Whitney Palmer

Healthcare. Politics. Family.

Retail Health Clinics on the Rise

Published in the April 12, 2o12, Billian’s HealthDATA/Porter Research Hub e-newsletter

By Whitney L.J. Howell

They’re in nearly every drug store, ready to provide a flu shot, answer questions about a skin rash, or conduct a blood pressure screening. And, every year, more retail health clinics (RHCs) appear to meet patient needs at an opportune time and place.

But with their increasing use of health information technology (HIT), RHCs are quickly moving from being clinics of convenience to being helpful partners in the overall healthcare system. This beefed-up use of technology makes it easier for patients to keep their doctors looped into their health history.

Although these clinics aren’t intended to be permanent or full-service medical homes, they do offer a wide variety of services that supplement the preventative care patients receive from their primary care providers. For example, patients can go to RHCs for routine cholesterol and blood pressure screenings; a variety of vaccinations; or treatment of respiratory infections, allergies, or some skin conditions.

The clinics are also a more affordable avenue for people who need care, but find themselves outside of the healthcare system. Data reported by the American Academy of Family Physicians has estimated a $40 service in an RHC could potentially cost more than double that in a doctor’s office, $120 in an urgent care facility, and $325 in an emergency room. Given that 16 to 27 percent of clinic patients have no health insurance, based on a 2011 RAND report, and only 39 percent have an existing relationship with a primary care provider, the lower cost could be beneficial not only to the patient’s pocketbook, but in the prevention of potentially future healthcare costs associated with developing chronic conditions.

“Retail health clinics are a huge convenience to patients,” said Mary Griskewicz, senior director of health information systems with the Healthcare Information and Management Systems Society (HIMSS). “They can be screened, get their flu shot, have a rash examined, and all of this is usually within 20 feet of the pharmacy where they can get medication.”

The Rise of the Retail Health Center
When RHCs first entered the market, some in the healthcare industry pushed back. Even though they are staffed by qualified nurse practitioners and physician’s assistants, many physicians contended they were inadequate clinical settings that should only be used in the most extreme circumstances.

Now, however, that opposition is disappearing, and RHCs are flourishing. In a healthcare environment where greater access is often the name of the game, a growing number of industry leaders now see these clinics as valued partners in providing preventative and primary care services.

“You are starting to see a newfound cooperation in the marketplace between retailers and their local hospital systems and physician groups,” said Thomas Charland, chief executive of Merchant Medicine, a research and consulting firm that tracks retail medical care service growth, related in a New York Times blog post earlier this year. “Physicians’ resistance is slowly melting away.”

The population of RHCs seems to have ballooned after two years of near-stagnant growth. Between 2010 and 2011, the number of these clinics rose by 11.2 percent to 1,355 nationwide. And, this trend shows no signs of slowing.

To date, retail drug stores, including Walgreen’s and CVS, have been the RHC leaders, with their Take Care Clinics and MinuteClinics, respectively. Currently, Walgreen’s has 350 Take Care Clinics nationwide, as well as 350 worksite locations. In addition, Walgreen’s announced last month that it will expand its relationship with the Tufts health plan in Massachusetts. CVS also has a considerable RHC presence – 650 MinuteClinics and a plan to add 500 more over the next five years.

Other retail giants, such as Walmart and the grocery store chains Kroger and Safeway, have launched RHC efforts within the last year.

Major hospitals and health systems are also adding clinics in retail areas in an effort to meet patients where they live and work. Recently, the Mayo Clinic opened its “Create Your Mayo Clinic Health Experience” in Minnesota’s Mall of America.” Mayo Clinic believes healthcare in the future won’t be limited to doctors’ offices and hospitals. Medicine needs to adapt to peoples’ changing needs, including seeing people where they are and when it is convenient for them,” said David Hayes, M.D., the clinic’s medical director, in an interview with FierceHealthcare. “Mall of America is the ideal gateway for many of Mall of America’s visitors to access Mayo Clinic in non-traditional ways.”

