include modest revenue growth for hospitals over the next 18 months, an expectation of continued "softness" in the economy, and challenges created by the care, payment, and regulatory transitions mandated by the Affordable Care Act, Moody's said.
"While performance in the sector is expected to remain variable in 2012, with certain organizations performing well despite the challenges, the preponderance of credit factors facing the industry is unequivocally negative, and is expected to remain negative for at least the next several years," the report stated.
Lisa Martin, senior vice president of Moody's Healthcare Group, says that any change in the dour outlook will depend upon what happens in the larger economy.
"Some of it is going to hinge on what happens with the economic recovery because that is underlying a lot of these pressures. To the extent the economy picks up that would be a primary factor driving a more stable environment," Martin told HealthLeaders Media.
Moody's cited several "negative factors supporting the outlook," including:
Pressures on hospital revenues coming from a variety of sources, including Medicare, Medicaid, and commercial payers
The myriad challenges brought on by healthcare reform, including the transition to a new care delivery model and the uncertainties that come with it, and the increase in physician employment
The soft economy, which will continue trends in lower utilization, high unemployment, and increase reliance on charity care, self-pay, and government payers.
Ongoing investment losses caused by volatile bond and equity markets, pension fund obligations, increased capital spending funded with cash reserves, increased exposure to non-cancelable operating leases, and negative valuation of swap portfolios.
All is not lost, however. Moody's identified several positive trends in the sector that may someday help to restore a positive outlook. Those trends include:
Mergers and acquisitions that generally strengthen health system balance sheets, improve efficiencies, and provide an exit strategy for bond holders
Historically low interest rates and low expense growth
Improved management and governance,
Growth in state-administered provider fee programs that create short-term relief from Medicaid reimbursement cuts
Bruce McPherson, president and CEO of the Alliance for Advancing Nonprofit Health Care, says the Moody's report raises legitimate concerns, but "overall they are more negative than I am."
"I don't disagree that there are a lot of financial challenges out there," McPherson told HealthLeaders Media. "But the hospital leaders that I talk to are pretty well on top of the challenges and are making very good progress in addressing them in terms of finding additional efficiencies and ways to improve quality. It's hard for anyone right now is on the investment side. What is a safe place to invest funds and make some sort of return? That non-patient care side of it is a real guessing game."
Martin and McPherson agree that the tough economy is forcing not-for-profit providers to run lean operations, and that is a good development.
"In this environment we are seeing more of the stronger management teams focusing on a number of areas and trying to be proactive ahead of some of the pressures that are coming," Martin says. "These management teams are focusing on being more efficient."
"In order to offset some of the revenue pressures there is a lot of focus on the expense side management," Martin says. "It's what I would call the first tier of expense management, things like restructuring employee benefits, in some cases downsizing the workforce to increase productivity. It is consolidating certain vendor contracts. It's what I would classify as blocking and tackling initiatives."
Martin says some of the more advanced managed teams are creating "tier two strategies" that involve a total process redesign to improve patient admitting, processing, and billing.
"It's more of the core way the hospital operates, things like reducing length of stay and implementing technology strategies so you can collect more data and reduce the variations in practice," she says. "There are also revenue strategies. Though in order to combat the reimbursement reductions, some are focusing on growth strategies, which can include mergers and acquisitions and also may include things like building patient outpatient centers."
McPherson says he's encouraged by the spirit of cooperation that nonprofit hospitals have undertaken during the down economy. "If there is an area that needs a new hospital or specialty program they are setting up joint ventures for those sorts of new facilities so they don't necessarily duplicate one another or staffing for specialized care because those resources are scarce," he says.
"There are other examples where folks are getting together and sharing ideas, sitting down and saying 'here is what we are doing to improve efficiency and quality. What are you doing?' I think it has turned into a much more collaborative environment," he says.
The economy is still too soft to change the negative outlook for not-for-profit healthcare providers in the United States in 2012, and that outlook may stay negative "for at least the next several years," says a report from Moody's Investors Service.
The bond rating agency's healthcare group is holding firm to the negative outlook it has maintained since 2008, based largely on issues that are beyond the control of providers.
