Transcript IOM – Delivering High-Quality Cancer Care

Cancer Care Workforce
Challenges: Can System
Changes Enhance
Survivorship Care?
Tracy Gosselin, PhD, RN, AOCN
Associate Chief Nursing Officer
Ambulatory Services & Oncology
Duke University Health System
June 25, 2015
Headlines Say – More Nurses Needed
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DRIVERS OF CHANGE
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IOM – Crossing the Quality Chasms
• Better care for individuals:
– Safety
– Effectiveness
– Patient-centeredness
– Timeliness
– Efficiency
– Equity
IOM. (2001). Crossing the Quality Chasm.
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IOM - Ensuring Quality Cancer Care through
the Oncology Workforce
• By 2020 81% increase in people living with or
surviving cancer
• 14% increase in the number of oncologists
• Shortage areas
– Allied health care professionals
– Advanced practice providers
– Nurses
– Social workers
– Others
IOM. (2009). Ensuring Quality Cancer Care through the Oncology Workforce: Sustaining Care in the 21st Century
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IOM - The Future of Nursing: Leading
Change, Advancing Health
• Four key messages:
– Nurses should practice to the full extent of
their education and training.
– Nurses should achieve higher levels of
education and training through an improved
education system that promotes seamless
academic progression.
– Nurses should be full partners, with
physicians and other health professionals, in
redesigning health care in the United States.
– Effective workforce planning and policy
making require better data collection and an
improved information infrastructure.
IOM. (2010). The Future of Nursing: Leading Change, Advancing Health.
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IOM – Delivering High-Quality Cancer
Care
• Trends - aging population, workforce shortages, reliance
on family caregivers and direct care workers, rising cost
of cancer care, complexity of care, and limitations in
tools to improve quality
• 10 Recommendations
– Coordinated team based care
• Goal 3 – members of the cancer care team should coordinate with
each other and with primary/geriatrics and specialist care teams to
implement patients’ care plans and deliver comprehensive, efficient,
and patient-centered care
– Core competencies for the workforce
• Goal 4 – all individuals caring for patients should have appropriate
core competencies
IOM. (2013). Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis.
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IOM – Delivering High-Quality Cancer
Care – Recommendation 3
• Federal and state legislative and regulatory bodies
should eliminate reimbursement and scope-ofpractice barriers to team-based care
• Academic institutions and professional societies
should develop interprofessional education programs
to train the workforce in team-based cancer care and
promote coordination with primary/geriatrics and
specialist care teams
• Congress should fund the National Workforce
Commission
IOM. (2013). Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis.
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IOM – Delivering High-Quality Cancer
Care – Recommendation 4
• Professional organizations that represent clinicians who care for
patients with cancer should define cancer core competencies for
their membership
• Cancer care delivery organizations should require that the members
of the cancer care team have the necessary competencies to deliver
high-quality cancer care, as demonstrated through training,
certification, or credentials
• Organizations responsible for accreditation, certification, and training
of non-oncology clinicians should promote the development of
relevant core competencies across the cancer care continuum
• The US Dept. of HHS and other funders should finance
demonstration projects to train family caregivers and direct-care
workers in relevant core competencies related to caring for cancer
patients
IOM. (2013). Delivering High-Quality Cancer Care: Charting a New Course for a System in Crisis.
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Other Drivers Impacting Care Delivery
• Meaningful Use
– Use of certified HER
– Improve quality, safety, efficiency and disparities – meds, allergies,
smoking status
– Improve care coordination
• Patient satisfaction/experience
– Interactions, culture, perception/s, continuum of care
– Clinician and Group Consumer Assessment of Healthcare
Providers and Systems (CG CAHPS)
– Hospital Consumer Assessment of Healthcare Providers and
Systems(HCAHPS)
• CMS Triple Aim
– Improve patient experience of care (includes quality and
satisfaction)
– Improve the health of population
– Reducing the per capita cost of health care Beryl Inst; Triple Aim Concept Design. 2009.