Connecting Patient Information
Despite being exempt from most Meaningful Use requirements and ineligible to receive incentive payments, HIMSS’ Griskewicz said implementing an electronic health record (EHR) is the most important HIT solution an RHC can employ. The nurse practitioner or physician’s assistant won’t complete the same level of patient history intake as a doctor’s office does, but an EHR allows them to document the encounter in some way. Patients can also potentially leave the clinic with access to an electronic copy of the record meant for his or her primary care physician.

According to Gabe Weissman, external relations manager with Walgreen’s, the company jumped head-first into HIT and developed its own EHR. The system allows any Walgreen’s nationwide to access a patient’s health records. For example, a provider in one of the Take Care Clinics can access the health records of a Pennsylvania resident who needs healthcare while on vacation in Florida.

“We’re working to ensure patients realize there are alternatives to the emergency room. We’ve formed relationships so nurse hotlines in hospitals are aware of Take Care Clinics and can route people there for services that aren’t appropriate for the ER,” he said. “We make sure we’re sharing records with primary care providers in the appropriate health system while filling a niche for slightly less emergent care.”

Walgreen’s also offers online appointment scheduling and recently launched an initiative through the social network Foursquare. Patients can use the smartphone application to electronically refill prescriptions, transfer prescriptions between Walgreen pharmacies, and schedule reminders to take medications.

The retailer’s Take Care health system was recently awarded Pointclear Solutions’ HIT Innovation Award for 2011 in recognition of its “innovation of online tools that allow patients, physicians and pharmacists to interact in near real-time, making patient health and wellness incredibly efficient for all participants, moving the healthcare industry dramatically forward,” according to a recent Pointclear press release.

One big challenge to fully utilizing an EHR still remains. There is often limited coordination between the RHC and a physician’s office or hospital. There simply are not enough resources available to safely and successfully link the RHC’s system with the wide variety of EHRs used by other clinical settings in each geographic area.

“The one problem with this situation is that there isn’t full EHR interoperability between pharmacies, hospitals and physicians,” she said. “Even if retail clinics are using an EHR, if it isn’t tethered to a physician’s office, the doctors aren’t getting the full picture.”

The one exception is e-prescribing – the only Meaningful Use requirement that does affect RHCs. Using e-prescribing services, such as Surescripts’ Clinical Interoperability, links provider, pharmacy and payer, and eliminates the need for pharmacies and physician offices to fax or mail prescription orders and patient information. Instead, with a few keystrokes, RHCs and providers can partner to compile more thorough patient histories that will lead to better, more efficient care in the future.

Griskewicz cautioned, however, that without proper staffing to fill the medication orders sent via an e-prescribing tool, the interoperability is ineffective.

More To Come
As quickly as RHCs are expanding, so are the HIT solutions to support them. Griskewicz predicted that most growth will occur with mobile technology, giving RHCs the ability to give patients their health information in easy-to-transport formats. The overall impact, she said, will be a positive effect on patient health and well-being.

“I encourage retail clinics. I encourage them to continue to use health information technology to work with outside organizations,” Griskewicz said. “They should continue down this path as technology evolves to make these health services more convenient for patients. It’s not just about bringing customers in and selling the candy on the shelves, but about improving the health of the patient.”

To read the article in its original location: http://www.porterresearch.com/Resource_Center/Blog_News/Industry_News/2012/April/Retail_Health_Clinics_on_the_Rise.html


April 12, 2012 Posted by | Healthcare | , , , , , , , , , , , , , , , , , , , , , , , , , , , , , | Leave a comment

The Changing Role of Nurses

Published in the March 2012 Hospitals & Health Networks Magazine

By Whitney L.J. Howell

Increasingly, hospitals rely on RNs to fill the primary care gap and meet the many new health care imperatives

The Mayo Clinic in Rochester, Minn., is no stranger to repeat patient visits. But providers were stunned when they realized one individual had 76 encounters in 2010. “According to the care coordinator, the patient came to urgent care, the emergency department, the primary care office and the hospital sometimes as often as two to three times a week,” says Diane Twedell, vice president and chief nursing officer for Mayo’s Austin Medical Center. “So, we took the needed steps and got those 76 visits in 2010 down to just four in 2011.”