The main reasons for the continued negative outlook include modest revenue growth for hospitals over the next 18 months, an expectation of continued "softness" in the economy, and challenges created by the care, payment, and regulatory transitions mandated by the Affordable Care Act, Moody's said.
"While performance in the sector is expected to remain variable in 2012, with certain organizations performing well despite the challenges, the preponderance of credit factors facing the industry is unequivocally negative, and is expected to remain negative for at least the next several years," the report stated.
Lisa Martin, senior vice president of Moody's Healthcare Group, says that any change in the dour outlook will depend upon what happens in the larger economy.
"Some of it is going to hinge on what happens with the economic recovery because that is underlying a lot of these pressures. To the extent the economy picks up that would be a primary factor driving a more stable environment," Martin told HealthLeaders Media.
Moody's cited several "negative factors supporting the outlook," including:
Pressures on hospital revenues coming from a variety of sources, including Medicare, Medicaid, and commercial payers
The myriad challenges brought on by healthcare reform, including the transition to a new care delivery model and the uncertainties that come with it, and the increase in physician employment
The soft economy, which will continue trends in lower utilization, high unemployment, and increase reliance on charity care, self-pay, and government payers.
Ongoing investment losses caused by volatile bond and equity markets, pension fund obligations, increased capital spending funded with cash reserves, increased exposure to non-cancelable operating leases, and negative valuation of swap portfolios.
All is not lost, however. Moody's identified several positive trends in the sector that may someday help to restore a positive outlook. Those trends include:
Mergers and acquisitions that generally strengthen health system balance sheets, improve efficiencies, and provide an exit strategy for bond holders
Historically low interest rates and low expense growth
Improved management and governance,
Growth in state-administered provider fee programs that create short-term relief from Medicaid reimbursement cuts
Bruce McPherson, president and CEO of the Alliance for Advancing Nonprofit Health Care, says the Moody's report raises legitimate concerns, but "overall they are more negative than I am."
"I don't disagree that there are a lot of financial challenges out there," McPherson told HealthLeaders Media. "But the hospital leaders that I talk to are pretty well on top of the challenges and are making very good progress in addressing them in terms of finding additional efficiencies and ways to improve quality. It's hard for anyone right now is on the investment side. What is a safe place to invest funds and make some sort of return? That non-patient care side of it is a real guessing game."
Martin and McPherson agree that the tough economy is forcing not-for-profit providers to run lean operations, and that is a good development.
"In this environment we are seeing more of the stronger management teams focusing on a number of areas and trying to be proactive ahead of some of the pressures that are coming," Martin says. "These management teams are focusing on being more efficient."
"In order to offset some of the revenue pressures there is a lot of focus on the expense side management," Martin says. "It's what I would call the first tier of expense management, things like restructuring employee benefits, in some cases downsizing the workforce to increase productivity. It is consolidating certain vendor contracts. It's what I would classify as blocking and tackling initiatives."
Martin says some of the more advanced managed teams are creating "tier two strategies" that involve a total process redesign to improve patient admitting, processing, and billing.
"It's more of the core way the hospital operates, things like reducing length of stay and implementing technology strategies so you can collect more data and reduce the variations in practice," she says. "There are also revenue strategies. Though in order to combat the reimbursement reductions, some are focusing on growth strategies, which can include mergers and acquisitions and also may include things like building patient outpatient centers."
McPherson says he's encouraged by the spirit of cooperation that nonprofit hospitals have undertaken during the down economy. "If there is an area that needs a new hospital or specialty program they are setting up joint ventures for those sorts of new facilities so they don't necessarily duplicate one another or staffing for specialized care because those resources are scarce," he says.
"There are other examples where folks are getting together and sharing ideas, sitting down and saying 'here is what we are doing to improve efficiency and quality. What are you doing?' I think it has turned into a much more collaborative environment," he says.
For the most part, the nation's hospitals have presented a united front throughout the great healthcare reform debate. What’s good for one hospital is good for all, or so goes the mantra.
The public statements of the American Hospital Association and other hospital lobbies on divisive issues like the Affordable Care Act are models of measured banality. And that is a good thing.
