Affecting Hospitals Today

Transcription

1 Volume 2 Issue 1 Affecting Hospitals Today 4 Behavioral Health Insight By ND Senator Judy Lee 6 Rural Health Care Delivery Relies on Critical Access Hospitals By US Congressman Kevin Cramer 12 NDHA Workforce Committee

2 INSIGHT SMOOTH OPERATOR A new ambulatory care center for the University of Minnesota Physicians and Fairview Health Services brings an ambulatory surgery center, comprehensive cancer center, and a wide variety of clinics under one roof with services like easy check-in and -out and valet parking to make healthcare even healthier. U OF M HEALTH CLINICS & SURGERY CENTER UNIVERSITY OF MINNESOTA In collaboration with CannonDesign Inc. Magazine s 50 Best Places to Work in America Architecture Magazine Top 50 US Firm 100% EMPLOYEE OWNED jlgarchitects.com 2 NDHA Volume 2 Issue 1

3 Affecting Hospitals Today Insight Submission Policy The ND Hospital Association is pleased to accept submissions for Insight. Submissions should be reasonable in length due to space considerations. In order to ensure the quality of our publication, editing for grammar, spelling, punctuation and content may occur. Articles, photos, and advertising should be submitted in electronic form. To submit, please NDHA at: The deadline for the Spring Issue is April 5th, 2017 Welcome to Insight The State of North Dakota is experiencing a variety of changes again this year. Some of the changes are normal evolutionary happenings and others will have a dramatic effect on the delivery of health care in our state. What we need to be cognizant of are the changes that will alter the way we deliver health care. In January we will have a new President and what the makeup of Congress will be is a guess. The President and Congress will have to deal with a number of issues, one being health care. In regards to health care; how does the nation deal with the uninsured, the behavioral/mental health problems and the opioid crisis? The question we will have to sort out is how do we as providers deliver quality health care when there is a shortage of workers and how will we be paid for the services we deliver. In North Dakota we will have at least 18 new legislators and a new Governor in December. When the 2017 Legislative Session starts in January they will need to deal with health care issues as well while trying to balance the budget with reduced revenues from agriculture and oil. The Insight magazine focuses on the future and we try to provide a perspective from individuals who work with the health care industry but are not necessarily providers. We want to capture the view of health care from the eyes of the consumer and our partners. We need to be aware of the national and state issues that are affecting the way we deliver health care and be ready to adapt to the changes. We no longer have months or years to change it has to be now. We need to be efficient and ready to make changes that are bold moves. Hopefully the articles in this edition of Insight will create those conversations within your management team and at the Board level. If you are standing still or waiting for someone to provide you with a road map to the future, you will be left behind. Enjoy the magazine and let us know if there are topics or ideas you want us to focus on. Jerry Jurena, President ND Hospital Association The ND Hospital Association 1622 E. Interstate Ave pcook@ndha.org Advertising Contact Information Joe Sitter - joe.sales@qpsnd.com Quality Printing Service, Inc NDHA Membership...48 Insight Circulation...1,100 Insight is published semi-annually by Quality Printing Service, Inc. All rights reserved. Information contained within may not be reprinted wholly or in part without the written consent of the publisher. Insight Contents 3 President s Message Welcome to Insight. 4 Behavioral Health Insight By N.D. Senator Judy Lee 6 Rural Health Care Delivery Relies on Critical Access Hospitals By Congressman Kevin Cramer Transforming the Perception on the Importance of the Healthcare Supply Chain New Oral Health Resources from the Center for Rural Health Louisiana Hospital Employee Assistance Fund Minimizing the Risk of Opioid Overdose through Clinical Practices NDHA Workforce Committee Veterans Choice Program Education for Community Providers Transposing LEAN Process Analysis on Clinic Design By Daniel J. Abeln and Chad Frost Save the 18 Date Volume 2 Issue 1 Summer