Curbing this excessive health care system use and ensuring that the patient received the appropriate care called for a simple solution, Twedell says: getting the care coordinator — in this case, a nurse — more involved at every step of the patient’s care. The nurse followed up with the patient after each appointment, designed different care plans and facilitated transitions between clinical settings. The result: health care that maximized quality and minimized cost.

Ultimately, that’s the intent of the accountable care model. Many industry leaders consider expanding the role of nurses and using their skills to the utmost essential in giving patients more coordinated, team-based care. If nurses have more responsibility over care management and a louder voice in designing workflow, not only will public health improve, but the health system also will be leaner and more effective, they contend.

Expectations and pressure are high as the field faces the impending influx of more than 30 million people with expanded coverage under health reform. However, there are still many questions about what responsibilities nurses should assume and how hospitals can best assess their own needs. There are also concerns about whether enough nurses will be available in the coming years to meet the needs of an aging and increasingly complex patient population.

Out from under the radar

In every clinical care environment — hospitals, nursing homes, ambulatory care centers — nurses nearly always have the closest relationship with patients. They are the front-line providers who monitor and meet patient needs; they are the information conduit from patient to physician; and they are the dogged patient advocate who lobbies for both patient and family.

But, as a group, nurses often neglect discussing their contributions to high-quality patient care and overlook opportunities to offer input on workflow design, says Pam Thompson, R.N., chief executive officer of the American Organization of Nurse Executives, an American Hospital Association subsidiary group. Effecting change will require nurses to be proactive.

“Nurses have pretty much always been invisible, but we must ask to be included in conversations about care management,” Thompson says. “We know how care is supposed to be delivered. From working across the continuum, to smoothing handoffs, to working to prevent readmissions, nurses cannot be silent. We must speak up and say, ‘We can do this.'”

The Future of Nursing: Leading Change, Advancing Health, a report published by the Institute of Medicine in October 2010, highlighted nurses’ ability to reduce gaps in care and stressed the imperative that they do so. According to the report committee, nurses are ready to stretch their wings as primary care providers to increase access to services and organize complex care plans for wide ranges of patients. They often prevent medication errors, reduce infection rates and facilitate patient transitions from hospital to home.

If allowed to work to their full potential, nurses can help hospital administrators strike the right balance between providing the best possible clinical care and controlling costs, says Patricia Hines, R.N., clinical and operations expert and vice president for the Camden Group, a health care consulting firm. “We must try to create an environment that optimizes the role of the professional nurse,” Hines says. “They can engage in value-based purchasing for the client; they can spend time on patient education, prepare for care coordination and increase their interaction with primary care providers.”

In many cases, nurses already are serving as care coordinators, health coaches, disease managers and community liaisons. Others conduct research at the bedside and analyze the data. But for nurses to assume these roles officially on a broad scale, a number of things need to happen, says American Nurses Association President Karen Daley, R.N.

The biggest is expanding the scope of nursing practice, she says. “The current hierarchy and archaic, traditional way of doing business within a lot of hospital environments impedes nurses’ ability to provide care,” Daley asserts. “Nurses must own their power and the potential of their practice.”

Not everyone agrees. The physician-led team is a tested strategy, according to the American Medical Association, and changing tactics when health care is facing a significant major influx of patients could impact all providers’ abilities to give patients the best, most cost-effective care.

“With seven years or more of postgraduate education and 10,000 hours of clinical experience, a physician is uniquely qualified to lead the health care team,” says AMA President Peter W. Carmel, M.D. “Physicians, physician assistants and nurses have long worked together to meet patient needs for a reason — the physician-led team approach to care works. Patients win when each member of the health care team plays the role he or she is educated and trained to play.”

Scope of practice is a controversial legislative issue. Most states restrict the services nurses, including nurse anesthetists and nurse practitioners, can provide without supervision. Only 14 states allow NPs to diagnose illness and prescribe medication without physician oversight, but the battle is building nationwide.

What nurses can do

As health care shifts toward a more team-based approach, many nurses already are moving into roles that build upon their previous responsibilities, such as developing greater care coordination and conducting population analyses.