They represent hospitals' interests on one of the most-bitter legislative battles in a generation, and have tried to remain bipartisan as best they can. That is harder than it seems when you consider that hospitals have constituents—and elected officials—in red and blue states, and in every sizeable town in the nation.
However, a couple of nettlesome issues that just won't go away could pit state hospital associations against one another, or force the hospital lobby to choose sides in a bitterly divided, locked-down Congress.
First, it appears that there is a growing rift between the AHA and House Republicans that apparently started with AHA’s support of the Affordable Care Act. AHA agreed to about $155 billion in funding cuts under ACA in exchange for expanded healthcare coverage.
That has not been forgotten by House Republicans opposed to the ACA, and who this month renewed their push for additional cuts to hospital Medicare reimbursements.
The reductions detailed in H.R. 3630 would take funding from hospitals and use it to cover the deficit created by the extensions of the Social Security tax holiday and unemployment benefits, and by the so-called "doc fix" that aims to address cuts to physician reimbursements.
AHA has issued a media release saying that the additional Medicare funding cuts under consideration in Congress, which include the cuts under mandatory sequestration, could cost the nation's hospitals $61.4 billion over the next decade, forcing them to trim their payrolls of nearly 278,000 jobs.
The Republican-controlled House Ways and Means Committee in a recent press release mocked the AHA's claims that the cuts would gravely harm the nation's hospitals.
"Not so long ago, the major hospital trade associations endorsed and strongly supported legislation that became law. It contained $155 billion in hospital Medicare cuts—more than 10 times the reductions in H.R. 3630," the GOP media release said.
When the leadership of one of the most powerful committees in the House issues a public statement ridiculing your fears, brace yourself. For House Republicans, it's payback time.
And then there is the "rural floor" issue and the Massachusetts Hospital Association’s exploitation of a loophole in the byzantine ACA bill that would give Bay State hospitals an additional $367 million in annual Medicare funding. That funding, only for Massachusetts acute care facilities, would be taken from Medicare funding for hospitals in the 49 other states, and those states are not happy about it.
The issue first came to light in August, and many state hospital associations are still quite incensed. Last week, the leaders of 19 state hospital associations complained in a letter to President Obama that Massachusetts' "manipulation" of the ACA would come at the expense of every other state. They asked the president to remove the loophole from his 2013 budget.
MHA defended the windfall and said in a statement that it "followed all the rules regarding the rural floor regulations."
So, state hospital associations that are supposed to wage the home front battles to preserve funding are instead fighting amongst themselves.
At the same time, the AHA's support for ACA has placed hospitals in the crosshairs for more funding cuts from an avenging Republican majority with an axe to grind.
At a time when hospitals need to project a united and bipartisan front as funding comes under attack, neither of these developments is healthy.
While healthcare continues to lead the nation in job growth, the employment landscape is ever-shifting. On Tuesday, notices of impending layoffs went out to employees of seven Louisiana State University public hospitals, as system executives prepared to implement $29 million in budget cuts ordered by Governor Bobby Jindal's administration. Nationwide, there were a number of notable moves in the C-suite:
Medicare funding cuts under consideration by Congress could cost the nation's hospitals $61.4 billion over the next decade, forcing them to trim their payrolls of nearly 278,000 jobs, the American Hospital Association said this week.
The reimbursement reductions detailed in H.R. 3630 would take funding from hospitals and use it to cover the deficit created by the extensions of the Social Security tax holiday and unemployment benefits, and by the so-called "doc fix" that aims to address cuts to physician reimbursements .
An analysis done for AHA by the researcher firm Tripp Umbach determined that if the provisions of H.R. 3630 were implemented, hospitals could see a reduction in funding of nearly $20 billion, along with about 83,000 job losses.
In addition, the study found that the mandatory sequestration that is scheduled to go into effect in 2013 could cost hospitals another 194,000 jobs and more than $40 billion in funding.
"Cuts in funding for hospital care will threaten jobs at a time when our nation needs to be creating jobs, not eliminating them," AHA President/CEO Rich Umbdenstock said Wednesday in a media release. "H.R. 3630 would lead to further job loss in hospitals, an ill-advised move in these tough economic times."