4 INSIGHT B e h av i o r a l Healt h Insight By ND Senator Judy Lee 100 years ago, we locked up people with mental illness in state hospitals. Today we put them in jail. This is not an improvement. said a prominent North Dakota physician. More people died from drug overdoses in ND and the US last year than from car crashes and gun shots. Mental illness and substance abuse are not just human services concerns; they are everyone s concerns. Lost productivity from untreated and mistreated mental illness costs $150 billion per year in the US. ND statistics are striking as well. Nearly 50,000 people had substance abuse disorders this past year. There are 185,000 people that indulged in binge drinking in the past month. Nearly 37,000 adults used illicit drugs this past month. Over 93,000 individuals had a mental illness, and 24,000 adults have had a serious mental illness in the past year. Nearly 18,000 adults have had both substance abuse and mental illness problems. It is estimated that, by 2020, mental illness and substance abuse disorders will surpass all physical diseases as a major cause of disability worldwide. The challenges in ND affect all regions of the state and all ages, including the very young. At a recent interim Human Services meeting, we heard testimony about the many challenges faced by our children. The trauma of a divorce, loss of a grandparent, drug or alcohol abuse by a parent or sibling, lack of housing or a job, violence in the home, all are keenly felt by the children. Schools often are faced with the reality of this trauma as children lose their focus, act out, and, in extreme cases, attempt or commit suicide. These students are our future, and early intervention in dealing with trauma should be everyone s concern. Many of those children with challenges end up in foster care or in the state s juvenile justice system and eventually enter the adult criminal justice system. The Department of Corrections and Rehabilitation (DOCR) states that 54% of male inmates and 56% of female inmates have a behavioral health disorder and substance use or personality disorder. Our foster care system is overtaxed, because of the number of children whose parents are addicted and who need to be removed to safe homes. Our prisons and jails are full. Nine counties are planning to expand or build new facilities, and two more are considering it. Capacity will be increased by 840 beds, or 48%. That is expensive in more than one way. Costs for transportation and housing of prisoners are skyrocketing. Taxpayers bear the burden. Prisoners may receive treatment, but when they are discharged, they walk out the door and fall off the cliff, because there are no community safe-living facilities and support to help their transition. Long mandatory sentences for drug crimes that seemed appropriate at one time are now being reviewed. People who sell drugs deserve to be locked up. But for those who are incarcerated for using, have served a significant amount of their sentences, and who have been in a treatment program, being in a secure treatment facility near their families could lead to a productive person, if the needed counseling and peer support are available. Building more prisons and jails is not the answer. ND has a workforce issue in the acute shortage of licensed addiction counselors, psychiatrists, psychologists, other counselors, and nurses to deal with the problems of mental illness and substance abuse. Too few clinical experience slots for students within the state lead to students leaving ND for internships and other career opportunities. The interim Health Services committee is studying ways to work with higher education to enable more in-state opportunities for those students interested in behavioral health careers. Additionally, we are discussing with licensing boards solutions in licensing and reciprocity approval processes. Lack of available child care for those who are working evening, night, and weekend hours is another barrier. The answer is not necessarily spending more resources, although that is one tool. The answer is going to be spending resources more wisely. There are things that can be done that do not cost money collaboration among professions, licensing board and curriculum streamlining to enable professional career changes with the field, telehealth to make it possible for someone to use a smartphone or tablet at his/her kitchen table to visit with a professional for regular contact, rather than having to drive long distances to keep a personal appointment every time. We need to ensure that evidence-based, high-quality care is provided consistently to people throughout the state. Just as cancer needs individualized treatment, so does behavioral health. Just as we do not stop giving insulin to a diabetic who has an incident, we must recognize that behavioral health and substance abuse problems are chronic diseases. In the 2014 interim, a consultant was hired to help determine the availability of and access to services and to develop a plan to address needs. We have learned about our workforce shortages, and we have task forces working to develop solutions, but it takes time. It continues to be difficult to recruit to rural areas. Studies were divided into children and adolescent behavioral 4 NDHA Volume 2 Issue 1

5 Affecting Hospitals Today health, adult behavioral health, substance abuse, and workforce. Over 400 people from around the state have been and continue to be involved with gathering information and developing recommendations. Several proposals were presented to the 2015 legislative session, and some were approved. However, they were part of a long-range plan which is proposed over 3 legislative sessions, and it is all needed more quickly than that. Vouchers were approved to enable people to see local providers, rather than having to travel to one of the 8 regional human service centers for care being reimbursed by Medicaid. There has been a delay in implementation, because of the allotment, but this is a creative and critical tool to enable more access. More than 7000 calls in 2015 were deemed behavioral healthrelated. Behavioral health beds are frequently full, so transfers are quite common, resulting in higher costs. Between 2011 and 2015, the top ten "frequent fliers called for ambulance services a total of 1584 times; 91% of those calls were either mental health or substance abuse related. Community paramedics are new additions to their staff who are helping to reduce the impact of these calls. We need to work together to address the problems relating to behavioral health and substance abuse and support the efforts being made across the state to ensure a healthy population. Please be part of the solution! Mobile crisis units which include people from a human service center, law enforcement, and an ambulance service, are important to each of the 8 regions. There has been one in Fargo for a couple of years, and one was scheduled for Burleigh County, but has also been delayed. It permits speedy responses to crises with the unit determining what the best response is for the person. F-M Ambulance reports that their total number of calls for service increased from 18,000 in 2011 to 25,000 in Onethird of their calls have a primary impression of psychiatric illness or substance abuse. Helping Clients Manage Risk HCIS/Vaaler Insurance means you get the right coverage to fit your risk. Whether you manage a hospital, clinic or senior care facility, we provide customized insurance. More than 100 hospitals and clinics and over 250 senior care facilities across the Midwest agree - healthy insurance starts with tailored coverage from HCIS/Vaaler Insurance vaaler.com Grand Forks.Fargo.Bismarck NDHA Board of Directors NDHA Jerry Jurena - President jjurena@ndha.org Phone: Fax: Bismarck Sanford Medical Center Bismarck Craig Lambrecht, MD Chair - President At-Large thru 2017 Carrington CHI Carrington Health MariAnn Doeling - President At-Large thru 2016 Fargo Sandford Medical Center Paul Richard - President AHA RPB 6 Alternate Delegate ( ) Essentia Health Tim Sayler - West Region COO At-Large thru 2018 Grand Forks Altru Health System Dave Molmen - CEO AHA RPB Region 6 Delegate ( ) Harvey St Aloisius Medical Center Greg LaFrancois - CEO At-Large thru 2016 Hazen Sakakawea Medical Center Darrold Bertsch, CEO At-Large thru 2018 Hillsboro Sanford Hillsboro Medical Center Jac McTaggart - CEO At-Large thru 2017 Valley City CHI Mercy Health Keith Heuser - President At-Large thru 2018 Watford City McKenzie County Healthcare System Daniel Kelly - CEO At-Large thru 2017 Williston Mercy Medical Center Matt Grimshaw - President At-Large thru 2016 Volume 2 Issue 1 Summer

