1. AAACN April 2008 Mary Ramos, PhD, RN The Role of Military Ambulatory Care Nurses in Facilitating the Best Evidence-based Care

2. Military Health System New to Provision of Broad-based Care Until 1880s cared only for Soldiers Until 1880s cared only for Soldiers After 1884 Medical Officers and Contract Surgeons cared for families free of charge as possible After 1884 Medical Officers and Contract Surgeons cared for families free of charge as possible World War II presented huge burden of obstetrical care World War II presented huge burden of obstetrical care December 7, 1956: Dependents Medical Care Act December 7, 1956: Dependents Medical Care Act CHAMPUS: 1967 CHAMPUS: 1967

3. The 1960s CHAMPUS provided ambulatory and psychiatric care for all family members and retirees by 1967: Modified HMO/PPO CHAMPUS provided ambulatory and psychiatric care for all family members and retirees by 1967: Modified HMO/PPO About 30 HMOs in commercial sector About 30 HMOs in commercial sector Beginning awareness of financial risk in provision of health care Beginning awareness of financial risk in provision of health care –Utilization Review –Cost Containment

4. 1980s Fee for Service Decreasingly Feasible in Community-based Care Fee for Service Decreasingly Feasible in Community-based Care Growth of Managed Care Environment Growth of Managed Care Environment CHAMPUS Reform Initiative in Military CHAMPUS Reform Initiative in Military TRICARE TRICARE

5. Military Health Care in 2008 TRICARE-contracted TRICARE-contracted Network-dependent Network-dependent Ambulatory Ambulatory Cost-focused Cost-focused Resource-strained Resource-strained Complex Systems Complex Systems High Technology High Technology High Expectations High Expectations Outcomes Measured and Compared Outcomes Measured and Compared

6. Key to Maximizing Quality of Care Attention to Processes Attention to Processes Balanced Team Approach Balanced Team Approach Patient Focus Patient Focus Data-based Decision-making Data-based Decision-making –Evidence-based Practices –Clinical Practice Guidelines –Using Available Data

7. The Best Position to Facilitate Change: Nurses Providers Look at One Patient at a Time Providers Look at One Patient at a Time Providers Should be Seeing Patients Providers Should be Seeing Patients Providers Need System Support Providers Need System Support Nurses Can Be System Thinkers Nurses Can Be System Thinkers Nurses Can Provide Data Nurses Can Provide Data Nurses Can Support Providers in Improving Population Health Through Data-based Decision-making Nurses Can Support Providers in Improving Population Health Through Data-based Decision-making

8. Clinical Practice Guidelines Evidence-based Evidence-based Algorithmic: Decision Matrices Algorithmic: Decision Matrices Outcomes-focused Outcomes-focused Bring Best Practices to the Patient Bring Best Practices to the Patient Decrease Unwanted Variation Decrease Unwanted Variation Free Providers to Concentrate on What Cannot be “Automatic” Free Providers to Concentrate on What Cannot be “Automatic”

9. https://qmo.amedd.army.mil/pguide.htm

10. https://qmo.amedd.army.mil/CPGShoppingCart/entry.aspx?link=/CPGShoppingCart/de fault.aspx

11. Diabetes Clinical Practice Guideline Recommendations A1C At Least Annually A1C At Least Annually Foot Exam Annually Foot Exam Annually Dilated Eye Exam Annually Dilated Eye Exam Annually Track Lipids Track Lipids Influenza/PNX Vaccine Influenza/PNX Vaccine Microalbumin Check Microalbumin Check

12. Provider Decisions? Research-based Research-based Universally Accepted Universally Accepted Patient Should be Involved in Planning Patient Should be Involved in Planning –Timing for A1C –Relationship of Diet and Exercise to A1C –Patient Ability to Assess Feet –Importance of Eye Exam –Diabetes and Kidney Function

13. Using Data in Clinical Settings Aggregation Aggregation Analysis Analysis Action Action

14. Aggregation Aggregation is putting individual numbers into sets that “fit” questions Aggregation is putting individual numbers into sets that “fit” questions The questions, then, must come first The questions, then, must come first

15. Know Your Enrollees How Many Enrollees By Benefit Category By Benefit Category By Age Group and Gender By Age Group and Gender By Function and Activity By Function and Activity By Condition By Condition

16. Know Your Providers How Many Providers By Category By Category –Primary Care vs. Specialty –Physician vs. NP and others By Population Benefit Category By Population Benefit Category By Population Age Group and Gender By Population Age Group and Gender By Deployment Status By Deployment Status By Population Condition By Population Condition