The Bureau of Labor Statistics reported this month that hospitals created 89,100 jobs in 2011, more than double the 37,300 jobs hospitals created in 2010.
In addition, AHA officials fear that hospitals may be caught in the political crossfire between the Obama administration and the Republican-controlled House. The AHA supported the Affordable Care Act and agreed to about $155 billion in funding cuts over the next decade in exchange for expanding healthcare coverage.
"The $155 billion was really tied to coverage expansion—that as coverage expands, there will be 31 million more people covered under Medicaid and the private exchanges and that provides an offset to some of the cuts in the $155 billion," Caroline Steinberg, AHA's vice president of trends analysis, told HealthLeaders Media.
Republicans on the House Ways and Means Committee, however, have openly dismissed the AHA's claims as alarmist. Last month the GOP leadership on the committee issued a press release stating that the cuts proposed by H.R. 3060 represented 0.5% of the $2.6 trillion in projected Medicare spending over the next decade, "hardly a 'major reduction.'"
"Not so long ago, the major hospital trade associations endorsed and strongly supported legislation that became law. It contained $155 billion in hospital Medicare cuts—more than 10 times the reductions in H.R. 3630," the GOP media release said.
A GOP staffer on the Ways and Means Committee told HealthLeaders Media Thursday that the House leadership stands by the points made in the media release.
Steinberg says hospitals are "very concerned about how this is going to shake out between figuring out ways to fund the physician fix."
"We are already facing a 2% sequester and then of course even with the sequester there will be more deficit reduction in the coming years. On top of that hospitals are seeing a lot of pressures from states on the Medicaid front," she said.
AHA officials fear the cuts in H.R. 3060 are a continuation of a larger assault on the nation's hospitals.
"The $155 billion that AHA put on the table for the Affordable Care Act was our attempt to show that it had to be a sacrifice for everybody," AHA Board Chair Teri Fontenot, the president/CEO of Woman's Hospital in Baton Rouge, LA told HealthLeaders Media.
"If you are going to get something—which we wanted more insurance coverage for uninsured patients—then you have to be willing to give something up. But everybody has a stake in this and each group ought to be looking at how they can work together."
"There really is a problem here financially, but to continually go after one segment of healthcare over and over again is patently unfair and enough is enough. That is why we are pushing back so hard on this right now," Fontenot says.
Fontenot adds that hospitals are hoping not to fall victim to the Beltway partisan politics.
"The healthcare sector is always in the cross hairs. It is such a huge piece of the federal budget and the federal deficit," she says. "And because the government is somewhat removed from providing the services. They've got the providers and the payers between that. I don't think they can appreciate the impact because they aren't working personally with the recipients."
She said hospitals are trying to play it down the middle and "work with everybody in Congress." That starts at the local level.
"We are constantly encouraging our members to work closely with their Congressional delegation members and staff, particularly when they are at home," she says. "We need to put pressure on them at home and explain to them very articulately what the consequences of the aggregate decisions that are being made at the federal level. It needs to be brought down to the patient level and how it affects that member of Congress's constituents, regardless of party affiliation."
Thomson Reuters on Tuesday named its "15 Top Health Systems" in the nation based on clinical performance.
The fourth annual study reviewed clinical outcomes at more than 300 health systems across the country and picked the top 15 based on a composite score of eight measures of quality, patient perception of care, and efficiency.
"This year we are seeing stronger system-wide performance and increased rates of improvement, particularly among the 15 Top Health Systems award winners," Jean Chenoweth, senior vice president for performance improvement and 100 Top Hospitals program at Thomson Reuters, said in a statement.
"Health system performance is beginning to reflect aspirations to provide more consistent outcomes across communities served. Healthcare reform appears to have stimulated the increased rate of improvement at the system level."
