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Pushing Discharges Forward

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					Utilizing Business Methods to Improve
 Outcomes at the Microsystems Level
           Timothy P. Shea, FACHE
              VISN 17 Director
Topics of Discussion

• Administrative Leader’s perspective of an
  CNL

• “Bridges to Health” Model: Using Population
  Segmentation to Provide Better Health Care
  for All

• Business Case Methods


                                                2
Administrative Leader’s Perspective of
the CNL
 Practice is at the microsystems    Nursing assessment is the
level                                 basis for theory and
                                      knowledge management
Client care outcomes are the
measure of quality practice          Good fiscal stewardship is a
                                      condition of quality care
Practice guidelines are based       Social justice is an essential
on evidence                           nursing value
Client-centered practice is         Communication technology
intra- and interdisciplinary          will facilitate the continuity
Information will maximize self-      and comprehensiveness of
care and client decision-making       care
                                     The CNL must assume
                                      guardianship for the nursing
                                      profession

                                                                       3
Practice is at the Microsystems Level

•   A CNL provides
    lateral integration of
    care services within a
    microsystem of care
    to effect quality, client
    and care outcomes




                                        4
 Client Care Outcomes are the Measure of
 Quality Practice

• CNL focus is on
  improving clinical and
  cost outcomes

• Analyze common
  clinical conditions that
  comprise the bulk of
  health care activity and
  costs that would have
  the greatest impact on
  the health care system
  and outcomes
                                           5
Practice Guidelines are Based On
Evidence
                    • Justify clinical actions
                      based on evidence

                    • Apply evidence that
                      challenges current
                      policies and procedures

                    • Incorporate evidence
                      into practice situations
                      and for education of
                      other health care team
                      members
                                                 6
Client/Patient-Centered Practice is Intra-
and Interdisciplinary
                      • CNL responsible for
                        coordinating the variety
                        of clinicians
                        participating in a
                        treatment plan for
                        patient

                      • Lack of communication
                        results in discontinuous
                        and frequently unsafe,
                        uncoordinated,
                        inappropriate care
                                                   7
 Information Will Maximize Self-Care and
 Client/Patient Decision-Making

• CNL responsible for
  teaching other direct
  care providers how to
  assist patients, families
  and communities to be
  health literate and
  independent managers
  of their own care




                                           8
Nursing Assessment is the Basis for Theory
and Knowledge Management
                        • Assess various clinical
                          groups or populations by
                          collecting data that
                          documents the
                          characteristics, conditions
                          and outcomes of these
                          groups

                        • Assessing these groups will
                          not only improve individual
                          plans of care but will be
                          integrated into information
                          systems to continuously
                          update decision support and
                          complete the cycle of
                          evidence-based practice

                                                        9
Good Fiscal Stewardship is a Condition of
Quality Care

• CNL is accountable for the cost-effective and efficient
  use of human, environmental and material resources

• CNL needs to understand how to identify:
   – Waste and manage resources
   – High cost/high volume activities
   – Procedure costs and how they compare nationally


• CNL should be able to read a balance sheet, know
  the difference between fixed and incremental costs,
  and how to establish per unit costs

                                                        10
Social Justice is an Essential Nursing Value

• Social justice directly
  addresses disparities in
  health and health care

• CNL will assume
  responsibility for addressing
  variations in clinical
  outcomes among various
  groups

• CNL will work with clinical
  populations and community
  to assess and implement
  strategies that address
  health disparities
                                               11
Communication Technology Will Facilitate the
Continuity and Comprehensiveness of Care

                        • Technological advances
                          in communication have
                          made it possible for
                          sustained and ongoing
                          contact with patients,
                          their families and
                          caregivers:
                            Telehealth
                            Email
                            Wireless devices
                            Computers
                            Internet (i.e.
                             MyHealtheVet)
                                                12
The CNL Must Assume guardianship For the Nursing
Profession


• CNL is expected to
  assume…
   – positions in
     professional, policy
     and regulatory
     organizations/agencies

   – Leadership positions in
     health care facilities,
     practice plans, and as
     faculty in institutions of
     higher education

                                                   13
How Is It All Linked Together?




  Nurse          Segmented
Assessment         Clinical
                 Populations




                                 14
 “Bridges to Health” Model: Using
Population Segmentation to Provide
     Better Health Care for All
Segmented Populations



 Segmenting patient populations can lead to
   more creative and effective strategies for
    safe, efficient, effective, timely, patient-
      centered and equitable health care




