Monday, October 20, 2014

Supreme Court Ruling in Federal Trade Commission Case Will Have Broad Implications for Scope of Practice Regulations

By Joanne Spetz, PhD

Last week, the U.S. Supreme Court heard arguments in North Carolina State Board of Dental Examiners v. Federal Trade Commission (FTC), a case that will have significant implications for scope of practice regulations across the country.   At the center of this case is the “state-action doctrine,” which provides immunity from federal antitrust liability for certain state-mandated activities. In this case, the FTC had filed a complaint regarding the Board’s efforts to stop non-dentists from offering teeth whitening services. The North Carolina Dental Board asserted state-action as a defense. The case centers on how the Board operates and whether its operations fall under the state-action doctrine. The FTC believes that the board, which is comprised mainly of practicing dentists, exceeded its authority and its actions were a private effort to eliminate competition from non-dentists – a violation of anti-trust law. The Board believes it is acting as a regulatory body to ensure consumer safety.

Last spring, the 4th Circuit Court of Appeals agreed with the FTC; the Board appealed to the Supreme Court. This case gives the Supreme Court an opportunity to decide whether health professions boards in general, which are usually established by state legislatures but whose members are private actors, fall under the state-action doctrine. If the Supreme Court sides with the FTC, it could have a significant impact on the capacity of dental, medical, nursing, and other boards to regulate health care services, especially when a compelling public safety argument cannot be made.  The Supreme Court’s decision also could provide clear guidance to states in how their boards can be appointed and function in order to adhere to anti-trust law. To follow the case’s history, look here

This same issue was addressed last June at an FTC public workshop in Washington, DC, titled, “Examining Health Care Competition. The workshop topics included professional regulation of health care providers, health care delivery innovations such as retail clinics, health information technology, health care quality, and price transparency. The meeting room was full for most of the two-day event, but attendance appeared greatest for the first session, “Professional Regulation of Health Care Providers,” for which I was one of the presenters. 

The session did not address any specific legal action related to health professions regulation, focusing instead on providing an overview of several important aspects of health professions regulation.  Barbara J. Safriet, JD, LLM, a Visiting Professor of Health Law and Lewis and Clark Law School, discussed the history of health professions regulation and the potential for legal collusion and hindrance of competition. Morris Kleiner, PhD, from the University of Minnesota, discussed health professions regulation in the context of professional regulation in general. He noted that health professions boards are often based at the same agencies as many other professions’ boards, so a single organization is charged with overseeing physicians, nurses, cosmetologists, pet groomers, and myriad other professions. Gail Finley of the Colorado Hospital Association discussed particular challenges that state faced regulating nurse anesthetists, and the battle between physicians and nurses regarding safe anesthesia care in rural communities. I discussed the impact of scope of practice regulations for licensed practical/vocational nurses on the demand by hospitals and nursing homes – we found that in states with stricter regulations, there is lower demand.

The FTC published a Policy Perspective paper in March 2014 on “Competition and the Regulation of Advanced Practice Nurses.”  The paper’s authors reviewed the rationale for establishing scope of practice regulations, noting that there are valid reasons to control scope of practice, even if it might reduce competition. However, they wrote: “…the FTC staff has consistently urged state legislators to avoid imposing restrictions on APRN scope of practice unless those restrictions are necessary to address well-founded patient safety concerns. Based on substantial evidence and experience, expert bodies have concluded that ARPNs are safe and effective as independent providers of many health care services within the scope of their training, licensure, certification, and current practice. Therefore, new or extended layers of mandatory physician supervision may not be justified.”

Unsurprisingly, there is great interest in the Supreme Court case throughout the health care industry. Among the entities that have filed amici briefs, are the American Dental Association, Federation of State Boards of Physical Therapy, American Association of Nurse Anesthetists, Association of Dental Support Organizations, Cato Institute, Pacific Legal Foundation, National Governors Association, California Optometric Association, and Public Citizen, and 23 states.  A decision is expected next year.

Joanne Spetz is a professor at the Philip R. Lee Institute for Health Policy Studies and associate director of research strategy for the Center for the Health Professions at the University of California, San Francisco.

