DiversityNursing Blog

New delivery models will bring an increase in community-based facilities

With population health gathering momentum in the wake of health care reform, more hospitals are either constructing community-based settings or are including them in their plans. The goal is to offer sophisticated levels of care at patient-friendly sites and reduce costs with fewer hospital admissions.

Montefiore Medical Center is a perfect example of what is expected to become a growing trend. It recently announced plans to lease a new 11-story, 280,000-square-foot building at Hutchinson Metro Center, a mixed-use development in New York City.

The project, scheduled for completion in the third quarter of 2014, will provide space for multidisciplinary care and integrate technology that allows Montefiore to provide necessary treatments without the need for hospitalization.

"This new tower will allow Montefiore to bring the health care of tomorrow to our patients here in the Bronx," says President and CEO Steven M. Safyer, M.D. "We are reshaping outpatient care and establishing leading practices that provide Montefiore's world-class treatments through multidisciplinary teams at a hospital without beds."

The decision to develop a freestanding ambulatory facility emerged because of several factors, including the ability to provide high-tech imaging and surgical procedures in an outpatient setting, says Ed Pfleging, vice president of engineering and facilities.

The site will include 12 operating rooms and four procedure rooms that will allow difficult cases requiring a hospital-type setting to be scheduled more easily and completed quickly, he says.

While not all new off-campus facilities will be as large as this one, the 2013 Hospital Construction Survey conducted by H&HN's sister publication, Health Facilities Management, and the American Society for Healthcare Engineering also identifies a trend involving increased community-based health care.

Of the 612 survey respondents — who include vice presidents and directors of facilities management and operations at U.S. hospitals — future facility development plans and construction projects include:

• 11 percent, ambulatory surgery centers, 
• 11 percent, satellite offices catering to specialities;
• 15 percent, outpatient facilities in neighborhood settings; 
• 12 percent, urgent care facilities in neighborhood settings;
• 15 percent, new medical office building construction.

According to the National Association of Community Health Centers, the number of Americans who rely on community health centers for care is expected to double to an estimated 40 million by 2015 — from about 20 million in 2010. The Affordable Care Act allocated $11 billion to expand these centers, including $1.5 billion for construction.

Richard Taylor, managing director, health care solutions group, Jones Lang Lasalle, a real estate services firm based in Chicago, says health care systems are evolving into integrated delivery systems that reach out to their customers through a variety of facility types.

"It's all part of that overall trend that you can track back to the health care legislation and consumer preferences," he says. Lower cost of delivery and competition are two other key factors in the trend, he adds.

Marisa Manley, president, Healthcare Real Estate Advisors, agrees that the drive is in full swing for hospitals to move urgent, ambulatory and primary care to community-based sites to meet patient preferences and to cut costs.

Another positive outcome of the trend is that hospitals likely will start to utilize some of the empty buildings and office spaces caused by the Great Recession in addition to building new facilities when necessary, she says.

Source: H&HN

By ABIGAIL ZUGER, M.D.
NYTimes.com

 
When a book is heavy with glossy photographs, you seldom expect too much from its words. In “The American Nurse,” though, it’s the narrative that hits you in the solar plexus.

Take the comments of Jason Short, a hospice nurse in rural Kentucky. Mr. Short started out as an auto mechanic, then became a commercial trucker. “When the economy went under,” he says, “I thought it would be a good idea to get into health care.” But a purely pragmatic decision became a mission: Mr. Short found his calling among the desperately ill of Appalachia and will not be changing careers again.

“Once you get a taste for helping people, it’s kind of addictive,” he says, dodging the inspirational verbiage that often smothers the healing professions in favor of a single incontrovertible point.
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Some of the 75 nurses who tell their stories in this coffee-table book headed into the work with adolescent passion; others backed in reluctantly just to pay the bills. But all of them speak of their difficult, exhilarating job with the same surprised gratitude: “It’s a privilege and honor to do what I do,” says one. “I walk on sacred ground every day.”