                                                   16
Segmented Populations

• Healthy               • Stable but serious
                          disability
• Maternal and Infant
  Health                • Short period of decline
                          before dying
• Acutely Ill
                        • Limited reserve and
• Chronic conditions,     exacerbations
  Normal Function
                        • Frailty with or without
                          dementia

                                                    17
  Estimated Number of People and Costs in
        Each Segmented Population
  Population Segment                                    Population                                    Total Costs

Healthy                                     160 million                                   $130 billion
Maternal and Infant Health 10 million                                                     $60 billion

Acutely Ill                                 12 Million                                    $300 billion

Chronic Conditions                          110 million                                   $800 billion

Stable but serious                          7 million                                     $290 billion
disability
Short Period of Decline                     1 million                                     $50 billion
Before Dying
Limited Reserve &                           2 million                                     $100 billion
Exacerbations
Frailty, with or without                    6 million                                     $270 billion
dementia
  Lynn, Joanne, Straube, Barry M., Bell, Karen M., Jencks, Stephen F. and Kambic, Robert T.,Using Population Segmentation to       18
   Provide Better Health Care for All: The 'Bridges to Health' Model. Milbank Quarterly, Vol. 85, No. 2, pp. 185-208, June 2007.
Healthy




          19
Maternal and Infant Health




                             20
Acutely Ill




              21
Chronic Conditions




                     22
Stable but Serious Disability




                                23
Short Period of Decline Before Dying




                                       24
Limited Reserve and Exacerbations




                                    25
Frailty, With or Without Dementia




                                    26
How Is It All Linked Together?




  Nurse          Segmented         Identifying
Assessment         Clinical        segmented
                 Populations       population
                                 needs by using
                                 business case
                                    methods




                                             27
Business Case Methods
A Business Case


• A business case is a decision support and
  planning tool that projects the likely financial
  results and other business consequences of
  an action




                                                     29
Components of a Business Case

• Introduction

• Methods and Assumptions

• Business Impacts

• Sensitivity, Risks, and Contingencies

• Conclusions and Recommendations




                                          30
Example of Business Case
Introduction

• Hospital ABC has noticed a change in community
  demographics. They are seeing more older, frail
  patients with multiple chronic conditions. They are
  also seeing a shift from private insurance to Medicare
  and Medicaid reimbursements.

• Hospital ABC also has an excess capacity in facility
  space and wants to determine if transitioning from an
  acute care rehabilitation model to a long term
  chronic/skilled model would help with management of
  this population.

• Application of the business planning model will help
  determine if opening this new unit will successfully
  manage this emerging patient population in a cost
  effective manner.                                      32
Methods & Assumptions

• Scope and boundary definitions
   – Time frame
   – Geographic areas served
   – Population

• Major assumptions
   –   Population growth rate
   –   Inflation will remain stable
   –   Staff Mix
   –   Length of Stay is 30 days or Less

• Methodology
   – As Is
   – Build Out
   – Fee or Purchase within the community   33
Business Impacts

• Competitors

• Financial Results

• Customer Satisfaction

• Community Relationships

• Research or Education




                            34
  Risks, and Contingencies


• Risk Analysis:
  – Will volume meet expected values?
  – Will cost exceed anticipated revenue?
  – Will we be able to get the Qualified Staff and Staff
    Mix
  – Can we address Post Discharge placement needs
    and timeliness
• Contingencies
  – Plan of care for this Population
  – Staffing and Equipment needs
  – Unit Costs
                                                           35
Conclusions and Recommendations

After analyzing costs, benefits, risk assessment,
and population demographics, Hospital ABC
has determined they will open a 20 bed Skilled
Nursing Unit with the focus of providing care to
new strokes, fractures or other diagnoses
requiring a specified period of rehabilitation,
which on average is less than 30 days.




                                               36
Next Steps
  From Business Case Analysis to Business
  Plans
Workload Projections:
• Patients admissions             Recurring Costs
• Population Age
                                  • Salaries
Start Up Costs
• Equipment                       • Supplies

• Renovation of Existing          • Training & travel
  Space
                                  • IT
• Start-up supplies & furniture
                                  • Utilities/Maintenance
• Recruitment/Incentives

                                                            38
• Initial training & travel
Conclusion


                      Quality




        Population
                     Outcomes   Access
        Segments




                       Cost




                                         39
Questions




            40

				
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posted:7/26/2011
language:English
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