17. Formulate Questions How many patients with asthma? How many patients with asthma? How many of those have had ED visits for asthma? How many of those have had ED visits for asthma? How many of them are on inhaled steroid medication? How many of them are on inhaled steroid medication? All answers readily available through the MHSPHP

18. Patient-level Data AgeBenCatPCM Na me Provider Group HospOP VisitsERDispCtrl RxCtrl Drug Name 40ADAQRPCMA030630-Oct-07ADVAIR DISKUS 35ADAQRPCMA01054-May-07ADVAIR DISKUS 49ADAQRPCMA010722-Oct-07ADVAIR DISKUS 34ADAQRPCMA000413-Sep-07ADVAIR DISKUS 47ADAQRPCMA00053-Sep-07ADVAIR DISKUS 51ADAQRPCMA000422-Oct-07ADVAIR DISKUS 47ADAQRPCMA0402128-Sep-07ADVAIR DISKUS 42ADAFQRPCMA0101131-Jul-07ADVAIR DISKUS 39ADAFQRPCMA000813-Aug-07ADVAIR DISKUS 46ADAFQRPCMA010419-Sep-07ADVAIR DISKUS 51ADAFQRPCMA010513-Sep-07ADVAIR DISKUS 41ADAFQRPCMA0101311-Oct-07FLOVENT HFA 36ADAFQRPCMA0001710-Sep-07SINGULAIR 26ADAFQRPCMA0140726-Sep-07SINGULAIR https://pophealth.afms.mil/tsphp/login/login.cfm

19. MTF-level Data https://cms.mods.army.mil/cms/secured/stoplights_frameset.aspx?metricCategoryCd=P OPH

20. Analysis Without analysis, numbers are just data – not information Without analysis, numbers are just data – not information Without analysis, we DRIP Without analysis, we DRIP Analysis is interpreting numbers to answer questions Analysis is interpreting numbers to answer questions The questions, then, must come first The questions, then, must come first

21. Analysis Analyze data sets separately Analyze data sets separately –ORYX –HEDIS –Other Applicable Data Analyze data sets together Analyze data sets together –ED Utilization against Portal Asthma data –Inpatient days for diabetes patients –Readmission for CHF and ORYX discharge education data

22. ORYX Analysis Tools www.mhs-cqm.info www.mhs-cqm.info www.mhs-cqm.info –MTF comparison charts –Can be edited to address local issues www.hcdinc.com www.hcdinc.com www.hcdinc.com –Process Control Charts (Consistency) –Comparison Charts (Observed vs. Benchmark) –Quality Reports (TJC Quality Check)

23. Action Having data is not enough Having data is not enough Everyone is involved in incorporating data into every day decision-making and strategic planning to modify processes to enhance and optimize patient care and patient safety Everyone is involved in incorporating data into every day decision-making and strategic planning to modify processes to enhance and optimize patient care and patient safety

24. Get your findings out of the office and into the field Get your findings out of the office and into the field Talk to the delivery teams about creative ways to improve numbers Talk to the delivery teams about creative ways to improve numbers Use data to feed and nourish quality improvement efforts Use data to feed and nourish quality improvement efforts Cross-pollinate Cross-pollinate

25. Ambulatory Nursing Interventions Design Systems to Support Care Delivery Design Systems to Support Care Delivery –Huddles –Order Sets –Availability of Data Integrated Teams Integrated Teams Patient Partnerships Patient Partnerships Case Management and Continuity of Care Case Management and Continuity of Care

26. Best Practices Mammography Self-referral Mammography Self-referral Integrated Diabetes Care Integrated Diabetes Care –Classes to Fit Patient Preferences –Comprehensive Cardiac Risk Management –Interdisciplinary Approaches Comprehensive Asthma Care Comprehensive Asthma Care –Integration with School Nurses –Involvement of ED –Diagnostic and Coding Issues Addressed

27. Expanded Roles for Nurses in Ambulatory Care Active Partnerships with Case and Disease Managers Active Partnerships with Case and Disease Managers Identifying and Eliminating “Silos” in Preventative Care Services Identifying and Eliminating “Silos” in Preventative Care Services Richer Mix of Professional Nurses Richer Mix of Professional Nurses Nurses More Involved in Direct Patient Care Nurses More Involved in Direct Patient Care Larger Voice in Administrative Decision- making and Systems Design Larger Voice in Administrative Decision- making and Systems Design

28. Golden Opportunities for Nurses Advocate for Patient-friendly Systems Advocate for Patient-friendly Systems Expand Responsibility and Partnerships Expand Responsibility and Partnerships Assume Responsibility for Optimal Patient Wellness Assume Responsibility for Optimal Patient Wellness Assist Military in Designing Assist Military in Designing Delivery Systems for the 21 st Century