They hail from a few dozen health care settings around the country, ranging from large academic institutions like Johns Hopkins in Baltimore to tiny facilities like the Villa Loretto Nursing Home in Mount Calvary, Wis., home to 50 patients and a collection of goats, sheep and other animals on a therapeutic farm. Some nurses are administrators, some staff wards or emergency rooms, some visit patients at home. Many are deeply religious, a few are members of the military, and a handful of immigrants were doctors in their home countries.

All describe unique professional paths in short first-person essays culled from video interviews conducted by the photographer Carolyn Jones. Their faces beam out from the book in Ms. Jones’s black-and-white headshots, a few posing with a favorite patient or with their work tools — a medevac helicopter, a stack of prosthetic limbs or a couple of goats.

But even the best photographs are too static to capture people who never stop moving once they get to work. For a real idea of what goes on in their lives, you have to listen to them talk.

Here is Mary Helen Barletti, an intensive care nurse in the Bronx: “My whole life I’ve marched to a the beat of a different drummer. I used to have purple hair, which I’d blow-dry straight up. I wore tight jeans, high heels and — God forgive me — fur (now I am an animal rights activist). My patients loved it. They said I was like sunshine coming into their room.”

Says Judy Ramsay, a pediatric nurse in Chicago: “For twelve years I took care of children who would never get better. People ask how I could do it, but it was the most fulfilling job of my life. We couldn’t cure these kids, but we could give them a better hour or even a better minute of life. All we wanted to do was make their day a little brighter.”

Says Brad Henderson, a nursing student in Wyoming: “I decided to be a nurse because taking care of patients interested me. Once I started, nursing just grabbed me and made me grow up.”

Says Amanda Owen, a wound care nurse at Johns Hopkins: “My nickname here is ‘Pus Princess.’ I don’t talk about my work at cocktail parties.”

John Barbe, a hospice nurse in Florida, sums it up: “When I am out in the community and get asked what I do for a living, I say that I work at Tidewell Hospice, and there’s complete silence. You can hear the crickets chirping. It doesn’t matter because I love what I do; I can’t stay away from this place.”

The volume is not entirely about selfless service: It was underwritten by Fresenius-Kabi, a German health care corporation and leading supplier of intravenous drugs in the United States. Presumably, crass public relations motives lurk somewhere in the background. But that’s no real reason to be meanspirited about the result, a compelling advertisement for an honorable profession.

Young people with kind hearts and uncertain futures might just sit themselves down with the book, or wander through the Web site featuring its video interviews, www.americannurseproject.com, and see what happens.

The Family Health Clinic of Carroll County, in Delphi, Ind., and its smaller sibling about 40 minutes away in Monon provide full-service health care for about 10,000 people a year, most of them farmers or employees of the local pork production plant. About half the patients are Hispanic but there are also many German Baptist Brethren. Most of the patients are uninsured, and pay according to their income — the vast majority paying the $20 minimum charge for an appointment. About 30 percent are on Medicaid. The clinics, which are part of Purdue University’s School of Nursing, offer family care, pediatrics, mental health and pregnancy care. Many patients come in for chronic problems: obesity, diabetes, hypertension, depression, alcoholism.

What these clinics don’t offer are doctors. They are two of around 250 health clinics across America run completely by nurse practitioners: nurses with a master’s degree that includes two or three years of advanced training in diagnosing and treating disease. By 2015, nurse practitioners will be required to have a doctorate of nursing practice, which means two or three more years of study. Nurse practitioners do everything primary care doctors do, including prescribing, although some states require that a physician provide review. Like doctors, of course, nurse practitioners refer patients to specialists or a hospital when needed.

America has a serious shortage of primary care physicians, and the deficit is growing. The population is aging — and getting sicker, with chronic disease ever more prevalent. Obamacare will bring 32 million uninsured people into the health system — and these newbies will need a lot of medical care. According to the American Association of Medical Colleges, the United States will be short some 45,000 primary care physicians by 2020.