Friday, October 3, 2014

Carrots and Sticks to Reduce Readmissions and Improve Home Health Care

Olga Jarrín, PhD, RN @OJ_RN
National Hartford Center of Gerontological Nursing Excellence, Claire M. Fagin Fellow Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing

The Affordable Care Act has generated carrots and sticks for hospitals to reduce readmissions. With the goal of achieving the Triple Aim (improving quality of patient care, improving population health, and reducing overall cost of care), innovative care delivery models are being tested locally and nationally, including the roll-out of Accountable Care Organizations and bundled payment programs. These programs create incentives in terms of shared savings for health care systems that provide high quality, coordinated care.
Olga Jarrín is a National Hartford Center of Gerontological Nursing Excellence, Claire M. Fagin Fellow at the Center for Health Outcomes and Policy Research.
Meanwhile, a readmission penalty has taken effect, and hit safety net and teaching hospitals hard. While increased referrals to home health care from hospitals might lower readmission, there is wide variation in home health agencies’ ability to keep patients safely in their homes, and out of the hospital.
Institute of Medicine Workshop on the Future of Home Health Care
Health services researchers, home health agency executives, other industry representatives, and stakeholders including patients and patient advocates met at the Institute of Medicine for a 2 day workshop on the Future of Home Health Care #FutureofHH September 30-October 1, 2014. Major challenges for home health include reduced/insufficient payment for home health care, misaligned regulatory requirements and statutes, and the image of the home health care industry, that has been tainted with fraud, abuse, and sub-optimal patient care. Core issues discussed at the meeting included the use of technology to enhance care, the need for interoperable health records, the need for statutory changes at the federal level to allow advanced practice nurses to sign orders for home health care, and new models of care.
In contrast, the existing way that home health care is provided to Medicare beneficiaries was criticized as fragmented, uncoordinated, siloed, slow, and unable to meet the functional or clinical needs of today’s population. The desire to scrap the entire system and start over was balanced by a call for action “Let's work to improve, not diminish our existing home health care system” from keynote Steve Landers, MD, President and CEO of VNA Health Group. Reminding the audience of the Jimmo v. Sebelius Settlement Agreement, Judith Stein, JD, founder and Executive Director of the Center for Medicare Advocacy, pointed out the discrepancy between how home health care has been provided to Medicare beneficiaries, and how it should be provided.
Home Health Agency Work Environment Study
Using publicly reported CMS Home Health Compare data linked with nurse-reported ratings of the home health agency work environment, researchers from the Center for Health Outcomes and Policy Research have established a mechanism for why some home health agencies have better outcomes. Hospitalizations, including both acute and long-term stays, were lowest for patients receiving services from home health agencies where nurses reported excellent working conditions. Nurses working in home health agencies with poor working conditions were much more likely to report being unable to complete necessary care coordination and patient teaching due to time constraints. These findings are published open access in the October issue of the journal Medical Care.
These findings have implications for hospital and home health administrators, as well as policymakers. Hospitals should consider partnering with home health agencies that have better nurse work environments as a strategy to improve their patient outcomes, and bottom line. Home health agencies should work towards creating optimal conditions for nurses to care for patients. Policymakers should remove barriers to full scope of practice for Advanced Practice Nurses (APNs) and Registered Nurses (RNs) working in home health care, especially the requirement for physician co-signatures of APN orders for changes to the home health plan of care, including medication changes. The federal statute restricting APN authority supersedes state laws, and provides a disincentive for home health agencies to hire and collaborate with expert nurse clinicians.
Some of the “new” care models highlighted at the IOM Workshop: The Future of Home Health Care were strikingly similar to old models of home health care provided by public health district nurses and community-based family practice doctors who made both house-calls and hospital-rounds. Removing barriers to practice in home health care for APNs to direct care and directly order services is a small but important step towards raising the quality, responsiveness, and cost-effectiveness of home health care.
 This post first appeared on the Leonard Davis Institute of Health Economics Blog (LDI Blog) of the University of Pennsylvania.