6 INSIGHT R u r a l H e a lt h Care De l i v e r y Re l i e s o n C r i t i c a l Ac c e s s Hospita l s By US Congressman Kevin Cramer In the nearly four years I have served North Dakotans in the House of Representatives, I am too often reminded that most people in Washington do not understand the concept of rural. They cannot comprehend the distances many North Dakotans travel to access services they take for granted as being much more convenient. I see this in transportation, education, veterans services and especially health care delivery. While many challenges remain, the Critical Access Hospital (CAH) designation has made a difference for rural hospitals. It s been nearly 20 years since this designation was established by the Centers for Medicare and Medicaid Services (CMS) in response to several closures of rural hospitals in the 1980s and early 1990s. CAH designation reduces the financial vulnerability of rural hospitals through cost-based Medicare reimbursement, and keeps essential services in rural communities. Among the requirements is a CAH must have 25 or fewer acute care inpatient beds, be located more than 35 miles from another hospital, maintain an annual average length of stay of 96 hours or less for acute care patients, and provide 24/7 emergency care services. North Dakota has 36 rural hospitals with the CAH designation, and as one indication of their quality, the National Rural Health Association last year named six North Dakota CAHs to its Top 20 listing. This is testament to the stewardship present in North Dakota s rural hospitals. I have visited many, and the mission of serving their community 6 NDHA Volume 2 Issue 1

7 Affecting Hospitals Today permeates the work of the staff as they go beyond the call of duty every day. This summer I intervened in resolving a decision that could have been devastating to the Jamestown Regional Medical Center ( JRMC) when it was notified by CMS its CAH status was being revoked. Because the North Dakota State Hospital is also located in Jamestown, someone at CMS determined there were two hospitals within 35 miles of each other and the JRMC could not retain its CAH designation. Although it has the word hospital in its name, the State Hospital provides psychiatric and chemical dependency treatment to North Dakotans who require in-service or specialized residential care. It does not, and never did, meet the traditional definition of a hospital. I immediately contacted CMS Acting Administrator Andy Slavitt to make him aware of what clearly had been a misunderstanding. Four days later, CMS called to inform me that the decision to revoke JRMC s CAH status had been paused and reassured me the issue would be resolved. An official decision in writing from CMS the first week of September put an end to the uncertainty that JRMC had endured for several weeks. There are more areas of concern with the most rural of the nation s critical access hospitals. My neighbors and colleagues, Reps. Kristi Noem of South Dakota and Ryan Zinke of Montana, joined me last year to introduce legislation to improve access to outpatient therapeutic services. H.R. 1611, the Protecting Access to Rural Therapy Services (PARTS) Act, offers rural hospitals flexibility to provide a full range of services to their communities. The PARTS Act requires CMS to allow a default setting of general supervision, rather than direct supervision, for outpatient therapeutic services; create an advisory panel to establish an exceptions process for risky and complex outpatient services; create a special rule for CAHs recognizing their unique size and Medicare conditions of participation; and hold hospitals and CAHs harmless from civil or criminal action for failing to meet the current CMS direct supervision policy. In 2009, CMS began requiring outpatient therapeutic services be done under the direct supervision of a physician, meaning the physician must be physically present in the department at all times when a Medicare beneficiary receives an outpatient therapeutic service. CMS has loosened these regulations slightly in the years since by allowing the direct supervision to be done by a non-physician practitioner, such as a nurse practitioner, clinical nurse specialist or physician assistant. However, CMS still requires these individuals be immediately available at all times when services are being administered. Year after year, Congress has worked to extend the enforcement deadline of these direct supervision rules. Recently, the House Ways and Means Committee reported a bill out of committee extending the deadline on supervision requirements through the end of this calendar year. However, to provide long-term certainty for local health providers, we must pass legislation like the PARTS Act, instead of continuing to kick the can down the road. In North Dakota, rural health care isn t a luxury, it s an absolute necessity. Without it, our small towns will continue to shrink as our friends and family move closer to cities with better health amenities. Delivering high quality health care to the most rural areas of America will always remain a challenge, especially in the current regulatory environment that promotes one-size-fits-all rules. That s why it s important that members of Congress who serve rural areas work together to ensure rural health issues are part of every health care discussion. We know that keeping preventative health care closer to home saves money in the long run. And, it is vital the network of critical access hospitals remain in rural America to provide these services. As a member of the House Energy and Commerce Committee, which has jurisdiction over many aspects of health care, I will continue to make access to health care a top priority. I appreciate what you as professionals in North Dakota s hospitals do to keep me apprised of your issues and concerns. Please contact me anytime. By working together, we can keep North Dakota s hospitals and health care centers the best they can be. Volume 2 Issue 1 Summer

8 INSIGHT T r a n s f o r m i n g the Pe r c e p t i o n on t h e Impor ta n c e of the Healt h c a r e S u p p ly Chain According to a recent USA Today article, Each of the nation s 5,700 hospitals must cut $2.6 million a year on average in costs in the next 10 years to meet the demands of proposed healthcare reform. Changing the perception and understanding the strategic importance of the supply chain is incredibly vital to the continued sustainability of healthcare providers. A contract portfolio is only part of a full supply chain solution. Most facilities and their group purchasing organizations (GPOs) leverage volume aggregation in an attempt to primarily solve for one business line, in one vertical, in one expense category. Volume aggregation in the current GPO industry tends to focus on those areas of mid to high category spend and low complexity. But it s not sufficient for healthcare to focus solely on cost reduction strategies. Supply chain services include procurement, logistics and more. Providers need infrastructure - people, processes, technology and governance. The scope of the supply chain extends across every healthcare vertical, across every business line and through all expense categories. Given how much waste and inaccuracy currently exist in healthcare, improving and re-engineering current processes using excellence and improvement methodologies and techniques is crucial. This is where the supply chain is so critical. What s important to understand is that savings in the supply chain go directly to the bottom line. If the supply chain organization saves $10,000 that would be the equivalent of the hospital bringing in an additional $300,000 of patient revenue. The potential margin on $300,000 is 3%. The impact is direct and significant. But the healthcare supply chain faces perception problems that are not inherent in other industries. For example: The most expensive and high risk items often have the least control. Personal preference drives many product decisions. Healthcare outsources less than most other industries. Purchasing and Accounts Payable are often disconnected. The healthcare industry has the lowest level of trust between buyers and suppliers (of any industry surveyed). Supply chain is still in the basement of many hospitals (literally) even though non-labor expenses are approaching 50% of total cost structure. Logistics costs in healthcare are more than 10X the costs of the retail industry. Providers need end-to-end supply chain solutions that give them the ability to optimize the people, processes and technology within their systems to deliver the greatest value. Their strategy must include aspects of: Inform and teach me (assessment and education). Do it for me (managed services). Show me (transformation services). The focus must be on helping to develop transformational solutions and providing information recognizing the importance of the healthcare supply chain in improving efficiency, maximizing financial value and enhancing providers ability to offer the highest quality of patient care. Providers must join the revolution to make supply chain excellence a core competency within their organizations and achieve their highlevel strategic goals through supply chain initiatives. HSIsolutions partners with Intalere (formerly known as Amerinet). Intalere focuses on elevating the operational health of America s healthcare providers by designing tailored, smart solutions that deliver optimal cost, quality and clinical outcomes. We assist our customers in managing their entire non-labor spend, providing innovative technologies, products and services, and leveraging the best practices of a provider-led model. For more information visit 8 NDHA Volume 2 Issue 1