As clinical leaders, nurses can have a significant impact through discharge planning, says Marilyn Chow, R.N., Kaiser Permanente’s vice president of national patient care services. They are uniquely qualified to recognize and provide tailored guidance for patients at risk for negative outcomes or a readmission. “At discharge, nurses can improve a patient’s outcomes by going through their medications, discussing any side effects, and asking if they have any questions,” she says. “Being proactive is very important.”

In many cases, Chow says, NPs serve as care coordinators, guaranteeing continuity under the collaborative model. As the primary provider, he or she can follow patients easily cross settings to monitor their progress and needs, as well as catch problems early.

NPs with Harvard Vanguard Medical Associates proved that point when they launched a program for congestive heart failure patients, many of whom received conflicting advice from their various physicians. Each patient is assigned an NP who works with specialists to design a single care plan. Within a year, the program slashed emergency department visits by 92 percent for that group of patients.

Nurses also can improve care in a patient’s home. Pittsburgh Regional Health Initiative’s CEO Harold Miller says the organization saw a 40 percent drop in readmissions for advanced lung disease patients when nurses began conducting home visits.

A nurse’s first-hand knowledge of a patient’s condition also can lead to discussions with colleagues about disease management for complex patients, says Patty Jones, R.N., a health care management consultant with independent actuarial firm Milliman. Floor nurses, she says, can expand their practice scope by providing follow-up care through home visits.

Maintaining these relationships bolsters nurses’ abilities to manage the needs of certain groups proactively, such as patients living with diabetes or children with asthma, she says. Through analysis of patient data, nurses can create interventions that potentially improve the group’s overall health.

Doing so makes nurses cost managers, as well. Not only do they augment the patient experience, they also positively impact population health. As a result, hospitals often see a drop in their patient per capita care costs, Hines says.

Broader nurse activity saved Wisconsin-based Marshfield Clinic $118 million during a five-year project funded by the Centers for Medicare & Medicaid Services. The clinic beefed-up its 24-hour nurse hotline to serve both adult and pediatric patients and added physician-directed, nurse-managed heart failure, high cholesterol and anticoagulation therapy programs.

A similar hotline program at the Mayo Clinic allowed nurses to provide more than 11,000 treatment protocols over the phone, including for urinary tract infection and sinusitis, within 18 months, freeing up office visits for patients with more acute needs, says Stephanie Witwer, R.N., a primary care nurse administrator with the clinic.

Skills nurses need

To fulfill their roles under an ACO or other coordinated care model, nurses will need additional skills in many areas — from technology to evidence-based research. Enhanced education will be the foundation of it all.

The IOM report called for at least 80 percent of practicing nurses to have a bachelor’s degree by 2020, and industry experts are supportive. “Nurses with a BSN have the skill set and critical-thinking abilities needed for evidence-based practice,” Hines says. “They have more exposure to collaboration and team-building and readily can create a culture of quality and safety.”

Many hospitals already have begun moving toward an all-BSN workforce. In October 2010, shortly before the IOM issued its recommendation, North Shore–Long Island Jewish Health System in New York mandated that all newly hired nurses hold a BSN, says Elaine Smith, R.N., vice president for system nursing education.

The Future of Nursing report bolstered our conviction that it’s necessary for nurses to be better educated,” Smith says. “As we look to change how the health care system is designed and better manage patients across transitions of care, our nurses need to have the skills that only can be acquired with higher education.”

Although the initiative is still too young to determine what, if any, improvements or benefits an all-BSN workforce brings to patient care, Smith says response to the move has been enthusiastic. There are, however, steps hospitals must consider to facilitate baccalaureate education for staff nurses who desire it. Institutions should negotiate with nursing schools to secure employee tuition discounts, partner with schools to provide classes on hospital grounds, and determine what type of tuition reimbursement to offer.

Achieving a higher level of education will expose more nurses to one of the most important aspects of health care reform: the push toward greater use of health information technology. For example, nurses who are proficient with telemedicine can monitor their patients easily in their homes, keeping tabs on any daily activity or medication needs.

To date, electronic health records are the most significant IT investment for most health care settings. It is clear CMS expects all clinical care environments to achieve HIT proficiency, and nurses must be among the most enthusiastic adopters, Daley says.