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Scope of Practice Overlap between Registered Nurses (RN) and
Physicians
Category of activities
Specific activities that overlap
Physical exam
Assessing vital signs such as measuring pulse, blood pressure, respiratory rate, temperature, and oxygen saturation
Auscultating lung, heart, and abdominal sounds
Assessing cranial nerves
Assessing eyes and ears using
ophthalmoscope and otoscope
Testing vision and hearing
Performing breast exam
Testing range of motion and muscle strength of upper and lower extremities
Assessing pain
Health assessment
Obtaining health history
Administering screening tests (e.g., domestic violence, depression)
Performing in person or telephone triage to determine need for further care
Identifying emergent complications, expected, or adverse response to medical treatment (e.g., a RN monitors blood
pressure after administration of blood pressure lowering medication or monitors for bleeding after surgery)
Identifying epidemiologic trends (e.g., a school RN notes sudden increase in flue cases and notifies health department of
the changes in population health trend changes)
Medical diagnosis
No overlap
Prescribing diagnostic tests and
pharmacological treatments
No overlap
Category of activities
Specific activities that overlap
Implementing treatments
Administering medications
Collecting blood, urine, stool samples
Obtaining sputum and wound cultures
Providing mental health and addiction counseling
Providing health counseling related to management of chronic diseases
Coordinating care
Providing wound care
Inserting foley catheter and nasogastric tube
Inserting peripheral intravenous catheter
Obtaining 12-lead electrocardiogram (ECG)
Djukic & Kovner. 2010. Overlap of Registered Nurses and Physician Practice: Implications for U.S. Health Care Reform. Policy, Politics, & Nursing Practice 11(1).
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Medicare Beneficiaries and Chronic
Conditions
D
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CMS. (2012). Chronic Conditions.
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Care Redesign
• Care in the US is suboptimal with some patients not
receiving care at the right place or time
• Our health care system is fragmented and has
barriers to how patients access care
• Care is not coordinated across the care continuum
• Resources are inefficient and mechanisms to
currently provide care can often be redundant or
missing
Hassett, MJ, et al. (2014).
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WORKFORCE TRENDS
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Future of the Nursing Workforce
• Nationally, the change in RN supply between 2012 and 2025
is projected to outpace demand.
• Approximately 2.9 million RNs were active in the workforce in
2012. Consistent with standard workforce research
methodology, the Health Workforce Simulation Model assumes
that the RN demand in 2012 equals the RN supply.
• Assuming RNs continue to train at the current levels and
accounting for new entrants and attrition, the RN supply is
expected to grow by 952,000 full-time equivalents (FTEs) – from
2,897,000 FTEs in 2012 to 3,849,000 FTEs in 2025 – a 33
percent increase nationally.
http://bhpr.hrsa.gov/healthworkforce/supplydemand/nursing/workforceprojections/nursingprojections.pdf
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Future of the Nursing Workforce
• The nationwide demand for RNs, however, is projected to grow
by only 612,000 FTEs – from 2,897,000 FTEs in 2012 to
3,509,000 FTEs in 2025 – a 21 percent increase.
• The number of new graduates that entered the workforce has
substantially increased from approximately 68,000 individuals in
2001 to more than 150,000 in 2012 and in 2013.
• While not considered in this study, emerging care delivery
models, with a focus on managing health status and
preventing acute health issues, will likely contribute to new
growth in demand for nurses, e.g., nurses taking on new and/or
expanded roles in preventive care and care coordination.
http://bhpr.hrsa.gov/healthworkforce/supplydemand/nursing/workforceprojections/nursingprojections.pdf
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Other Team Members
• Demand for oncology services to grow 42% with only
28% growth in supply of oncologists by 2025 (-1,500)
• Nurse educators
• Social workers approximately 1,200
• Pharmacists
• Laboratory technicians
• Radiology technicians
• Registrars
ICAN 2004-2005; http://www.asco.org/practice-research/cancer-care-america#recommendations
http://www.ashp.org/DocLibrary/MemberCenter/SPPM/2013-ASHP-Staffing-Survey.pdf
http://bhpr.hrsa.gov/healthworkforce/reports/clinicallab.pdf
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STRATEGIES
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Oncology Nursing Society
• Mission
– To advance excellence in oncology nursing and quality
cancer care
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Incorporated July 17, 1975
Headquarters Pittsburgh, PA
Reduced dues for student nurses
Reduced dues for early career professional
Support for National Student Nurses Association
Local chapter support (225)
– Partner with local colleges/universities
– Scholarships
– Meeting attendance
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Oncology Nursing Society
Advocacy endeavors
– ONS Director of Health Policy – Alec Stone
– Hill Day events
– ONS Capital Gang
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participating in Capitol Hill lobbying days
meeting with members of Congress and their staff
attending federal agency meetings
reviewing and providing input on draft legislation on
proposed regulations
• representing ONS at press conferences or other public
meetings
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Oncology Nursing Society – Priority 1
Preserve and promote oncology nurses’ practice to
the full scope of their ability.
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To accomplish this top priority, ONS closely supports the
recommendations of the Institute of Medicine in its landmark report,
The Future of Nursing: Leading Change, Advancing Health
Nurses should practice to the full extent of their education and training.
Nurses should achieve higher levels of education through an improved
education system that promotes seamless academic progression
Nurses should be full partners with physicians and other healthcare
professionals in redesigning health care
Effective workforce planning and policy making require better data
collection and information infrastructure
https://www.ons.org/advocacy-policy/priorities
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Oncology Nursing Society - Priority 2
Improve the quality of cancer care.