The study divides the 15 top health systems into large, medium, and small groups based on total operating expenses. The winners are as follows:
Large Health Systems
More than $1.5 billion total operating expenses:
Banner Health, Phoenix, AZ
CareGroup Healthcare System, Boston, MA
Jefferson Health System, Radnor, PA
Memorial Hermann Healthcare System, Houston, TX
St. Vincent Health, Indianapolis, IN
Medium Health Systems
Between $750 million-$1.5 billion total operating expenses:
Baystate Health, Springfield, MA
Geisinger Health System, Danville, PA
HCA Central and West Texas Division, Austin, TX
Mission Health System, Asheville, NC
Prime Healthcare Services, Ontario, CA
Small Health Systems
Less than $750 million in total operating expenses:
Baptist Health, Montgomery, AL
Maury Regional Healthcare System, Columbia, TN
Poudre Valley Health System, Fort Collins, CO
Saint Joseph Regional Health System, Mishawaka, IN
Tanner Health System, Carrolton, GA
Thomson Reuters says its study looked at eight metrics that gauge clinical quality and efficiency: mortality, medical complications, patient safety, average length of stay, 30-day mortality rate, 30-day readmission rate, adherence to clinical standards of care (evidence-based core measures published by CMS), and HCAHPS patient survey score.
The study found that regardless of their size the top health systems shared many of the same qualities, including:
Lower 30-Day Mortality Rates
The 15 top health systems held post-discharge 30-day mortality rates steady. Peer health systems showed a significant increase in post discharge mortality.
Better Survival Rates
Top hospitals had 17% fewer deaths than expected considering patient severity, while non-winning hospitals had 4% more deaths than expected.
Fewer Complications
Patients of top health systems had 19% fewer complications.
Shorter Hospital Stays
Patients treated in top systems have an average length of stay of 4.7 days, nearly half a day shorter than their peers' median of 5.1 days.
Better Patient Safety and Core Measure Adherence
Top health systems had 23% fewer adverse patient safety events than expected and had better adherence to core measures of care than their peers.
The study used the 2010 Medicare Provider Analysis and Review (MedPAR) and the CMS Hospital Compare data sets to examine health systems with two or more short-term, general, non-federal hospitals; cardiac and orthopedic hospitals; and critical access hospitals.
Thomson Reuters on Tuesday named its "15 Top Health Systems" in the nation based on clinical performance.
The fourth annual study reviewed clinical outcomes at more than 300 health systems across the country and picked the top 15 based on a composite score of eight measures of quality, patient perception of care, and efficiency.
"This year we are seeing stronger system-wide performance and increased rates of improvement, particularly among the 15 Top Health Systems award winners," Jean Chenoweth, senior vice president for performance improvement and 100 Top Hospitals program at Thomson Reuters, said in a statement.
"Health system performance is beginning to reflect aspirations to provide more consistent outcomes across communities served. Healthcare reform appears to have stimulated the increased rate of improvement at the system level."
The study divides the 15 top health systems into large, medium, and small groups based on total operating expenses. The winners are as follows:
Large Health Systems
More than $1.5 billion total operating expenses:
Banner Health, Phoenix, AZ
CareGroup Healthcare System, Boston, MA
Jefferson Health System, Radnor, PA
Memorial Hermann Healthcare System, Houston, TX
St. Vincent Health, Indianapolis, IN
Medium Health Systems
Between $750 million-$1.5 billion total operating expenses:
Baystate Health, Springfield, MA
Geisinger Health System, Danville, PA
HCA Central and West Texas Division, Austin, TX
Mission Health System, Asheville, NC
Prime Healthcare Services, Ontario, CA
Small Health Systems
Less than $750 million in total operating expenses:
Baptist Health, Montgomery, AL
Maury Regional Healthcare System, Columbia, TN
Poudre Valley Health System, Fort Collins, CO
Saint Joseph Regional Health System, Mishawaka, IN
Tanner Health System, Carrolton, GA
Thomson Reuters says its study looked at eight metrics that gauge clinical quality and efficiency: mortality, medical complications, patient safety, average length of stay, 30-day mortality rate, 30-day readmission rate, adherence to clinical standards of care (evidence-based core measures published by CMS), and HCAHPS patient survey score.
The study found that regardless of their size the top health systems shared many of the same qualities, including:
Lower 30-Day Mortality Rates
The 15 top health systems held post-discharge 30-day mortality rates steady. Peer health systems showed a significant increase in post discharge mortality.
Better Survival Rates
Top hospitals had 17% fewer deaths than expected considering patient severity, while non-winning hospitals had 4% more deaths than expected.