“Nurses need the most in-depth knowledge and hands-on experience with health information technology,” she says. “Many nurses already are skilled far beyond basic competencies. They have a comfort level with this technology that can help them communicate with other providers and can allow them to make the most of their role in coordinated care.”

But it’s not enough for nurses to simply use an EHR, says Milliman’s Jones. Hospitals must include nurses from the beginning of the IT planning process and request their feedback about what works and what does not throughout the selection and implementation process.

Community care settings offer the biggest opportunity for nurses to use technology to improve the quality of care, Jones says. The data nurses gather from the older and underserved populations who receive health care in the community can be used to improve patient care processes within hospitals.

Community-acquired information also can be used to support evidence-based research, says the ANA’s Daley. Armed with outcomes data, nurses can present hospital administrators with process changes to improve both workflow and patient care. For example, nurses with the public-private Community Care of North Carolina analyzed claims data, including repeat emergency department visits and chronic-condition diagnoses, to pinpoint patients who likely would benefit most from case management. According to a 2008 Annals of Family Medicine article, by tracking utilization and communicating with other managers, CCNC nurses have saved the state about $160 million annually.

Bringing such an impact to widespread fruition, however, often means nurses must improve their communication channels with physicians and hone their leadership skills, Daley says.

According to Kaiser Permanente’s Chow, any skill improvements or systems changes should be achieved with a singular goal in mind: improving transitions not only between shifts but also between care environments.

“Everything we do and put in place as nurses should be done to strengthen handoffs, especially among inpatient, outpatient and home care settings,” Chow says. “We are always motivated to make situations better for our patients, and the best way to do that is to ask for their perspectives.”

Kaiser Permanente nurses routinely ask patients about any fears or questions they have regarding their care plan, how involved they wish to be in their health care, and what, if any, additional information would help medical staff provide better care, she says.

Hospital preparations

While most experts agree patients benefit when nurses are more active in designing care plans or working in the community, for many clinical settings, putting nurses in those roles will take time. Health care has a long-standing perception of nurses as providers who implement physician orders and have little impact on a patient’s well-being. For systemwide reform to succeed, that view must change, Daley says.

Pittburgh Regional Health Initiative’s Miller agrees, noting that the current silo structure can thwart efforts to expand teamwork.

But hospitals must be ready for the change, says HSS’s Goldberg. The first step toward broader nurse activities is to ensure that the facility’s executive committee is on board with the idea.

Secondly, the CNO must meet with all senior leadership to conduct a gap analysis and choose external benchmarks by which they can measure their success against other organizations. Goldberg suggested using patient satisfaction scores or data from the National Database of Nursing Quality Indicators.

“This is the time for the hospital’s administrators to take stock of what they don’t have, what they need to do to get there,” she says. “Then, they can lay out a two- to three-year plan on how to accomplish it all.”

During these conversations, Jones says, hospitals should assess whether their nursing staffs have the necessary skills to put any new policies into place. Administrators should look for nurses who are experienced in teamwork, familiar with evidence-based research, fluent in HIT, and armed with the knowledge and skills that will lead to quality improvement.

Hospitals also should create a long-term succession plan. Although the current weak economy has pushed many people to either continue practicing or enter nursing as a second career, the much-publicized nursing shortage will return, Hines warns. “It would be appropriate for facilities to identify their next tier of nurse leaders now and pair them with a mentor from a group that likely will leave the workforce once the economy settles,” she says. “This way, they can avoid having a nurse leader gap.”

The road ahead

Accountable care will change how and by whom services are delivered. Perhaps the greatest challenge for nurses, Jones says, will be to relinquish responsibility. Many nurses accustomed to carrying heavy workloads may have difficulty delegating tasks to other providers.

But reassigning the jobs others can do will free nurses to step into positions that will affect systems change and directly impact patients more readily.

“Nurses have so much to contribute to patient care by means of quality and efficiency,” Daley says. “We haven’t begun to tap even a small percentage of their potential within health care.”

To read the article at its original location: http://hhnmag.com/hhnmag_app/jsp/articledisplay.jsp?dcrpath=HHNMAG/Article/data/03MAR2012/0312HHN_FEA_movingforward&domain=HHNMAG

March 15, 2012 Posted by | Uncategorized | , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , | Leave a comment


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