Tuesday, September 23, 2014

INQRI Study Shows Nursing Improvements Could Boost Outcomes for 7 Out of 10 Critically Ill Black Babies

Identifying the reasons for racial health disparities and ways to address them is a significant, complex challenge in health care. A new INQRI-funded study led by Eileen T. Lake, PhD, RN, FAAN and Jeannette A. Rogowski, PhD, provides insight into the issue of very low birth weight (VLBW) infants, who are disproportionately black, and finds that it’s not just their race that’s a factor in their health outcomes, it’s the quality of care at the hospitals where they’re born. The study was published in the journal Health Services Research.

The research team examined data on 8,252 VLBW infants in 98 Vermont Oxford Network member neonatal intensive care units (NICUs) throughout the country and the results of a survey of 5,773 NICU nurses. They found that nurse understaffing and practice environments were worse at hospitals with higher concentrations of black patients, contributing to adverse outcomes for VLBW infants born in those facilities.

Since 7 out of 10 black VLBW infants are born in hospitals with a high concentration of black patients, researchers concluded that improvements in nursing at such hospitals have the potential to boost the quality of care for many black VLBW infants. The study looked at two nurse-sensitive perinatal quality standards—hospital-acquired infection and discharge without having started breast milk, which have long-term health implications for VLBW infants—and found higher rates of both in high-black-concentration hospitals. NICU nursing features ultimately accounted for one-third to one-half of hospital-level health disparities.

“Very low birth weight infants are at a high risk for a lifetime of health challenges,” said Lake. “The birth hospitalization is the starting point.  With a high number of black infants born in relatively few hospitals, tackling a previously unaddressed question—do infants cared for in hospitals with a high concentration of black infants have poorer perinatal quality outcomes?—gives us an opportunity to make a positive impact on population-level health disparities.”

The study highlights dramatic differences in the distribution of care for black infants, with nearly three-fourths of black VLBW infants born in a third of hospitals that care for critically ill newborns. Only 1 in 20 black infants are born in hospitals with better nursing characteristics, and odds of adverse outcomes related to nurse-sensitive perinatal quality standards are at least 60 percent higher for infants born in disproportionately black hospitals.

The team also included Jeffrey Horbar, MD, chief executive and scientific officer, Vermont Oxford Network and  professor of pediatrics, University of Vermont; Michael Kenny, MS, research biostatistician, University of Vermont; Thelma Patrick, PhD, RN, associate professor, the Ohio State University College of Nursing; and Douglas Staiger, PhD, professor of economics, Dartmouth College.

Thursday, September 18, 2014

RN Researching Communication Tool that could Reduce Readmissions

A nurse researcher is exploring whether or not hospital readmissions among elderly patients in assisted living could be reduced through improved communications between medical providers, the Lubbock Avalanche Journal reports.

Alyce Ashcraft, associate dean for research at the Texas Tech University School of Nursing, is conducting a study with a customized Situation, Background, Assessment and Recommendation (SBAR) tool that gathers additional patient information and forces more transparency in nurse-provider communication.

Over a 16 week-period, Ashcraft instructed nurses at a retirement community in Lubbock, Texas, to document all of their consultations with health care providers, including phone and fax communications, on SBAR forms. The intent is to eliminate repeats tests and create more efficient care by recording when nurses contact other providers about a patient’s condition, and the actions taken. The data is still be collected and analyzed.

“I don’t care if you’re here in long-term care, or the hospital or home health, it doesn’t matter,” Ashcraft, told the Journal. “Communicating the right information and getting the residents’, the patients’, the clients’ story right so that decisions can be made that are good for them; [t]hat’s what we hope to do.”

INQRI researchers at Marquette University, led by Marianne Weiss and Olga Yakusheva, studied what hospital-based nurses do to influence outcomes, including readmission rates, after a patient is discharged from a hospital. Specifically, they identified the contributions that nursing staff make to the quality of discharge teaching and the impact of that teaching on patient outcomes, readiness and readmission rates of patients who are discharged home. They found that when units had more RN hours per patient day, fewer overtime hours and fewer vacancies, the discharge teaching was of higher quality, patients reported greater readiness for hospital discharge, and post-discharge utilization of readmission and emergency room visits was lower.