Fewer Complications
Patients of top health systems had 19% fewer complications.
Shorter Hospital Stays
Patients treated in top systems have an average length of stay of 4.7 days, nearly half a day shorter than their peers' median of 5.1 days.
Better Patient Safety and Core Measure Adherence
Top health systems had 23% fewer adverse patient safety events than expected and had better adherence to core measures of care than their peers.
The study used the 2010 Medicare Provider Analysis and Review (MedPAR) and the CMS Hospital Compare data sets to examine health systems with two or more short-term, general, non-federal hospitals; cardiac and orthopedic hospitals; and critical access hospitals.
It seems each new study that examines a particular facet of nursing also reinforces the notion that nurses are the backbone of healthcare delivery in the United States.
Nurses play the leading role in delivering and coordinating care for patients, safeguarding them against medical errors, and acting as the patients' advocate at a time when patients are struggling with anxiety, fear, pain, and confusion.
The role of nurse advocate and care coordinator will only grow in coming years as the practice of medicine gets more complex, and the medical care team approach becomes more entrenched. One could argue that experienced and well-trained nurses at the bedside are as big a factor in determining healthy patient outcomes as any other component in healthcare delivery. Someone will have to lead the care team, and nurses are the obvious choice.
The common sense findings in a Robert Wood Johnson Foundation study this month underscore the importance of nurses' critical thinking skills as the key component in reducing errors and improving outcomes.
Independently reconciling medications with patients' records;
Verifying medications and doses with colleagues;
Coping with interruptions and distractions;
Interpreting physicians' orders;
Documenting near misses;
Communicating openly with physicians, pharmacists and other team members.
This is not breaking news. Everything on that list would prompt a knowing nod from nurses.
However, these findings also give those who aren't nurses a better idea of the challenges that nurses face every day and the skills they need to do their job effectively. Imagine the sum total of these 10 focus points for each patient, multiply it by the number of patients under a nurse's care at just about any time and on no particular floor, and you might have a better idea of the pressures on time that are placed upon nurses on any given 8- or 12-hour shift.
Among the most serious problems nurses continually face are missing medications and the timeliness of medication delivery, the study found. Administering medication seems simple enough until the pressures and distractions that nurses routinely face are factored in.
For example, medication delivery schedules at hospital pharmacies may not jive with nurses' work schedules. Or, the patient may be scheduled for other tests that coincide or interfere with medication times. The INQRI study found that effective strategies to ensure medication compliance included repeated calls to the pharmacy to check on medications' status, marking drugs to be given immediately, and often picking up the medications themselves instead of waiting for delivery.
The study made clear that the ability of nurses to effectively communicate with everyone in the care continuum—from the patient to the subspecialist—is particularly important.
Coauthor Linda Flynn, RN, professor and associate dean for graduate nursing education at Rutgers, said the study "identified communication with doctors, pharmacists and other nurses as an indispensable part of preventing medication errors and ensuring patient safety."
"That means that nurses also (should) take responsibility for developing good relationships with all members of the health care team, so that when they have to locate missing medication, double-check doses or ask questions about new medications, they get the answers they need when they need them," Flynn said.
The study recommends tapping into nurses' clinical reasoning as a foundation for reducing medication errors in the care team environment. Such a program would push nurses to move beyond the "five rights" of medication administration (1. Right patient, 2. Right Route, 3. Right Dose, 4. Right Time, 5. Right medication) and to use clinical reasoning to protect their patients from harm.
The study also calls for retooling provider education to promote the team care approach. That includes learning basic errors theory and team-centered clinical problem-solving exercises.
As the study makes clear, nurses will face a variety of new challenges in the coming years as they are asked to play a greater role in patient care coordination. Everyone else in the healthcare delivery system must understand that role and must be willing to provide nurses with the support and resources they need to do their many jobs.
A new program at Spectrum Health in Grand Rapids, MI is identifying "frequent fliers" at the system's emergency departments and placing those patients with a multi-specialist intervention team.
The program, while only six weeks old, has steered more than 140 patients to the less-expensive coordinated care program and has saved the health system a net total of about $300,000.
