1. EMPOWERING NURSES TO LEAD
ND Center for Nursing
FUTURE OF NURSING
CAMPAIGN FOR ACTION

2. NAVIGATING THE COMPLEX HEALTH SYSTEM
A Primer for The Nurse

3. Leadership Program is divided into 4 main areas
Leadership Program is divided into 4 main areas. Communication is foundational for learning and understanding about systems. Knowledge of how systems function is necessary to institute change. The ability to accept and engage in change is necessary to be an advocate for health policy. All nurses are expected to lead!

4. What is Nursing
Nursing is the protection, promotion, and optimization of health and abilities, prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations. ANA

5. What is a Complex System
A complex system is a system composed of interconnected parts that as a whole exhibit one or more properties (behavior among the possible properties) not obvious from the properties of the individual parts

6. Too Many Silos

7. System vs Silo “System”
OB/Gyn – Oncology – Schedule – Surgery – Follow-up
Fear – Trust - $$
“Silo”
OB/Gyn
Oncology
Schedule
Surgery
Follow-up
Fear – Emotional upheaval – Time - Travel - $$$$$
2/5/2014

8. From Agency for Healthcare Research & Quality
“it is in inadequate handoffs that safety often fails first”
“nurses are the health care professionals most likely to intercept errors and prevent harm to patients”

9. Knowledge of “System” Recognize “how things work” – and why
Know who is responsible
Ensure transfer of correct information
Provide patient support to wellness—
Track referrals & help resolve problems
Lead your Team to excellent patient service
Help patients identify sources of service & make appointments – Care Coordination

10. Why Understand ‘Systems’
Nurse is primary to patients (leader of the care team)
First connection in most any setting
Knows diagnosis, plan of care, desired outcome
Knows Patient vulnerabilities
Last connection in most any setting
Nurse most trusted of care-givers
Nurse facilitates Care Coordination: internal & external

11. Why Care Coordination?
Patients and families hate it that we can’t make this work
Happier patients
Poor hand-offs lead to delays, lapses in care, adverse drug effects, and other situations that may be dangerous to health
Fewer problems – for patient and for health system
Improve the health of the population
Less waste
Enormous waste is associated with duplicate testing, unnecessary referrals, unwanted specialist-to-specialist referrals, and failed transitions from hospitals, EDs, & nursing homes.
Clinical practice will be more rewarding

12. THE PATIENT Life-style Diagnoses Treatment options Family obligations
Hopes/dreams
Support systems
The patient, not the diagnoses should be the center of the discussion.

13. OBJECTIVES
Review the health care system’s care provider types and levels of service, regulation, and reimbursement mechanisms;
Investigate your organization’s structure and processes;
Describe your position/role within the organizational structure; and
Demonstrate your knowledge of the health system to help a patient (and family) consider and access viable options for achieving personally desired health outcomes.

14. Types of Providers Community Outpatient Inpatient In-home
Available to the community at large or a specific segment of the population for prevention, support, or treatment
Outpatient
The patient receives treatment and services; remains less than 24 hours
Inpatient
The patient stays overnight for treatment, support, and lodging
A hospital Medicare “Observation” patient is considered an outpatient in terms of reimbursement even though housed for up to 5 days in a hospital bed. This designation is being contested.
In-home
The patient receives prevention, support, and treatment services in the individual’s private home or in a current place of residence such as a group home or assisted living facility that does not prohibit such services

15. Ownership & Management
General Providers – Available to qualified general population
Religious Organizations
‘Community’ owned
Privately owned
Government owned
Special Population Providers
Veterans Health Administration (VAMC)
Indian Health Service (IHS)
Migrant Health Services
Public Health Services (PHS)
Government owned
Homeless

16. Community Health Providers
Public Health – Counties/Cities
Rural Health Clinics , FQHC -- Medicare/Medicaid certified – different fee structure
WIC
School Nurses
Wellness/Fitness Centers
Vaccination Clinics
Faith Community Nurses
Community Action Agencies
Social Service/Mental Health Agencies
Durable Medical Equipment Suppliers
Pharmacies
Industrial Health – may be limited to certain employees

17. Outpatient Providers Medical Clinics – 305 est (52 RHC, 7 FQHC)
Ambulatory Surgery Centers - 12
Renal Dialysis Centers (ERSD) - 16
Physical, Occupational, Speech Therapy - 1 CORF, ?? # independent
Cardiac and Wellness Centers
Addiction/Mental Health Therapy - 54
Telehealth -
Adult Day Care – Respite Care
Diagnostic Services
Laboratory
Radiology
Screening
Telehealth