Wednesday, September 3, 2014

Webinar to Help Nurses Manage Alarm Fatigue

Advance Healthcare Network for Nurses is hosting a webinar on the issue of nurses facing alarm fatigue. The webinar is scheduled for Thursday, October 16, 2014 from 3:00pm-4:00pm ET. The webinar will provide information about:
  • Current literature on alarm fatigue.
  • Systems and human issues that contribute to alarm fatigue.
  • A system wide approach that can be developed to address alarm fatigue.
The webinar will also feature a question and answer session. Registration is available here. The webinar is sponsored by Covidien.

An INQRI-funded study found a unique way to use different sounds to reduce alarm fatigue and help keep patients safe. Led by Tracey Yap and Jay Kim the team used music to reduce the incidence of pressure ulcers. The study used music to cue patients in long-term care facilities to move in order to avoid getting pressure ulcers. The music also cued staff to help to move those patients who could not move on their own.

Thursday, August 28, 2014

Team-Based Interdisciplinary Care

This blog post originally appeared on the RWJF Human Capital Blog

The Robert Wood Johnson Foundation’s (RWJF) LEAP National Program is working to create a culture of health by discovering, documenting and sharing innovations in the primary care workforce. To advance this goal, the program is holding a series of six webinars that highlight best practices. (Read a post summarizing the first of the six webinars.) The second of the webinars in the series focused on team-based care for complex cases. Presenters included leaders from four primary care sites around the country that the LEAP program has deemed exemplars.

Managing Care for the Most Complex Patients

Kathy Bragdon, RN, director of care management at Penobscot Community Health Center in Bangor, Maine, discussed the rapid growth of the health center, and went on to describe its system of care management for the most complex patients.

The center relies on a transitions care manager, who shares information back and forth with the hospital and with patients’ medical homes. In addition, the manager meets with patients when they are in the hospital, looking to identify potential barriers to recovery and to provide any needed referrals.

“One of the big roles—we didn’t realize how big—was that a tremendous number of patients had no primary care at the time of admission,” she said. “We worked really closely with the hospitals trying to provide those services and make that linkage to those patients who needed primary care providers.”

Bragdon explained that the center’s biggest initiative was to embed care management at its larger facilities, using nurses, medical assistants, health coaches and social workers focused on improving patients’ self-management skills, thus reducing the number of hospitalizations and readmissions, and improving the overall quality of care. The initiative is built around face-to-face visits, as well as phone calls with a focus on hospital follow-up. They try to reach every patient within 72 hours after they’ve been discharged from acute care.

Finally, the center uses a community care team (CCT) to work on its most complex cases. In addition to the supports provided via embedded care management, the CCT conducts a team visit that includes both a social worker and a nurse, meeting the patient where it is convenient for them—at a doughnut shop, a homeless shelter, or wherever else makes sense. “We do this because the RN and the social worker look at the situation through very different eyes in trying to see what is driving that person to the emergency room,” she explained, adding that the effort is “focused on the highest utilizers of health care dollars.”

The cost savings generated by the CCT program are significant, she said, cutting costs to the state in half.

The Integrated Care Team

From Daughters of Charity Health Centers in New Orleans, Roslyn Arnaud, RN, chief nursing officer, and Grace Mena, RN Care Manager, discussed the center’s Integrated Care Team. Arnaud began by sketching out the members of the team. They include:
  • An RN Care Manager, who identifies patients who are not being treated appropriately by a primary care provider, generally at-risk patients with comorbidities. The nurses respond to patients from local safety net hospitals and provide intense follow-up support for them after discharge. They help patients understand what took place and make sure they have medications, have a follow up appointment with their primary care provider and reconcile medications. The RN Care Manager is also responsible for monitoring and tracking patients on anticoagulation therapy.  Additionally, they are responsible for overseeing the tracking of abnormal cancer screens.
  • A Patient Care Coordinator, who provides administrative support, including making appointments for patients for services the Health Center does not have provide onsite. Coordinators also make sure patients know about their appointments and work to ensure that they go. They also ensure that preventive care is completed, including mammograms, colonoscopies, pap smears, and other cancer-tracking.
  •  A Behavior Health Social Worker, who serves as a consultant to the patient, helping them identify the need for change, and establishing goals that are appropriate for that patient.
The team members also collaborate with a local university to arrange for the services of a clinical pharmacist and a certified asthma educator.