9 Affecting Hospitals Today New Oral Health Resources from the Center for Rural Health The Center for Rural Health has new fact sheets, reports, and presentations on oral health in North Dakota. The latest research reveals that the state does not have the amount of workforce needed to meet the oral health needs of its residents. The Center for Rural Health works in a variety of ways to address oral health issues in the state, such as evaluating unmet needs, examining the impact of efforts to improve access to dental services, analyzing oral health data, assessing oral health services among long term care facilities and clinic providers, and collaborating to provide resources for best practices in oral healthcare. Visit our oral health topic page on our website for the latest resources. oral-health Can your or your Organization HELP Louisiana Hospital Employee Assistance Fund In the aftermath of the devastating flooding in Louisiana, it is estimated that more than 5,000 hospital employees have suffered significant property loss to their homes. In an effort to provide some relief, the Louisiana Hospital Association Research and Education Foundation has established the Louisiana Hospital Employee Assistance Fund to provide support to their family of hospital employees who so desperately help. If you or your organization would like to contribute to this effort, please visit www. LaHospitalEmployeeFund.org. Improve patient care and increase staff productivity with the latest in nurse call system technology from BEK Care Solutions. For inquiries, call or Kevin: kevinl@bektel.coop Volume 2 Issue 1 Summer

10 INSIGHT M i n i m i z i n g the Risk of Opioid O v e r d o s e thr o u g h C l i n i c a l Pra c t i c e s By Pamela Sagness, Behavioral Health Division Director Overdose deaths in North Dakota increased from 20 deaths in 2013 to 43 deaths in 2014 (CDC/NCHS, National Vital Statistics System, Mortality). You can prevent opioid overdose through the care you take when prescribing opioid analgesics, monitoring your patient s response, and effectively identifying and addressing opioid overdose. The risk of opioid overdose can be minimized through adherence to the following clinical practices, which are supported by a considerable body of evidence: Assess the patient: Obtain history of the patient s past use of drugs (illicit and prescribed medications with misuse potential) by asking specific questions that may indicate behaviors of misuse. For example, Have you taken a medication to give you more energy or to cut down on your appetite? and Have you been taking anything to help you sleep (including medications or alcohol)? Take precautions with new patients: Determine who has previously cared for the patient, what medications have been prescribed and for what indications, and obtain medical records (with patient s consent.) In an emergency, prescribe the smallest possible quantity, typically not exceeding a three-day supply, and arrange for a return visit the following day. Utilize the North Dakota Prescription Drug Monitoring Program (PDMP): Designed to monitor the prescribing and dispensing of controlled prescription drugs to patients, the PDMP can give you critical information regarding the patient s controlled substance prescription history before selecting a medication for the patient. For more information on North Dakota s PDMP, visit: Select an appropriate medication: Rational drug therapy demands that the efficacy and safety of all potentially useful medications be reviewed for their relevance to the patient s disease or disorder. When an appropriate medication has been selected, the dose, schedule, and formulation should be determined. These choices often are just as important in optimizing pharmacotherapy as the choice of medication itself. Even when sound medical indications have been established, physicians typically consider three additional factors before deciding to prescribe an opioid analgesic: (1) the severity of symptoms; (2) the patient s reliability in taking medications; and (3) the dependence-producing potential of the medication. Educate the patient: Inform the patient about risks and benefits of the proposed therapy and ethical and legal obligations such therapy imposes on both you and the patient. Patient education should specifically address the potential for physical dependence and cognitive impairment as side effects of opioid analgesics. The patient s obligation extends The patient's to keeping obligation the medication extends to keeping a locked the medication in a locked cabinet or otherwise cabinet or otherwise restricting restricting access access to to it it and to and safely to safely disposing disposing of any of unused any unused supply. supply. Visit Visit TakeBackProgram.htm for for a a local local Take Take Back Location. Location. Execute the prescription order: Careful execution of the prescription order can prevent manipulation by the patient or others intent on obtaining opioids for non-medical purposes. 10 NDHA Volume 2 Issue 1