18. Inpatient Providers Hospital Acute General Critical Access - 37
Swing Bed (LTC) - 37
Prospective Payment – 6
Rehabilitation - 1
Long Term Acute Care - 2
Acute Psychiatric - 3
Acute Special – transplantation - 2
Nursing Facility ,213 residents in 2012
Basic Care Facility – 68 (may be wing of nursing facility) 4,152 residents in 2012
Assisted Living Facility – ,195 residents in 2012
Hospice – 13
“Treatment” Centers -
Group Homes -
g. "Hospital" means a facility that provides continuous nursing services, the principal activity or business of which is the reception of a person for diagnosis, medical care, and treatment of human illness to meet the needs of the patient served.
(1) "General acute hospital" means a facility with physician services available, permanent facilities that include inpatient beds, and continuous registered nurse staffing on a twenty- four-hour basis for treatment or care for illness, injury, deformity, abnormality, or pregnancy.
(2) "Primary care hospital" means a facility that has available twenty-four-hour licensed health care practitioner and
nursing services, provides inpatient care to ill or injured persons prior to their transportation to a general acute hospital, or
provides inpatient care to persons needing acute-type care for a period of no longer than an average of ninety-six hours,
excluding persons participating in a federal swing-bed program.
(3) "Specialized hospital" means a facility with hospital characteristics which provides medical care for persons with a categorical illness or condition.
h. "Licensed health care practitioner" means an individual who is licensed or certified to provide medical, medically related, or advanced registered nursing care to individuals in North Dakota.

19. In-Home Providers Home Health - 35
Therapy -- Physical, Occupational, Respiratory, Speech
Personal Care – Family, Private, HCBS
Homemaking
Hospice - 13
Telehealth
Diagnosis -- Lab draws, Mobile radiology

20. INDEPENDENT HEALTH PROFESSIONALS
Physicians – Primary and specialty care
Dentists
Pharmacists
Advanced Practice Nurses – 558 with prescriptive authority
Optometrists/Opticians
Chiropractors
Psychologists
Counselors
Addiction Counselors

21. Levels of Service Preventive – Clinic, Community
Acute Care – Clinic, Hospital
Chronic Care – Clinic, Hospital, Long Term Care, In-Home Care
Long term Care – Nursing Facility, Basic Care, Assisted living, In-Home Care
The goal would be to make Preventive always the first level

22. Preventive Services
Medical Clinic –screening, diagnosis, education, referral
Hospital – diagnosis, treatment, education, referral
Outpatient Providers – screening, diagnosis, treatment, support
Therapies – diagnosis, treatment, training, education, referral
Wellness Centers – training, education, support
Community Services – treatment, education, support, referral
Family services – domestic, financial
Support Groups
Nutrition
Personal care

23. Acute Services
Medical Clinic – diagnosis, treatment, education, referral
Hospital – diagnosis, treatment, education, referral
Outpatient Providers – diagnosis, treatment, education, referral, support

24. Chronic Care Services
Clinic – screening, diagnosis, treatment, education, referral
Hospital – diagnosis, treatment, education, referral
Long Term Care providers – diagnosis, treatment, education,
personal care, support
In-Home – treatment, personal care, support
Community – treatment, education, support, referral

25. Long Term Care Services
Assisted Living – lodging, meals, optional services (Med Management, diet)
Basic Care – lodging, personal care, med management, nutrition, activities
Nursing Facility – lodging, personal care, treatment, skilled nursing,
Group Homes – specific population housing, treatment, support, supervision,
Mental Illness
Developmental Delays
Traumatic Brain Injury
Addictions

26. Outside Forces or at least ‘outside’ to individual caregivers
Regulating
Standardizing
Defining
Measuring
Enabling
Limiting
Improving
Enriching
Challenging
Reimbursing
Much different from most other businesses – multiple ‘layers’ with indirect management and mixed messages

27. Who Defines Providers & Services
Legislature – Laws
City - Regulations & Enforcement
State agencies – Regulations & Enforcement
Licensing Agencies (Health, Human Services, Professional Boards)
Congress – Laws
Federal Agencies – Regulations & Enforcement
Department of Health & Human Services
Centers for Medicare and Medicaid, VAMC, IHS
FDA, DEA, OSHA, CDC, DOL
Health Care Industry - Financial Viability, Patient Demands, Workforce Availability
Insurance Carriers – Financial Viability, Population, Marketplace
Technology -- Pharmaceuticals - Research & Development, Financial Viability
Public – Liability suits, (Lack of) Advance Directives, Requests and Demands for Service
Professional/Trade Organizations – Education, Lobbying, Research
Academia – Education, Research

