Transcript Presentation

Nurse-Managed Health Clinic &
Convenient Care Clinic
Contributions to the Advancement of the
National Prevention Strategy
June 21, 2012
Tine Hansen-Turton, JD, MGA, FCPP, FAAN
Chief Executive Officer, National Nursing Centers Consortium
Executive Director, Convenient Care Association
Chief Strategy Officer, Public Health Management Corporation,
a PA Public Health Institute
Overview of Today’s Presentation
• Understand the history and current role of nurse-led
care in the US, mainly Nurse-Managed Health Clinics
(NMHCs) and Convenient Care Clinics (CCCs)
• Examine the growth of NMHCs in the primary care
workforce and their role in preventive and primary care
• Understand how NMHCs fit into the larger context of
state and national health care reform and the national
Prevention Strategy
• Describe the current challenges – and opportunities –
for nurse-led care
History of NMHCs
• Date back to early part of the 20th Century in U.S.
– Community health visionary Lillian Wald
– Nurse Midwife Mary Breckenridge
• Substantial contributions to primary care and
prevention
• Serve diverse populations in diverse settings
• Currently there are about 250 nurse-managed
health clinics operating throughout the US with 2/3
run by schools of nursing
According to the Affordable Care
Act…
… a nurse managed health clinic is a nurse
practice arrangement, managed by
advanced practice nurses, that provides
primary care or wellness services to
underserved or vulnerable populations and
that is associated with a school, college,
university or department of nursing,
federally qualified health center, or
independent nonprofit health or social
services agency.
Source: Affordable Care Act, Section 5208
What are NMHCs?
1. NMHCs offer high quality, affordable, accessible community
oriented primary care, health promotion and disease prevention
2. The majority of care is provided by nurses—in interdisciplinary
teams led by nurse practitioners other advanced practice nurses
3. NMHC offer patients direct access to APN care
4. Dominant theme: Nurses control their own practice and
patient care
Common NMHC models:
– Convenient Care Clinics
– Birthing Centers
– School Based Centers – Academically affiliated NMHCs
– Mobile Vans
– Wellness centers
About NNCC/CCA
The National Nursing Centers Consortium
(NNCC) advance nurse-led health care through:
•
•
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Policy/education
Consultation
Programs
Applied research
…to reduce health disparities and meet people’s
primary care and wellness needs.
The Convenient Care Association (CCA) is the
trade association for retail-based convenient care
clinics
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Snapshot on Safety-Net NurseManaged Primary Care and
Wellness Clinics
7
Diverse Settings, Geographic Areas and Demographics
Public schools
University Housing
University Housing
Mobile Vans
Academic Health Centers
Rural Settings
NMHC Payer-Mix
2%
37%
46%
7%
Medicaid
Medicar e
Pr ivat e/ commer cial
uninsur ed
ot her
8%
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Most Common Diagnoses in NMHCS
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Hypertension
Depression
Diabetes
Child Health Exam
Hyperlipidemia
Adult Health
Maintenance Exam
Obesity
URI
Asthma
Normal pregnancy
Source: NNCC membership survey
data
Average Revenue & Cost/Visit Comparisons
For NMHCs & FQHCs
Revenue Comparisons
Cost/Visit Comparisons
NMHCs
FQHCs
$126
$128
Nurse-Managed Health Clinics
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High patient satisfaction
ER use 15% less than aggregate
Non-maternity hospital days 35-40% less
Specialty care cost 25% less than aggregate
Prescription cost 25% less than aggregate
Nurse-managed health clinics see their
members an average of 1.8 times more than
other providers
12
Data on Cost-Effectiveness
• NPs provide equivalent quality care to
that of physicians at a lower cost*
• The national average cost of a NP visit
was 20% less than a visit to a
physician.*
• Insurance reform in Massachusetts,
helped the state realized they could
gain a cost savings of $4.2 to $8.4
billion over a 10-year period from
increased use of NPs.*
• A worksite clinic run by an NP resulted
in direct medical care cost-savings of
nearly $2.18 million over a two-year
period.**
*Eibner, E et al. (2009). Controlling Health Care Spending in Massachusetts: An Analysis of Options. Rand
Health.
**Chenoweth, D. et al. (2008). Nurse Practitioner Services: Three-Year Impact on Health Care Costs.
Journal of Occupational and Environmental Medicine, 50, 1293-1298.