11 Affecting Hospitals Today Monitor patient response to treatment: Proper prescription practices do not end when the patient receives a prescription. Recognizing the potential for non-adherence, especially during prolonged treatment, is a significant step in overdose prevention. If you become concerned about the behavior or clinical progress (or lack thereof) of a patient being treated with an opioid analgesic, it is advisable to seek consultation with an expert in the disorder for which the patient is being treated and an addiction expert. Prescribe naloxone along with the patient s initial opioid prescription: Prescribing naloxone is a vital link in preventing overdose deaths from opioid pain medications and heroin. Naloxone competitively binds opioid receptors and is the antidote to acute opioid toxicity. With proper education, patients on long-term opioid therapy and others at risk may benefit from a naloxone prescription. Consider prescribing intranasal spray (Narcan ) or auto-injector (Evzio ) naloxone to patients who are: - Taking high doses of opioids for long-term pain management - Receiving rotating opioid medication regimens (at risk for incomplete cross-tolerance) - Using opioids for legitimate medical need, coupled with a suspected or confirmed history of substance use disorder or non-medical use of prescription or illicit opioids - Using a combination of opioids plus a benzodiazepine or other sedative - Combining opioids with alcohol, OTC, or other central nervous system depressant Legal and Liability Considerations Legal and Liability Considerations Prescribing naloxone is consistent with the Prescribing drug s FDA-approved naloxone is consistent indication, resulting with the in drug's no increased FDA-approved liability so long as indication, the prescriber resulting adheres in no to increased general rules liability so long as the prescriber of professional conduct. You are adheres to general rules of protected professional under conduct. North You Dakota are law. North Dakota protected offers under immunity North Dakota from civil law. and criminal North Dakota liability offers to individuals immunity who from prescribe, civil and distribute, criminal liability dispense, to individuals receive, possess, who prescribe, or administer distribute, an opioid dispense, antagonist receive, possess, under North or administer Dakota Century an opioid antagonist under North Dakota Code Century Code Recently released from incarceration or an abstinent based program (and presumably with a reduced opioid tolerance and high risk of relapse) - On certain opioid preparations that may increase risk for opioid overdose such as extended release/longacting preparations Most private health insurance plans, Medicare, and Medicaid cover naloxone for the treatment of opioid overdose. Decide whether and when to end opioid therapy: If out-of-control behaviors indicate that continued prescribing is unsafe or causing harm to the patient, immediate cessation of prescribing is advised. These may include altering or selling prescriptions, accidental or intentional overdose, multiple episodes or running out early, doctor shopping, or engaging in threatening behavior. When such events arise, it is important to separate the patient as a person from the behaviors caused by the disease of addiction, as by demonstrating a positive regard for the person but no tolerance for the aberrant behaviors. Visit for more information. Source: Substance Abuse and Mental Health Services Administration. SAMHSA Opioid Overdose Prevention Toolkit. HHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration, Volume 2 Issue 1 Summer

12 INSIGHT NDHA W o r k f o r c e Commit t e e NDHA Workforce Committee NDHA Workforce Education/Training Focus Group Carla Gross, PhD, MSN, RN, Education & Training Subcommittee Chair At the first meeting on June 16, 2016, the focus group established the following goals: 1) Explore the possibility of targeting new Americans to fill workforce needs in health care; 2) Explore strategies to recruit health care providers in rural communities by providing more internship and preceptorship opportunities in rural health care facilities; 3) Develop more collaborative efforts to fill all slots in the nursing programs across the state and to provide nonaccepted applicants guidance in developing a health care career path. Working groups were created to address each goal. New Americans: To be successful in health care positions at any level, these individuals need to develop improved English language skills. The working group explored what programs exist and do they need to be better developed? They learned that teaching new Americans English language skills is not a quick fix to meet the state s health care work force needs, but can be part of a more long term solution. The ND Department of Public Instruction (DPI) has been working on this issue. There are 16 Adult Learning Centers located across the state, serving 3,500 to 4,000 adults per year. English as a Second Language (ESL) individuals make up 47% of their participants. English language skills education is offered to ESL participants to help them learn English for employment. The Centers teach writing, reading, speaking, social and living skills. They evaluate their personalities, experience, and skills to target them for the most appropriate employment opportunities. In some cases, they teach more extensive skills to help participants get a better job. New Americans fill low paying jobs in hotels/motels that are harder to fill and are then advanced to hospitals as housekeepers, CNAs, interpreters, phlebotomists, transporters, etc. while they continue their learning. Medical terminology is taught in the pre-cna course. The group identified strategies to enhance collaboration between the Centers and health care facilities to meet unfilled employment needs. Recruitment in Rural Facilities: Increasing the number of internships and preceptorships offered by rural health care facilities for nursing students and other health care students is a good recruitment strategy for rural communities. In the process, communities need to provide ways to promote the attractiveness of rural communities (e.g. social activities, safe environments, friendly, etc.) Rural facilities need to inform nursing programs in the state about internship/preceptorship opportunities so that information can be sent out to students via list services, posted on bulletin boards, or announced in classes. Another strategy is to establish a centralized clearinghouse for clinical placement to keep information regarding opportunities in one place. Housing in the rural communities will be an important barrier to overcome. The following ideas were generated: identifying host families who would provide housing, identifying elderly community members who desire a companion or some assistance, and providing housing facilities similar to those used by MD students (e.g. apartments, hospital rooms, etc.). 12 NDHA Volume 2 Issue 1