Mena explained that the center is now testing a team model with a different composition, bringing together a physician, nurse practitioner, medical assistant and care coordinator, with social workers also available to patients. She noted that the nurse practitioner provides patient education and patient engagement.   “The key part of this work is communication between the nurse practitioner and RN care manager,” she said.

Continuity and Coordination of Care for Complex Patients

Larry Holly, MD, CEO of Southeast Texas Medical Associates, then discussed his six-site clinic’s efforts to care for complex patients as they transition from one setting to another.

He said that the care transition process begins at hospital admission, when the patient receives a care plan to transition from the ambulatory to in-patient setting. Then, at the end of their hospital care, the patient receives materials that detail necessary follow-up appointments and include a medication reconciliation plan. Associates follows that up with a “care coaching call,” and then the patient completes the process with a follow-up appointment at the clinic.

Associates also uses a Hospital Consumer Assessment Health Care Provider and Systems audit that assesses whether the care provided has been patient-centered and of sufficient quality. It asks whether the physician explained the care plan, answered all of patient’s questions without interrupting, inquired about whether care at home was adequate, and wrote down what potential symptoms would necessitate a return to the hospital. The clinic reviews results of the assessment with the hospital.

Associates also features a Care Coordination Department that identifies and tries to overcome barriers to care, Holly explained. So if patients lack transportation to appointments, can’t afford their medication, or are in need of dental care, the patient is referred to other resources.

Said Holly: “This system has integrated a number of complex problems that have befuddled physicians for years. Now we can easily provide those in the context of continuity of care and transitions of care for complex patients. These are critical parts of a medical home.”

Expanding the Team for Complex Cases

Craig Robinson, MPH, executive director of Cabin Creek Health Systems (CCHS), and Amber Crist, MS, CCHS director of education and program development described their efforts to treat patients with chronic pain using interdisciplinary teams.

CCHS has four sites in rural southern West Virginia, Robinson and Crist explained. The program began with an effort to identify older, frail patients in the area in need of care focused on reducing pain from chronic conditions.

“We quickly realized [such patients] increase the complexity of our system,” Crist said, going on to explain that the system needed to adapt. “We needed to expand our clinical team. It couldn’t just be the medical provider. Accordingly, the team grew to include the MD, a nurse practitioner, a physician assistant, a medical assistant, a behavioral health coach, a pharmacist, a health coach, and administrators.”

“If we can keep these patients out of the hospital, we save the system money. That’s where the suffering, is and that’s also what’s sometimes burning our staff out,” she said. “Our providers feel alone in the room. [Otherwise,] they feel they don’t have anyone else to turn to and are alone dealing with these complex patients.”

The RWJF Human Capital Blog will report on additional LEAP webinars in coming weeks.

Friday, August 22, 2014

More Nursing Schools Focus on Interdisciplinary Care

A number of the nation’s top nursing schools now require students to participate in at least one interprofessional education course or activity, according to a “dashboard” report recently released by the Future of Nursing: Campaign for Action, an initiative of RWJF and AARP.

Experts have been calling for interprofessional education for decades, but more schools are now responding because requirements are being written into health professions accreditation standards, Barbara Brandt tells RWJF’s Sharing Nursing’s Knowledge (SNK) newsletter. Brant is head of the National Center for Interprofessional Practice and Education, a public-private partnership supported by RWJF, the U.S. Health Resources and Services Administration, and other organizations. While there is not yet any comprehensive data quantifying the number of interprofessional activities and courses offered nationwide, Brandt said that there is “no question” the number of schools requiring these types of activities is growing rapidly.

INQRI is credited in the SNK article for helping to foster interdisciplinary research and collaborative practice. The ongoing impact can also be seen in health journals, where the number of articles in 10 of the top health services research journals co-authored by a registered nurse (RN) is increasing dramatically, according to a supplemental dashboard indicator, which shows that articles co-authored by RNs jumped from 80 to 145 from 2010 to 2012.

“For much of history, physicians made the major care decisions,” INQRI Grantee Joanne Spetz said. “We need to start teaching nursing students that they bring a set of skills to the table that are unique and distinct, and add value to the skills provided by other professionals. That will help them develop good, collaborative relationships over time.”