What Patients Saying About NMHCs:
• “The preventive part, the education piece has been done
outstandingly.”
• “It gives you more continuity of care. Because you have your
specific provider that sees you on a regular basis they’re
quite familiar with your health care needs.
• “I mean it’s caring, follow-up. We’ve never had care like that
in our 75 years.”
• “The other thing is that it is a gateway for complex and
advanced care.”
• “And they will follow-up and call you. That is like getting the
doctor to come out in the middle of the night.”
• “It is good because it is a neighborhood clinic and the
neighborhood side of it means it is accessible to people.”
• “If the clinic was not here it would be a real disaster”
Current Data Snapshot on
Convenient Care Clinics
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CCC Background
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In 2006,150 clinics were
open.
Clinics were mostly cashonly, offered a very limited
scope of services, and
were nearly all operated
or owned by corporations.
Many questioned the
viability and legitimacy of
the model.
Early opposition tried to
beat industry back.
Convenient Care Clinics
Accessibility
 Services primarily provided by NPs
 Located in retail outlets with retail service hours
 No appointments necessary – 15-20 minute visits
Affordability
 Transparent pricing; prices are clearly posted
 Services cost between $40 and $75.
 CCCs accept insurance
Quality
 Use EMRs
 Use evidence-based medicine
CCC Services
•
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Work with patients from 18 months
through 65+
– Acute care
– Immunization
– Wellness/preventative services
– School, camp and sports
physicals
– EpiPen Instruction and
Prescription
Physical assessments/diagnostic
encounters (need specific but
general data here)
– 20-40 patients/day
– Strep testing
– Urine analysis
– Influenza A and B testing
– TB/PPD testing
•
Chronic disease detection and
management
– A1C hemoglobin/blood glucose
testing
– Hypertension analysis
– Spirometry screenings
– Nebulizer treatments
– Injection services
•
Education and wellness
– Smoking Cessation
– Weight Management
– Diabetes Education
•
Prescribe medications when
necessary
Where CCCs Are at Today
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More than 1,350 clinics with expectations for
growth in coming years.
•
Clinic operators consist of hospitals and health
systems and corporations, and corporations are
increasingly affiliating with health systems.
•
Greater acceptance publicly and support for an
emphasis on patient-centered care.
What The Research Shows About CCCs
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Clinics are good for access.
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Clinics are good for cost reductions.
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Clinics are good for quality.
Improving Access
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As many as 60% of clinic patients report
not having a PCP (Mehrotra et al., 2008).
 93% of patients report highly on the
convenience (Wall Street Journal/Harris
Interactive, 2008).
 Nearly 30% of the U.S. population lives
within a ten-minute drive of a clinic
(Rudavsky et al., 2008).
 ~12 to 14% of all ED visits can be seen at
convenient care clinics (Weinick et al.,
2010; Mehrotra et al., 2008).
Decreasing Costs
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Costs of care at a convenient care clinic are
significantly lower than those at an urgent
care center, primary care office, or
emergency department (Mehrotra et al.,
2009; Thygeson et al., 2008).

Blue Cross and Blue Shield of Minnesota
eliminated co-pays for enrollees who used a
clinic, citing $1.2 million in cost savings
(Minneapolis/St. Paul Business Journal,
2008).
Meeting Standards of High Quality
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99.15% of convenient care clinic providers
adhered appropriately to diagnostic and treatment
guidelines for acute pharyngitis (Woodburn et al.,
2007).
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Quality scores and rates of preventive care
offered are similar for convenient care clinics as
for other delivery settings (Mehrotra et al., 2009).
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All clinics that are members of the CCA are either
certified or accredited by a third party.
The Current Crisis in Access
to Preventive Care and How
NMHCs and CCCs are
Responding
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The Harsh Reality about How Shortage of
Providers is Impacting Access
•
The Association of American Medical Colleges predicts
a shortfall of 29,800 primary care physicians by 2015,
and 65,800 by 2025
•
People are experiencing limited access to routine and
preventive care
•
70% of Americans can’t get same-day appointments
with their PCP
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30% of Americans lack a regular source of primary care
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Half of all emergency room visits are non-emergent
•
The number of uninsured went up in 2011 and 1 in
every 8 children are uninsured
•
Health care costs are rising at unsustainable rates
•
Consumers are increasingly pressed for time and are
demanding convenience
Growing numbers of NMHCs and NPs are
Helping to Fill Gaps in Care
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Approximately 85,000 out of 158,000+ nurse
practitioners now provide primary care
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NPs are legally authorized to perform the functions
of a primary care provider in all 50 states
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Approx. 70% of NMHCs offer primary care
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“Nurse practitioners are by far the fastest growing
group of primary care professionals in the
country”*
* Statement of A. Bruce Sternward, Health Care Director, U.S. Government Accountability Office, Testimony Before
the Committee on Health, Education, Labor and Pensions, U.S. Senate, 2008.