The primary care physicians who do exist are badly distributed — 90 percent of internal medicine physicians, for example, work in urban areas. Some doctors go to work in rural areas or the poor parts of major cities, treating people who have Medicaid or no insurance. But they are few.

In part it’s the money. Primary care doctors make less than specialists anywhere, but they take an even larger financial hit to treat the poor. Particularly in the countryside — even with programs that offer partial loan forgiveness, it’s very hard to pay off medical school debt treating Medicaid patients, much less those with no insurance at all.

And the job of a primary care doctor today is largely managing chronic disease — coordinating the patient’s care with specialists, convincing him to exercise or eat better. Poor patients can be a frustrating struggle. Compared with wealthier patients, they tend to have more serious diseases and fewer resources for getting better. They are less educated, take worse care of themselves and have lower levels of compliance with doctors’ orders. Very few people start medical school hoping to do this kind of work. Those who do it may burn out quickly.

It might seem that offering the rural poor a clinic staffed only by nurses is to give them second-class primary care. It is not. The alternative for residents of Carroll County was not first-class primary care, but none. Before the clinic opened in 1996, the area had some family physicians, but very few accepted Medicaid or uninsured patients. When people got sick, they went to the emergency room. Or they waited it out — and then often landed in the emergency room anyway, now much sicker.

Just as important, while nurses take a different approach to patient care than doctors, it has proven just as effective. It might be particularly useful for treating chronic diseases, where so much depends on the patients’ behavioral choices.

Doctors are trained to focus on a disease — what is it? How do we make it go away?

Nurses are trained to think more holistically. The medical profession is trying to get doctors to ask about their patients’ lives, listen more, coach more and lecture less — being “patient-centered” is the term — in order to better understand what ails them.

“I’ve been out of nursing school since 1972 and I still remember that when faculty members finished talking about the scientific parts of the disease they would talk about the psycho-social part,” said Donna Torrisi, the executive director of the Family Practice and Counseling Network, which has three clinics in Philadelphia. “It’s not about the disease, it’s about the person who has the disease. While in the hospital you’ll often hear doctors refer to a patient as ‘the cardiac down the hall.’”

Younger doctors are no doubt better at this than their older peers. But the system conspires against them. The 15-minute appointment standard in fee-for-service medicine — which pays doctors according to how many patients they see and treatments they provide — makes it unlikely that doctors will spend time discussing a patient’s life in any detail. Physician reimbursement places a zero value on talking to the patient. But nurse practitioners are salaried, giving them the luxury of time. At the Family Health clinics, appointments last half an hour — an hour for a new diabetic or pregnant patient.

Jennifer Coddington, a pediatric nurse practitioner who is a co-clinical director of Family Health Clinics, said that she spends a lot of time teaching patients and their families about their diseases and how to manage it. “We want to know socially and economically what’s going on in their life — their educational level, how are they making it financially,” she said. “You can’t teach patients if you’re not at their educational level. And if a patient can’t afford something, what’s the point of trying to prescribe it? He’s going to be non-compliant.”

A physician might suggest that a patient lose weight and hand him a diet plan — or refer him to a nutritionist. At the Family Health clinics, nutrition counselors — graduate students at Purdue — will sit down with patients to talk about the specific consequence of their diet, and suggest good foods and how to cook them, Coddington said. “When you don’t have enough money to buy fruits and vegetables, so you go to the dollar menu at McDonald’s — we help those people put planners together for the week.”

Data has shown that nurse practitioners provide good health care. A review of 118 published studies over 18 years comparing health outcomes and patient satisfaction at doctor-led and nurse practioner-led clinics found the two groups to be equivalent on most outcomes. The nurses did better at controlling blood glucose and lipid levels, and on many aspects of birthing. There were no measures on which the nurses did worse.

Nurse-led clinics can save money — but not always in the obvious way. Many are cheaper than comparable physician-led clinics. Suzan Overholser, the business manager of the Family Health clinics, said that their cost per patient was $453 per year — lower than the Indiana average for similarly federally qualified clinics (all the others physician-led) of $549. But nurse-led clinics aren’t always cheaper. Coddington examined published studies of clinic costs and found that in some cases, nurse-managed clinics had slightly higher per-patient costs than traditional clinics.