13 Affecting Hospitals Today Collaborative Efforts among Nursing Programs: The group discussed the need for collaboration by nursing programs across the state to assure all slots in nursing programs are filled and to re-direct non-accepted applicants to other alternative paths to pursue a nursing degree or another health profession degree. The CUNEA (College and University Nursing Education Administrators) organization serves as a mechanism for administrators to share information regarding the number of slots open in each program. A website will be developed on the ND Center for Nursing s webpage to provide easily accessible information about N.D. nursing programs. For example, there could be an Apply to Nursing School section that provides links to the application process for each nursing school in the state. The site should be promoted in high schools, colleges and hospitals. Standardized information should be developed regarding other opportunities in health care (e.g. radiology tech, lab tech, behavioral health providers, OT, PT, RT, social work, etc.) that could be provided to students who are not admitted to a nursing program. This information could also be placed on the NDHA website. The importance of getting new graduates information about all open health care/ profession positions across the state was discussed (e.g. a placement registry) in order for new graduates to learn about job opportunities. This information is available at com. Colleges and universities need to make sure students are aware of this website when seeking employment. North Dakota Hospital Association Regulatory Subcommittee Synopsis Dr. Stacey Pfenning APRN FNP Regulatory Subcommittee Chair The ND Hospital Association (NDHA) Workforce Committee initiated the Regulatory Subcommittee following the May 26, 2016 meeting to address licensure and regulation themes. The Regulatory Subcommittee 2. To Propose a Tri-Regulator Collaborative (TRC) and develop recommendations to include rationale, goals, timeline, and meeting logistics. Rationale: Promote collaboration on healthcare issues. Facilitate multidisciplinary approach to position statements affecting healthcare for citizens of ND. included associates from NDHA, ND Medical Association, ND Board of Nursing, Essentia Health, Sanford Health, ND Nurse Practitioner Association, ND Nurses Association, and Altru Health Systems. The subcommittee convened June 24, July 15, and August 12 of The meeting minutes may be requested by contacting the NDHA. During the initial Regulatory Subcommittee meeting, the following goal was established: To develop regulatory initiatives related to healthcare workforce and make recommendations to the NDHA Workforce Committee. The subcommittee discussed licensure and registration, telemedicine, interstate compacts, and collaboration trends among healthcare regulatory agencies. After initial discussions, the following initiatives with rationale provided the focus of the Regulatory Subcommittee: 1. To support healthcare interstate compacts when presented during legislative sessions. Rationale: Enhance workforce mobility and portability. Improve citizens' access to healthcare. Initiative 1 resulted after exploration of published advantages and disadvantages of healthcare interstate compacts. The Regulatory Subcommittee agreed to recommend support of the compacts. The subcommittee developed draft letters of endorsement for healthcare licensure interstate compacts, including Interstate Medical Licensure Compact, Physical Therapy Licensure Compact, Enhanced Nurse Licensure Compact, and Advanced Practice Registered Nurse Compact. The intention of the letters is to provide NDHA Workforce Committee support to the boards intending to move forward with legislation. To address initiative 2, the subcommittee discussed the national TRC, which includes the National Council of State Boards of Nursing, Federation of State Medical Boards, and National Association of Boards of Pharmacy. Minnesota supports a similar, state-based collaborative. These collaboratives aim to support interprofessional patient care and regulation. The TRCs have produced joint positions statements specific to telehealth, team-based care, and pain management. To view a TRC position statement, go to TriReg_Practice_Location.pdf. The Regulatory Subcommittee developed a draft charter document for a potential ND TRC outlining meeting objectives and logistics. The subcommittee shared the draft charter document with the respective licensure board executive directors for feedback. The Regulatory Subcommittee will present the letters of endorsement for interstate compacts and charter document for potential ND TRC for consideration at the full convened NDHA Workforce Committee in September Continued page 14 Volume 2 Issue 1 Summer

14 INSIGHT NDHA Workforce Committee Delivery and Innovation Subcommittee Darrold Bertsch, CEO, Delivery & Innovation Subcommittee Chair Following the initial meeting of the North Dakota Hospital Association (NDHA) Workforce Committee held on May 26, 2016, three subcommittees were established to address workforce challenges. The Delivery and Innovation Subcommittee met via conference call on five different that will include leaders from the region and across the country to share best practices and information gathered by the other subcommittee telehealth action items. Workforce Innovation: Challenges exist in the recruitment and retention of the human resources needed by the state s health care providers. A variety of innovative efforts are taking place at the organizations across the state that have been effective in reducing the staffing challenges that exist. The subcommittee will work to gather interested healthcare human resources professionals to share best practices and disseminate these strategies, so that other facilities might learn what has been successful. The HR professionals will be encouraged to work collaboratively with the Department of Commerce and other groups in this effort. Team Based Care/Inter-professional Training and Care: occasions, following individual interviews conducted by the subcommittee chairperson. The subcommittee included representation from the NDSU College of Health Professions, UND School of Medicine, North Dakota Long Term Care Association, North Dakota Hospital Association, North Dakota Center for Nursing, North Dakota Organization of Nurse Executives, acute hospitals, along with Critical Access Hospitals. This diverse group discussed opportunities and challenges associated with how care is delivered across the state and opportunities that exist to be more efficient and innovative. Also discussed were challenges in recruiting and retaining the workforce needed to provide the entire continuum of care. Through these discussions the subcommittee developed the following initiatives: Telehealth Services, Workforce Innovation, Team Based/Inter-professional Training and Care, and Interoperability of Electronic Health Records. For each of the initiatives, action items were developed that included the individuals responsible for moving the initiative forward. The initiatives were are as follows: Telehealth Services: The delivery of health care services has been enhanced through the utilization of telehealth services. Opportunities exist to expand the use and availability of telehealth services in North Dakota; however, barriers and hurdles exist. In an effort to address these challenges, the subcommittee will inventory, document and disseminate a list of all telehealth services and capacity in North Dakota. The group will also review barriers that exist such as resources available, regulations and reimbursement and will develop a report of potential strategies to address them. The university systems will host a symposium The transformation to team based care is a reality today for health care providers across the country. Many examples of team based care exist across the state of North Dakota. Along with that, academic programs are transitioning to inter-professional training to better prepare future healthcare providers to this shift in how care is delivered in today s health care environment. An opportunity exists for academic programs and health care providers to work together to develop inter-professional clinical demonstration sites to better prepare students for their practice. A workgroup will be developed to identify demonstrations sites and develop an RFP to connect academic programs with employers to enhance clinical experiences. Interoperability of Electronic Health Records Health care providers continue to work together to provide care to patients. In order to do so in the most cost effective and efficient manner, accessibility to a patient s health information is essential. The North Dakota Health Information Network (NDHIN) is an important part of that exchange of health information. As of today, it can t provide all of the information that is needed by providers. In order to support the strategic goals of the NDHIN and expand the interoperability and information available, health care associations in the state will work together with the NDHIN to determine future needs and identify opportunities to expand accessibility to health information. Summary: The Delivery and Innovation Committee will continue to meet on a periodic basis to share information and update progress on the action items developed. 14 NDHA Volume 2 Issue 1