NMHCs and Workforce Development
1. NMHCs provide clinical placements for undergraduate and
graduate nursing students necessary to increase
enrollment in nursing education programs – helping to
eliminate shortages in supply of nurses.
2. NMHCs provide primary health care experience with
underserved populations. This exposure enhances the
chances the students will select to practice in underserved
areas.
3. NMHCs give students the unique opportunity to integrate
classroom learning with community-based care.
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NMHCs and Workforce Development
700
Year 1, n=26
NMHCs, 1491
students
Year 2, n=24
NMHCs, 1457
students
Year 3, n=20
NMHCs, 1435
students
Year 4, n=19
NMHCs, 1101
students
600
500
400
300
200
100
0
Source: INC four year membership survey
What Students Say About NMHC Clinicals
• Emphasis on the community--Community based
experiences that were not found in other clinical
rotations
• Patient diversity emphasized
• Addressing health disparities
• Ideal setting to teach business and financial
concepts
• Site consistent with conceptual model of nursing
practice presented in the classroom
The CCC Industry is also Growing to Meet
the Demand for Care
•
Growth in the number of clinics is anticipated in the coming
years (Deloitte Center for Health Solutions, 2009).
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Scope of services is being expanded with an eye towards
disease prevention and chronic disease monitoring.
•
More hospitals and health systems now operate clinics than
non-hospital companies, though the majority of individual
clinics are still operated by non-hospital companies.
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Growth among hospitals is largely due to perceived benefits
of the relationship in supplementing and extending existing
care (RAND, 2010).
CCCs and Workforce Development
CCCs offer nursing students:
• Autonomous NP operated
clinical experience
• Exposure to an NP-centric
model with NP leadership
• Opportunity to provide care in
an evidenced based practice
environment
CCCs and Workforce Development
•
Experience in the clinics
leads to:
– Exposure to the
importance of
clinical,
patient/consumer
and financial
business metrics
– Career exposure and
opportunities
– Research and
project opportunities
The Role of NMHCs and
CCCs in State & Federal
Health Care Reform & the
National Prevention Strategy
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Does Coverage = Care?
Experiences in Massachusetts suggest not…
- Across Mass., wait to see doctors grows: Access
to care, insurance law cited for delays (Boston
Globe, Sep. 22, 2008)
- Numbers dwindle for primary care doctors:
Medical students in US choosing other specialties
(AP, Sep. 10, 2008)
- Workforce Study Confirms Shortage of Primary
Care Physicians (Mass. Med. Soc., Aug. 2007)
Comparing Two State Approaches
• Massachusetts invested in insurance access before
ensuring it had the infrastructure to handle increased
demand for services.
• In Pennsylvania, Governor Rendell learned to invest
in health care infrastructure first, setting the stage for
insurance reforms in the future.
Reform in Massachusetts
Since reform in 2006, Massachusetts
went from having as many as 650,000
uninsured residents to having less
then 168,000 (the lowest rate of
uninsured residents in the nation)
-But there were not enough primary
care providers (PCPs) to fill the
need!
Reform in Massachusetts
• In August 2008, S. 2863 was passed (“An act to
promote cost containment transparency, and efficiency
in the delivery of quality health care”).
• Intended to address new issues raised by increased
access to health insurance
• Focused on:
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Health IT
Care Coordination
Increased utilization of non-physician providers – NPs!
Pay-for-Performance
Reform in Pennsylvania – RX for PA
PA Reform called for approximately 49 statutory/regulatory
changes to allow NPs to practice to the full extent of their scope
of practice. NPs in PA can now:
5. Make respiratory and
1. Order home health and hospice
occupational therapy referrals
care
6. Perform disability
2. Order durable medical
assessments for the program
equipment
providing Temporary
3. Issue oral orders to the extent
Assistance to Needy Families
permitted by the state’s health
(TANF)
care facilities
7. Issue homebound schooling
4. Make physical therapy and
certifications
dietitian referrals
8. Perform and sign the initial
assessment of methadone
treatment evaluations
Reform in Pennsylvania
Pennsylvania Governor Edward G. Rendell
signs first pieces of the “Prescription for
Pennsylvania” health care reform plan into
law at the University of Pennsylvania School
of Nursing, July 2007.