• Ensure that inpatient and outpatient quality measures used are
meaningful, relevant, and promote quality cancer care
• Quality Improvement Registry – CMS approved with QCDR and
PQRS
• Identify opportunities related to medical homes, accountable
care organizations, and other emerging healthcare delivery
models
https://www.ons.org/advocacy-policy/priorities
https://www.medconcert.com/content/medconcert/ONSQIR/
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Oncology Nursing Society – Priority 3
Advocate for payment models that incorporate the
work of oncology nurses and positively impact
oncology practice.
• Ensure adequate reimbursement of nursing care in CMS
processes to develop chronic care management codes and
payment schedules
• Impact decision making and rules for the Centers for Medicare
and Medicaid Services (CMS) value-based purchasing initiatives
https://www.ons.org/advocacy-policy/priorities
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Title VIII – Nursing Workforce
Reauthorization Act
• In existence five decades
• Representatives Lois Capps (D-CA) and David Joyce
(R-OH) reintroduced H.R. 2713
– Maintain funding at FY15 of $232 million
• Entry level to graduate education
• Largest source of federal funding for nursing
education
– Financial support for nursing education
programs
– Individual students
– Nurses
FY06-12
450,000
https://www.aamc.org/advocacy/hpnec/
http://www.rnaction.org/site/PageNavigator/nstat_take_action_title_viii_issues.html
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CMS Graduate Nurse Demonstration
Project
• Mandated by section 5509 of the Affordable Care Act
• 2012 call for application
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More community based training sites
More nurse practitioners
• Five sites awarded
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Duke University Hospital in Durham, N.C.
Hospital of the University of Pennsylvania in Philadelphia, Penn.
Memorial Hermann-Texas Medical Center Hospital in Houston, Texas
Rush University Medical Center in Chicago, Ill.
Honor Health (formerly Scottsdale Healthcare Medical Center) in Scottsdale, Ariz.
• Four year initiative, wrap up 2017
• Evaluation by American Institute Research
• Presentation to Congress
http://innovation.cms.gov/initiatives/gne/
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CMS Graduate Nurse Demonstration
Project
• Focuses on
– Primary care
– Preventative care
– Transitional care
– Chronic care management
– Other services appropriate to Medicare beneficiaries
• Post graduation
– Non hospital based setting
– Rural communities
http://innovation.cms.gov/initiatives/gne/
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2015 Nursing Workforce Study
• National Council of State Boards of Nursing &
National Forum of State Nursing Workforce Centers
• Focus on supply of nurses
• Sample
– RNs & LPNs
– 260,000 of 4.5 million licensed (5.8%)
• Paper or web based survey
– June to September
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Advanced Practice Registered Nurse
(APRN)
• Full practice authority
– Limited by state regulations – not uniform
– Limited by provider
• 21 states plus DC permit nurse practitioners (NP) to diagnose, treat
and prescribe without physician oversight
• 7 states require physician oversight of NP prescribing
• 22 states require oversight of diagnosis, treatment, and prescribing
• Payer policies
• Consensus Model for APRN Regulation: Licensure, Accreditation,
Certification and Education - Endorsed by ONS and ONCC
• North Carolina – Modernizing Nursing Practice Act (SB 695/HB 807)
– Regulatory, supervisory & oversight requirements
https://www.ncsbn.org/Consensus_Model_for_APRN_Regulation_July_2008.pdf
http://www.ncnurses.org/practice/docs/OptimizingNurseRolespaper2015-06.pdf
http://www.nihcr.org/PCP-Workforce-NPs 31
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Traditional Career Path
for the New Graduate Nurse
Med/Surg
Hospital
Specialty
Field
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According to a study by
Kovner, Brewer, Fairchild,
Poornima, Kim & Djukie
(2007), of the over 3,000
newly licensed RN’s
comprised in 35 states and
the District of Columbia,
approximately 85% began
their careers in acute care
settings while less than 4%
entered the workforce in
outpatient or ambulatory
settings.
Ambulatory
Care Setting
Workforce Development & Support to
Improve Survivorship Care
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Prelicensure ambulatory rotations
Professional Nursing Student Internship
Curriculum
Ambulatory oncology nursing residency programs
Scope of Practice
Post graduate fellowship program for nurse practitioners
Leveraging technology
Collaboration & Partnerships
– Primary Care
– Business development
– Colleges/schools
• Burnout/compassion fatigue
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Conclusion
• Collaboration across
stakeholder groups
• Modernization of Nurse
Practice Acts
• Funding for entry and
advanced practice
education
• Discovery and funding for
innovative models of care
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