28. The Regulation of Health Care
Licensure – State -- description of service & enforcement
the state or condition of having a license granted by official or legal authority to offer specific services and take specific action not permitted by persons without such a license: i.e. Registered Nurse, Pharmacist, Hospital, etc. (edited)
Certification – Federal -- Medicare/Medicaid – description of service & payment
The Social Security Act (the Act) mandates the establishment of minimum health and safety and CLIA standards that must be met by providers and suppliers participating in the Medicare and Medicaid programs.  These standards are found in the 42 Code of Federal Regulations.  The Secretary of the Department of Health and Human Services has designated CMS to administer the standards compliance aspects of these programs. 
Some individual professions are ‘certified’ rather than ‘licensed’
Accreditation -- The Joint Commission, etc.
Joint Commission standards are the basis of an objective evaluation process that can help health care organizations measure, assess and improve performance. The standards focus on important patient, individual, or resident care and organization functions that are essential to providing safe, high quality care. The Joint Commission’s state-of-the-art standards set expectations for organization performance that are reasonable, achievable and surveyable.
Licensure of an entity or individual requires certain conditions to be met by anyone holding that license. This establishes standardization of definition.
Compliance with licensure requirements is evaluated by the licensing agency.
Certification of an entity or individual requires certain conditions to be met by anyone holding that license.
Certification requirements for compliance with Medicare and some Medicaid providers are enforced under contract by State departments of health
Certification requirements for compliance with some Medicaid providers are enforced by State Medicaid agencies
Accreditation is a voluntary quality measurement system, with payment by the accredited entity.
Some compliant accredited agencies are deemed to be in compliance with Medicare certification requirements.

29. Nongovernmental Governing Bodies
Governing Body(ies) of a Facility (Board of directors, owners, medical staff, and department heads – even the community) establish direction; determine scope of services; determine financial status; establish personality.
Professional Associations keep membership informed on changes and regional or national issues; advocate for providers with legislative lobbying; offer education; afford peer support.
Provider Organizations keep membership informed on changes and regional or national issues; advocate for providers with legislative lobbying and marketing efforts; offer education; afford peer support
Institutions of Higher Learning set the attitude and abilities of students; perform research that leads to new treatment and technology; develop clinical expertise and standards; contribute to standards of ethics.
Payers of Service define elements of services (allowable/covered vs. non-allowable/uncovered): not always coherent with regulations and standards of (clinical) practice. Government pays for a lion's share of the health care that is delivered and determines what is covered or not. Insurance companies have stock-holder profit motives. The general public who utilize health care services generally expect to rely on the health care delivery system to fix them when something goes wrong.
Customers have the least impact on governing the health care system except by seeking alternative providers.

30. Reimbursement for Health Services
Private Health Insurance (much based on Medicare Rules)
Premium paid by insured and/or employer
Payment for covered services by participating providers
Private Self Pay
For uninsured patients or non-covered services
Medicare
For age and disability qualified
Payment for covered services by participating qualified providers
Medicaid
For income, age , and disability qualified
Population based VAMC, IHS, Public Health,
For specific populations for covered services by participating qualified providers
Reduced fees (sliding scale based on income) and Free (charity care)
When there is no other pay source
Providers (except hospitals) may choose to not accept/treat patients with no payment source
Rugby Hospital had the first HMO in North Dakota – many years ago. And it still operates successfully

31. Definitions Covered Services Participating Providers/Practitioners
Medical and health care services defined by the paying agency. Restrictions vary by paying agency and specific coverage plan. i.e., a. May require specific sequence of diagnostic tests or treatments to qualify for payment;
b. Pay for specific treatment for only specific diagnosis. Neither the patient nor the provider or practitioner decides what is a covered service although both agree by virtue of the contract.
Participating Providers/Practitioners
Providers and Practitioners who have an agreement with the paying agency for certain services under certain conditions
Qualified Providers/Practitioners
Providers/Practitioners who are licensed or credentialed to perform service for which payment is requested
Prospective Payment System
A means of determining reimbursement to hospitals based on predetermined prices, commonly from Medicare. Payments are typically based on codes such as Diagnosis-related Groups (DRGs), Current Procedural Terminology (CPTs), or Ambulatory Payment Classifications (APCs)
Fee for Service – Cost-based
Services are unbundled and paid for separately

32. Employer Organization
Legal Description
Licensure –
Certification –
Accreditation –
Organizational Governance
Mission Statement
Who is responsible
Organizational Structure
Ownership - Corporation, proprietorship, partnership, government
For Profit/Nonprofit
Single site? – Multiple sites?
Related Providers
Mission/Vision Statements
Teaching Facility?
From Employer Agency Annual Report or Website