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Policy Gains on the Federal Level
In 2009 NNCC introduced a bill to create a
federal grant program for NMHCs
- In the House, the bill was introduced by Lois
Capps (D-CA) and Lee Terry (R-NE)
- In the Senate, the bill was introduced by Daniel
Inouye (D-HI) and Lamar Alexander (R-TN)
In 2010 the bill became law when it was
inserted into the Affordable Care Act
– Where did that get us?
Policy Gains on the Federal Level
NMHCs Defined in Federal Law - ACA Definition:
– “A nurse managed health clinic is a nurse practice
arrangement, managed by advanced practice nurses,
that provides primary care or wellness services to
underserved or vulnerable populations and that is
associated with a school, college, university or
department of nursing, federally qualified health center,
or independent nonprofit health or social services
agency.”
NMHC Grant Program Created:
– Provided $15 million to 10 NMHCs in 2010
– Congress has never appropriated funding
CCCs and Health Care Reform
Clinics Provide Opportunities in
Response to Health Reform
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Access points for ~30 million more insured.
Being included in medical home/accountable
care organization concepts as
alternative/complimentary delivery sites
Focus on preventive and wellness focused
healthcare
Retail clinics engage in creative partnerships
(employers, community health centers,
private sector, payors)
The National Prevention Strategy
Borrowed from: National Prevention Council, National Prevention Strategy, Washington, DC: U.S.
Department of Health and Human Services, Office of the Surgeon General, 2011.
National Prevention Strategy
The National Prevention
Strategy’s overarching goal is
to increase the number of
Americans who are healthy at
every stage of life.
National Prevention Strategy
Strategic Directions of the National Prevention Strategy:
• Healthy and Safe Community Environments: Create, sustain, and
recognize communities that promote health and wellness through
prevention.
• Clinical and Community Preventive Services: Ensure that preventionfocused health care and community prevention efforts are available,
integrated, and mutually reinforcing.
• Empowered People: Support people in making healthy choices.
• Elimination of Health Disparities: Eliminate disparities, improving the
quality of life for all Americans.
NMHCs and the National Prevention
Strategy
NMHCs focus on all seven of the NPS priorities:
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Tobacco Free Living
Preventing Drug Abuse & Excessive Alcohol Use
Healthy Eating
Active Living
Injury and Violence Free Living
Reproductive and Sexual Health
Mental and Emotional Well-Being
Retail Health and the National Prevention Strategy
CCCs focus on many of the NPS priorities through
education, like:
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Tobacco Free Living
Healthy Eating
Active Living
Injury and Violence Free Living
Challenges and Opportunities
for NMHCs
Nurse-led Primary Health Care is the Model for the
Future of Nursing Report …
Report Recommendations
 Nurses should practice to the full extent of
their education and training
 Preparing and Enabling Nurses to Lead
Change and Advance Health
 Nurses should be full partners, with physicians
and other health professionals, in redesigning
healthcare in the United States
Opportunities for the Future
• More to do than Traditional Policy Work
– Change insurer credentialing and contracting policies
• Highmark, Aetna, others, have done the right thing
• But about 50% of insurers are still not contracting
with NPs
– Support other existing nurse-led practice models
• CCCs, School-based centers and private practices
– Push to ensure NMHCs are included in state and
federal patient centered medical home demonstration
projects and insurance exchanges
Opportunities for the Future
•
The Center for Medicare and Medicaid Innovation
– Triple Aim
• Better healthcare: Improve individual patient experiences of
care along the Institute of Medicine’s six domains of quality:
Safety, Effectiveness, Patient-Centeredness, Timeliness,
Efficiency, and Equity
• Better health: Encourage better health for entire populations
by addressing underlying causes of poor health, such as
physical inactivity, behavioral risk factors, lack of preventive
care and poor nutrition
• Reduced costs through improvement: Lower the total cost
of care resulting in reduced monthly expenditures for each
Medicare, Medicaid or CHIP beneficiary by improving care
NMHCs and CCCs fit the bill!
For More Information
Tine Hansen-Turton
215-731-7140 (phone)
[email protected]
www.nncc.us
www.ccaclinics.org