"It's going really well—better than we had hoped," says R. Corey Waller, MD, a specialist in addiction and emergency medicine, and director of the Spectrum Health Medical Group Center for Integrative Medicine.
"We are focusing on getting the patients better and not decreasing ED visits, because if you do the one the other will follow," he says.
The program was launched in early December and identified about 950 patients who'd used the emergency rooms at Spectrum's Butterworth and Blodgett hospitals more than 10 times in a year. Those patients accounted for more than 20,000 total visits and up to $50 million in costs annually.
The center randomly contacted about 190 patients, 140 of whom agreed to the coordinated care treatment regimen.
"By the time we get them they are pretty broken and the ones that show up are the ones that want help. What we are seeing right now is going to be a skewed view to the person who is sicker and wants help because they are coming in willfully," Waller says.
"Once we get them into the center they stay because they realize the approach we take is different," he says. "We don't fire them and we tell them straight up we don't care what they are doing that may have irritated other doctors in the past. We just need to know it so we can come together with a plan."
The center's treatment team uses addiction specialists, psychologist, RN case managers, and social workers to confront not only the medical issues—often pain, addiction, or both—that are driving these patients into the ED, but also the psychological and social issues that may be exacerbating the problems.
"Most of these patients don't know what do to. They really want someone to guide them through this," Waller says. "There are times when the RN case manager or social worker is able to guide them better than I do. We work together with each of the patients after we do our intake. Any plan I come up with has to be in line with the psychological side and the social side. We manipulate our plans so they work together and we present that to the patient before we finalize the plan."
Waller says the patients are not chastised nor forced to agree to treatment plans dictated by the medical staff. "We don't have them sign any contracts and that is the big thing," he says. "If you have someone with true pain or who has a true neurobiological addiction who is not being treated they are not going to adhere to some contract because they don't see risk and benefit the same way we do."
The program is expected to grow as more eligible patients learn about it and understand that it's not a trick.
"They're scared. They think it is a bust," Waller says. "When they realize we are trying to get them some help they come back. It's a matter of getting them to trust us. Now we have a core group of patients in the neighborhood saying 'they are here to help you out.'"
As many as 40% of the center's patients are neurobiologically addicted to some substance. Waller says the center has successfully developed a treatment regimen that couples medication with behavioral therapy and modification. "More than 90% have stayed clean since they started treatment here," he says.
The net savings of $300,000 in six weeks and the drop in ED use has attracted the attention of payers, including commercial insurers with Medicaid plans.
"I just want them to pay for an episode of care. 'You give me the money we will get them better.' It is a small amount of money but it helps us to get closer to solvency," Waller says. "This is not a clinic built to make money but to save money. What we are trying to do is make sure that it is a sustainable business model. Right now we have a three-tiered payment system. We get $700 for an easy patient, $1,400 for a medium patient, and $2,100 for a difficult patient. And that covers everything. It saves a ton of money."
The center has kept detailed data on the program.
"The goal is to come up with a screening tool so we can identify them on visit No. 2 to the ED and get them the social or psychological or medical services they need before they turn into high frequency use," he says.
With the implementation of the Affordable Care Act, Waller says Spectrum's model could provide an affordable way to control healthcare costs for that high-usage population.
"One of the biggest issues is how do we create comprehensive care and still pay your bills? If you try to create comprehensive care in every doctor's office you will lose your shirt," he says.
"What needs to happen is a model like this that is more of a specialty place where you filter patients so that everyone who has a questionable issue or multiple issues would come through here and be medically, psychologically and socially evaluated and stabilized."
When that's done, Waller says, the patients can be transferred to a traditional primary care environment. "All they have to do is maintain it," he says, "because it becomes so expensive if every doctor's office has to have a psychologist or a social worker or five RN case managers."
Waller says he wants to show other health systems how to replicate Spectrum's success.
"We are retooling efficiencies right now," he says. "The reality is you have to have appropriate through-put without marginalizing the information we are getting. In two weeks we will have that on paper so we can have the billing codes and the ways it has to be documented set up."
"Within two to three weeks we are going to be able to tell somebody how to replicate this if they would like to."