Although nurses are paid less than doctors (Medicare reimburses them at 85 percent of what it pays doctors,) nurse-led clinics are often very small, and so don’t have the variety of practitioners necessary to keep a clinic running at full capacity. They also serve the most difficult and expensive patients.

The biggest financial benefit, however, likely comes from offering patients an alternative to the emergency room. Coddington’s review cites studies showing large savings in paramedic, police, emergency room and hospital use. A traditional clinic in an underserved area would do that, too, of course — it’s just that nurses tend to go where doctors won’t.

There are about 150,000 nurse practitioners in America today. The vast majority practice in traditional settings — only about a thousand are in nurse-managed clinics. One reason these clinics are rare is that they may equal traditional clinics in health care, but not in business success.

Nurse-managed clinics have to overcome regulatory and financial obstacles that traditional clinics don’t face. Powerful physicians’ groups such as the American Academy of Family Physicians oppose allowing nurses to practice independently. “Granting independent practice to nurse practitioners would be creating two classes of care: one run by a physician-led team and one run by less-qualified health professionals,” says a paper from the A.A.F.P., citing the fact that doctors get more years of education and training. “Americans should not be forced into this two-tier scenario. Everyone deserves to be under the care of a doctor.”

Only 16 states and Washington, D.C., allow nurses complete independence. In other states, some of the restrictions are bizarre — in Indiana, for example, nurse practitioners may do everything doctors do, with two exceptions: they can’t prescribe physical therapy or do physicals for high school sports.

Jim Layman, the executive director of the Family Health clinics, said he thought that nurse practitioners cared for the majority of Medicaid patients in Indiana. But if you look through Medicaid records, you’ll find only doctors — nurses are not allowed to be the primary caregiver of record. So the Family Health clinics, like others, employ a physician off-site from 4 to 6 hours a week who uses electronic health records to examine a sample of cases and consult when necessary. Medicaid is billed in his name.

It is not easy for nurse-run clinics to win status as a Federally Qualified Community Health clinic, which would allow them to get federal grants. This is largely because most come out of universities, and most universities don’t want to cede control to the community — a requirement for this status. Purdue decided it would, and the Family Health clinics qualified in 2009. Before that, they received some money from the state, and raised the rest from local March of Dimes, United Way and Chamber of Commerce donations, plus fund-raising dinners and auctions. This was enough to support just one full-time provider at each clinic. Getting F.Q.C.H. status allowed them to hire more staff and move the Carroll County clinic into a modern new building — and probably saved them from collapse. “It would have been very difficult for us had we not gotten F.Q.C.H. status,” said Coddington. The Affordable Care Act — Obamacare — did authorize $50 million for five years for nurse-managed clinics. So far 10 clinics have gotten a total of $15 million.

In some ways, the nurse practitioner-managed clinic is a throwback to the small-town family practice, when your doctor asked about the schoolyard bully and your dad’s unemployment. Among the many changes needed in how America values and reimburses health care, it’s important to encourage and support these clinics. They may be old-fashioned, but that doesn’t mean they should be financed with bake sales.

11:10AM EDT October 5. 2012 -From USAtoday.com

As Baby Boomers age into retirement by the millions each year, their growing health care needs require more people to administer that care.

That makes fields such as nursing one of the fastest-growing occupations, and hospitals are hiring now to prepare for what's to come.

Central Florida Health Alliance has 140 to 170 open positions a week, and almost 90% of them are for jobs that include registered nurses, pharmacists, physical therapists and pharmacy technicians, says Holly Kolozsvary, human resources director.

The two-hospital system based in Leesburg and The Villages is hiring for its peak season from January to April, when many retirees seek winter refuge in the Florida sun. But it's also managing a trend that requires it to employ more people year-round: More retirees aren't leaving at the end of spring, Kolozsvary says.