15 V e t e r a n s Choice Pr o g r a m E d u c at i o n f o r Communit y P r o v i d e r s The Veterans Choice Program was established so that eligible Veterans who are enrolled in the VA health system can receive care in their communities. Health care providers interested in participating in the Veterans Choice Program must establish either a Patient Centered Community Care (PC3) contract or a Choice Provider agreement with one of the U.S. Department of Veterans Affairs-approved contractors, Health Net Federal, or TriWest Healthcare Alliance. Both offer educational resources to help providers better understand the process. TriWest offers free live, interactive webinars for providers that cover the appointing and authorization process, secondary authorization requests, overall health care management process, billing and claims procedures, other health insurance, and medical documentation requirements. A live demo also explains how to use the secure Provider Portal to complete administrative tasks, such as uploading medical documentation and checking claims status. To register for a TriWest webinar, Affecting Hospitals Today visit provider-webinars to view the webinar schedule. Choose the webinar date and time which works best for you, and follow the registration instructions on Page Two. Please note: all webinars are scheduled in Mountain Standard Time or Arizona Time. Similarly, Health Net s provider orientation webinar covers an overview of Patient-Centered Community Care (PCCC) and the Veterans Choice Program, including covered regions, how to become a provider, and Veteran eligibility. Also, a presentation familiarizes providers with Health Net s PCCC program, regions and attributes. The application promotes awareness of the Veteran experience: where they live; unique needs and challenges such as Veteran Integrated Service Network locations, socio-economic and health challenges; and VA resources. To access Health Net s provider resources, visit provider/education.html. Sharing what you need to hear, not just what you want to hear It s how Troy Nelson became one of Barron s Top 1,200 Financial Advisors. And, it s how Troy helps his clients work toward important financial goals in Bismarck, ND. Troy has been named No. 1 in North Dakota for the 5th year in a row. Troy Nelson Edward Jones Financial Advisor 1701 Burnt Boat Dr. Bismarck, ND Troy.Nelson@edwardjones.com Barron s Top 1,200 Financial Advisors, Mar. 6, Barron s Top 1,200 criteria based on assets under management, revenue produced for the firm, regulatory record, quality of practice, philanthropic work and more. The rating is not indicative of the financial advisor s future performance. Neither Edward Jones nor its financial advisors pay a fee to Barron s in exchange for the rating. Barron s is a registered trademark of Dow Jones & Co. TAL-7212C-A-AD Member SIPC Volume 2 Issue 1 Summer

16 INSIGHT T r a n s p o s i n g LEAN Pr o c e s s A n a ly s i s o n Cl i n i c Design By Daniel J. Abeln and Chad Frost Clinical design is ever-evolving, as forces such as, but not limited to, insurance reimbursement, patient expectations, administrative migration, and regulatory guidelines simultaneously apply forces to an already amorphous target. These forces increase the complexity of the overall care system and historically have created waste and interruptions of flow within the core processes of the clinic environment. Consistent through this evolution is the need to provide a safe, private, comfortable environment to all patients while maintaining maximum efficiency in clinical operations. Efficiency equals profitability, and that efficiency must be analyzed through the lens of LEAN with an intense focus on the reduction of waste and improvement of flow. Consumables, travel distances, throughput times, or perhaps most notably, talent, are common, yet overlooked waste areas in this process. Two of the hottest hot-button issues over the past couple of years are tied to legislative changes in reimbursements and healthcare staffing. Legislation has trended towards reimbursements being matched to patient satisfaction and effectiveness of treatment while reductions in reimbursement levels have strengthened the incentive to maximize throughput. In addition, several recent industry surveys have indicated that the biggest challenge facing healthcare administrators is shifting from those behind-the-scenes financial issues to the front-line of skilled staffing for patient care, licensed and registered nurses. Simply, how to attract, compensate, and retain top talent. All of this points to a generally cohesive goal, thoughtfully designing and constructing patient care facilities that break the tendencies of traditional practice and re-prioritize to these ends. This is where we are given the unique Horizon Clinic, Bismarck, ND IMPROVING THE PATIENT EXPERIENCE Providers are increasingly asking for facilities with flexible adaptable designs so that they can re-purpose spaces as new care delivery models and technologies evolve. At EAPC, our integrated healthcare team designs highly efficient, sustainable and innovative facilities that help our clients improve the health of patients and communities NDHA Volume 2 Issue 1