33. Nursing Facility/Assisted Living Facility Owner
Organizational Chart
Nursing Facility/Assisted Living Facility Owner
Governing Body
Administrator Medical Director
Consultants Pharmacist Dietitian Social Worker ________________________________________________________________________________________________________________________________
Dietary Building/Grounds Nursing Activities Social Work Business Office
FSS Plant Manager Director of Nursing Activities Director Social Work Designee Business Office Manager
Cook Assistant MDS RN Volunteers Purchasing
Dietary Aides Housekeepers Staff Nurses Clerk
Laundry Workers Nurse Aides OR
Examples of Organizational Charts

34. Employer Description Services Provided Population Served
Management Team
Hiring, Orientation, Training, Retention
Policies
Procedures/Processes
Quality Assessment/Performance Improvement
Level of Decision-making
Community Involvement
Complete Handout – Employer Organization Worksheet

35. Reflect on your Employer Organization
Accurately describe the Provider Type and Services provided
List Operational Priorities - from Your Perspective
Do you understand the political climate -?
Within the organization
Within the Community
What are usual referral patterns?

36. Nursing Department Organizational Location -- refer to chart
Intra-Organizational Communication
Clear Expectations
Two-way Interactions
Patient Care Policies
Staffing Patterns
Contribute to Organizational Decision-making?

37. What is your position title? Do you ‘fit’ your position?
Your Position within the Department Level of Responsibility & Accountability
What is your position title?
Do you ‘fit’ your position?
Do you like your position?
Do you have & use opportunities for growth?
more
Complete Handout – Job.Communications

38. What Can I Do? Trusted and Trusting Mindful
Accountable
Responsible
Mindful
Aware of
Considerate of co-workers, patients, families
Personal skills to influence – from THIS Position
Empower – self, co-workers, patients
Creative, generate positive excitement –
Facilitate (Coordinate !) – work environment, inter-departmental relationships, patient services,

39. Develop a plan to assist your patient to move into/access required level of service
To be expanded and Section to follow for Objective #4
Diagnosis
Treatment
Preferred site (inpatient, outpatient, home)
Support resources
Transportation
Pay source
Activities of daily living
Instrumental activities of daily living
Supply delivery

40. Barriers to Access/Success
Mixed Priorities – Patient vs System
Financial
Language/Cultural/Belief System
Educational
Generational
Geographic
Patient looking for something different than health care team plans
Lack of Advance Directives – patient advance planning
Family has different ideas
Lack of pay source
No patient understanding of cost of care due no financial responsibility
Nonmedical expenses may be devastating -- bankruptcy
Unrealistic expectations – “miracle cure”
Lack of communication or poor comprehension of communication
Differences in social and moral issues
Growing population new to USA ideas of
Speak to patient’s level of understanding
Distinct generational expectation and belief differences
6. Access to services may be limited where patient wants them

41. Generational Differences

42. Something with Nursing Process and Handoffs
Nursing Process: a five-part systematic decision-making method focusing on identifying and treating responses of individuals or groups to actual or potential alterations in health. Includes assessment, nursing diagnosis, planning, implementation, and evaluation.
MediLexicon International Ltd, Bexhill-on-Sea, UK, MediLexicon International Ltd © All rights reserved.

43. “The Patient Experience” copied from NDHCRI
National Perspective
1 in 5 Medicare beneficiaries are readmitted to the hospital within 30 days
1 in 3 beneficiaries are readmitted within 90 days
2 of 3 patients with medical conditions are either rehospitalized or died one year after discharge
90% of rehospitalizations were unplanned
76% of 30-day readmissions are potentially preventable
Hackbarth, Reischauer, and Miller. Medicare Payment Advisory Committee

44. Patient Experience From ND HCRI
Abrupt transitions between settings
Brief hospital days
Sudden self-management with minimal preparation
Poor communication between care providers

45. Care Coordination

46. NOT A SILO “System” OB/Gyn – Oncology – Schedule – Surgery – Follow-up
Fear – Trust - $$
“Silo”
OB/Gyn
Oncology
Schedule
Surgery
Follow-up
Fear – Emotional upheaval – Time - Travel - $$$$$
2/5/2014

47. ND Dept of Human Services Available to all ND residents

48. Care Coordination
NDDOH – Children’s services

49. Wrap-up Reflect on the complexity of the overall healthcare system
Reflect on your organization within the system
Reflect on your position within your organization
Reflect on the result of your patient advocacy experience
How could a different reality have made your experience more successful and satisfying?
What will you do to move toward that different reality?
And so we move into the Change & Innovation module

50. References Demographics – numbers of providers
North Dakota Healthcare Association
ND Long Term Care Association
Closing the Loop with Referral Management, Ed Wagner, MD, MPH, MACP MacColl Center for Health Care Innovation Group
Health Research Institute, Linda Thomas-Hemak, MD, The Wright Center for Primary Care. February 26, 2013