"It's kind of a domino effect," she says. "They move here, they're well, they get sick, they're left here through their cancer or heart disease, and we have to take care of them."

Job postings on Monster.com for positions including registered nurses, physical therapists and physician assistants rose 13% from June 2011 through June 2012, according to a 2012 health occupational report by the job site.

The additional demand could be due partly to hospitals preparing for the retirements of many older nurses as the economy gets better, increasing the need for new skilled workers. Scripps Health, a group of five hospitals and 23 outpatient facilities in San Diego, plans to hire about 400 nurses a year over the next three years but might need to increase that by 200 annually because of retirements, says Vic Buzachero, senior vice president for human resources. About 30% of the hospitals' nurses are older than 50.

Jamie Malneritch applied for a part-time job as a registered nurse with Scripps in March and heard from the hospital the same day she submitted her application. She started working a month later.

The 31-year-old, who has worked as a nurse for four years, says the job security and growth opportunities were primary drivers in her decision to go to nursing school in 2006.

"It seems like we always need more hands," she says. "Nursing is flourishing."

With an average salary of $64,690 a year, according to 2010 data from the Bureau of Labor Statistics, registered nursing may be the more desired profession, but lower-paid home health aides are actually in higher demand.

An industry shift that puts more emphasis on outpatient care and home health services makes home health and personal care aides two of the fastest-growing occupations in the country. Employment in both positions, which have an average salary of about $20,000 a year, is expected to grow by about 70% by 2020, BLS data show. Registered nursing is expected to grow 26%.

ResCare HomeCare, a national provider and employer of home health and personal care aides, who work primarily with seniors with chronic illnesses or disabilities, has received 32,000 applications this year, a 23.3% jump from last year, and it hired 6,000 of the people who applied, about 5% more than in 2011, says Shelle Womble, senior director of sales.

Home health and personal care aides are generally the same, providing services such as checking vitals, prepping meals and bathing and grooming the patient. But home health aides are funded by Medicare and, in some states, require more training, while personal care aides are funded privately and may require less training, Womble says.

ResCare, where aides make $22,000 to $30,000 a year, is anticipating the need for more workers in the near future.

"Right now, one of our key positions is that we are hiring the talent before we even get the clients so we can be prepared and have the staff available," Womble says of home health and personal care aides. "There's a lot more competition for that type of employee."

From http://www.diversityinc.com

Federal healthcare law changes dramatically impact how the  industry—hospitals, health-insurance companies and pharmas—do business today. University Hospitals in Cleveland has been aggressively reaching out to the newly insured, predominantly Blacks and Latinos. University Hospital’s Case Medical Center’s Rainbow Babies & Children’s Hospital, known asUH Rainbow, is receiving a $12.8-million grant to implement a Physician Extension Team, which works to improve the healthcare of about 68,000 children on Medicaid with high rates of emergency-room visits.

Dr. Drew Hertz, medical director for UH Rainbow Care Network and an assistant clinical professor at Case Western Reserve University School of Medicine, was a guest speaker at DiversityInc’s Innovation Fest! event where he explained how this innovative program will provide 24/7 access to nurses and doctors for referrals, advice and healthcare coordination. University Hospitals is one of the 2012 DiversityInc Top 5 Hospital Systems. View the video below.

By David Schepp

Growing demand for health services and declining productivity will result in millions more health-care jobs by the end of the decade -- regardless of how the U.S. Supreme Court rules next week on "Obamacare," a new Georgetown University report shows.

The demand for workers within the health-care industry is expected to grow by 3 million to about 13.1 million by the end of the decade, up from slightly more than 10.1 million in 2010.

Adding in "replacement jobs," those left open by retirements, deaths and resignations, Georgetown researchers forecast the number of jobs to grow nearly 30 percent to 5.6 million by 2020.

Despite legal challenges to the the president's health care reform law -- formally known as the Patient Protection and Affordable Care Act -- Georgetown researchers concluded that the law will have a "negligible" effect on the growth in the number of health care jobs.