17 Affecting Hospitals Today opportunity to merge two industries ripe with acronyms and buzzwords. The patient-centered, medical-home model, which is about providing assessment and care in teams, is an emerging trend in outpatient clinical design. In this team-based model of care led by primary care physicians, medical professionals provide continuous and coordinated care to ensure the highest level of healthcare. Taking this model a step further, Altru Health System recently opened an Orthopedic Clinic at the Professional Center in Grand Forks that incorporates wearable technology into the clinic, allowing patients to room themselves and staff to be alerted when a room is occupied. This process improvement eliminates the need for the otherwise wasted talent of having a nurse escorting patients throughout the day. It also eliminates the need for the oversized waiting room, and all but eliminates preappointment waiting, a top-rated patient dissatisfier. Combining that with housing physicians in modular workstations, rather than traditional oversized offices, the clinic is able to use otherwise overhead space to include approximately four additional exam rooms, further enhancing efficiency in throughput and reducing waiting. A unique opportunity to perform a post occupancy validation analysis of such a clinic from a LEAN waste and flow perspective was attained in A current and future state was established for the organization using a specific value stream, New Patient cycle, to see if the LEAN approach to this facilities new design yielded the desired results. An example of this type of data collection is described below using travel distances and stops from a patient's point of view: Further LEAN assessments could refine the clinical process and are being integrated daily. Inventory tracking systems, specialty casework that can be accessed from both on-stage during consultation and off-stage by non-providers, and long-term data collection and analytics through the patient tracking software all provide further opportunities and insight for the next clinic s design. Going forward, it is important to understand the factors that go into a truly efficient and effective clinical operation. Thoughtful design can allow for a reduction in the actual footprint or more efficient use of the space, reduced throughput times, increased patient and staff satisfaction, and increased profits. Well directed capital investments can also be offset by the reduced staffing required or increased revenue generation. Obviously, there is much to be gained from applying LEAN to the design of healthcare spaces where our clients are providing important and critical services to patients in our communities. Design Impact on Travel Distances Layout Design New Patient Cycle Walking Distance (ft.) # of Patient Stops (e.g. Waiting) Old New Difference (46) (1) In comparison to the previous operation, patients in a typical New-Patient Process saw an 11% reduction in steps, which may not seem significant until you look at a 100 New Patient cycles per day viewpoint, where that reduction equals upwards of 26 miles of reduced travel distance per month. Results, in terms of patient and staff satisfaction, are not scientific at this time. But those who responded verbally and voluntarily overwhelmingly spoke positively about the experience of the new clinic, giving credibility to providing a space where staff feel like they can be effective and thrive is one means by which to attract talent. Volume 2 Issue 1 Summer

18 INSIGHT ND Hospital Association s 82nd Annual Convention & Trade Show October 4-6, 2016 at the Hilton Garden Inn, Fargo Opening Keynote: Preparing for Tomorrow s Payer & Purchase Expectations Presented by Andrew Cohen General Session: Healthcare Hotspotting Presented by Kelly Craig, Camden Coalition of Healthcare Providers Closing Keynote: Let it Go, Just Let it Go Presented by Kent Rader HSI Solutions Update Conference October 24-25, 2016 at the Holiday Inn, Fargo Retire ON YOUR TIMETABLE Have you considered your timetable for retirement? Would you like to retire early? Do you want to work into your 70s? By preparing now, you can make the financial decisions that may help you to retire when you want, early, late or otherwise. Find out more. Contact: Rob Montgomery 4431 Memorial Highway Mandan, ND / rob.montgomery@securiannd.com Rob Montgomery is a registered representative and investment advisor representative of Securian Financial services, Inc. Securities and investment services are offered through Securian Financial Services, Inc., member FINRA/SIPC. Securian Financial Advisors of ND, Inc. is independently owned and operated. Securian is a trademark of Securian Financial Group, Inc. and it has been licensed for use by Securian Financial Advisors of North Dakota Securian Financial Advisors of ND, Inc. David Wald 1550 Burnt Boat Drive Bismarck, ND david.wald@securiannd.com David Wald is a registered representative and investment advisor representative of Securian Financial Services, Inc., and is located at Capital Credit Union. Securities and investment services are offered through Securian Financial Services, Inc., member FINRA/SIPC. Securian Financial Advisors of ND, Inc. is independently owned and operated. Securian is a trademark of Securian Financial Group, Inc. and it has been licensed for use by Securian Financial Advisors of North Dakota. Neither Securian Financial Advisors of ND, Inc. nor Securian Financial Services, Inc. are affiliated with Capital Credit Union. Capital Credit Union is not a registered broker/dealer or registered investment advisor. Services and products offered through Securian Financial Advisors of ND, Inc. and through Securain Financial Services, Inc. are not FDIC/NCUSIF insured, not a deposit product, may lose value, are not a condition of any credit union service, are not credit union affiliate guaranteed, and there is no guarantee of insurance underwriter performance. TR# , DOFU: Statement Printing and Processing Transferring invoice and statement information over the internet is convenient, timely, and secure. Presort Plus, LLC will facilitate the processing of your statements and your business can focus on what it does best providing attention to your core business activities. Security Information provided online is handled with discreet and timely attention. We follow HIPAA regulations and guaranty that the security and privacy of personal information will not be compromised. Upload data to secure FTP site. Savings Presort Plus, LLC will process, print, fold, insert and mail your statements at the lowest rate possible thus saving you money. By sending statements in a timely and efficient manner, you are sure to receive your payments faster! And all mailings are presorted, CASS-certified, and include bar codes for speedy delivery. Options Customize your statements by printing black & white or color statements using your company colors, logo, tag line and watermark for easy identification. For more information or to request a quote: Tom Kloster or - Toll free: PO Box Bismarck, ND NDHA Volume 2 Issue 1

19 Pulling TOGETHER Inspired by your well-being In North Dakota, BCBSND and your doctors are pulling together for you. Through Blue Alliance, we re changing the way we define success, in well child visits, preventive care, and an overall renewed focus on keeping you well. THIS IS HEALTH CARE North Dakota Style BCBSND.com/BlueAlliance