The study's projections show that health care reform's implementation would "shift some jobs around inside health care," but lead author Anthony Carnevale says that the law's impact on employment levels is likely to be minimal simply because the sector is so big and growing so rapidly.

"It doesn't affect the industry that way," Carnevale told AOL Jobs in an interview.

Where there is likely to be an impact is among those holding or pursuing jobs as nurses.

Other findings from the report:

• Nursing is becoming an increasingly educated profession, especially among younger workers.
• People of color have been well-represented in the sector, but greater educational requirements may result in some minorities being pushed out. The study found 51 percent of white nurses under 40 have bachelor's degrees, compared to only 46 percent of Hispanics and 44 percent of African-American nurses.
• The industry has the largest number and proportion of foreign-born and foreign-trained workers in the U.S. The report finds 22 percent of health-care workers are foreign-born, compared to 13 percent of all workers nationally. Most foreign-born nurses come from the Philippines, India and China.
• White males still hold most of the high-paying jobs. The report found 81 percent of dentists are white men. Just 30 percent of doctors are female.

While most of these occupations have modest educational requirements, only 20 percent of health-care professional and technical occupations earn less than $38,000 a year, and nearly 50 percent earn more than $60,000.

Without cultural diversity amongst healthcare providers, it is almost impossible to provide quality nursing care to people from different ethnic and socioeconomic backgrounds. A multicultural representation of nurses, physicians and clinicians is important to ensure the healthcare being delivered is sensitive and meets the physical and holistic needs in our “patient palette”.

In the United States, a rise in the population and increase in minorities further challenges our healthcare system to provide appropriate care to the ever changing population it serves.

Some of the major findings in a study on the changing demographics and the implications for physicians, nurses and other healthcare workers conducted by the US Department of Health and Human Resources are bulleted here:

• Minorities have different patterns of health care use compared to non-minorities. Disparities in access to care account for part of the difference in utilization.
• Demand for health care services by minorities is increasing as minorities grow as a percentage of the population. Between 2000 and 2020, the percentage of total patient care hours physicians spend with minority patients will rise from approximately 31percent to 40 percent.
• Minorities are underrepresented in the physician and nurse workforce relative to their proportion of the total population.  As minorities constitute a larger portion of the population entering the workforce, their representation in the physician and nurse professions will increase. The U.S. will increasingly rely on minority caregivers.
• Minority physicians have a greater propensity than do non-minority physicians to practice in urban communities designated as physician shortage areas. An increase in minority representation in the physician workforce could improve access to care for the population in some underserved areas.

The study also summarizes: “Advocates for increased minority representation in the health workforce argue that increasing the number of minority physicians will improve access to care for minorities and vulnerable, underserved populations. These advocates argue that increased representation of minorities in the health workforce not only will increase equity, but will also improve the efficiency of the health care delivery system”. (HRSA 2000)

Men (of all backgrounds) are also far under-represented in nursing.  Less than 1 percent of the population are male nurses.

As our nursing population lacks diversity, statistics show that the US population is becoming more diverse and will continue on through the decades.

Below are projections for the increase in diversity amongst minorities in the United States:

Source: Modified version of Census Bureau middle series projections.

As our demographics continue to change, one of our greatest challenges is getting hospital organizations along with healthcare administration to realize that, in order to provide the best care and ensure successful patient outcomes, we have to embrace diversity. This is especially challenging to nurses because they will be expected to deliver care that encompasses these differences. Many nursing task force teams and associates have been organized to address this issue of healthcare diversity, such as:

• Asian American/Pacific Islander Nurses Association, Inc. (AAPINA)
• National Alaska Native American Indian Nurses Association, Inc. (NANAINA)
• National Association of Hispanic Nurses, Inc. (NAHN)
• National Black Nurses Association, Inc. (NBNA)
• Philippine Nurses Association of America, Inc. (PNAA)

For nursing care of all cultures and backgrounds, we owe it to our profession to increase our awareness and get involved to ensure delivery of the best care possible. One of the most important steps any of us can take is to first embrace diversity.

Source: Nursingideas.ca