Nurse-Managed Health Clinic & Convenient Care Clinic Contributions to the Advancement of the National Prevention S

1. Nurse-Managed Health Clinic & Convenient Care Clinic Contributions to the Advancement of the National Prevention StrategyJune 21, 2012 Tine Hansen-Turton, JD, MGA, FCPP, FAAN Chief Executive Officer, National Nursing Centers Consortium Executive Director, Convenient Care Association Chief Strategy Officer, Public Health Management Corporation, a PA Public Health Institute

2. Overview of Today’s Presentation • Understand the history and current role of nurse-led care in the US, mainly Nurse-Managed Health Clinics (NMHCs) and Convenient Care Clinics (CCCs) • Examine the growth of NMHCs in the primary care workforce and their role in preventive and primary care • Understand how NMHCs fit into the larger context of state and national health care reform and the national Prevention Strategy • Describe the current challenges – and opportunities – for nurse-led care

3. History of NMHCs • Date back to early part of the 20th Century in U.S. • Community health visionary Lillian Wald • Nurse Midwife Mary Breckenridge • Substantial contributions to primary care and prevention • Serve diverse populations in diverse settings • Currently there are about 250nurse-managed health clinics operating throughout the US with 2/3 run by schools of nursing

4. According to the Affordable Care Act… … a nurse managed health clinic is a nurse practice arrangement, managed by advanced practice nurses, that provides primary care or wellness services to underserved or vulnerable populations and that is associated with a school, college, university or department of nursing, federally qualified health center, or independent nonprofit health or social services agency. Source: Affordable Care Act, Section 5208

5. What are NMHCs? NMHCs offer high quality, affordable, accessible community oriented primary care, health promotion and disease prevention The majority of care is provided by nurses—in interdisciplinary teams led by nurse practitioners other advanced practice nurses NMHC offer patients direct access to APN care Dominant theme: Nurses control their own practice and patient care Convenient Care Clinics Academically affiliated NMHCs Mobile Vans Common NMHC models: • Birthing Centers • School Based Centers • Wellness centers

6. About NNCC/CCA The National Nursing Centers Consortium (NNCC) advance nurse-led health care through: • Policy/education • Consultation • Programs • Applied research …to reduce health disparities and meet people’s primary care and wellness needs. The Convenient Care Association (CCA) is the trade association for retail-based convenient care clinics

7. Snapshot on Safety-Net Nurse-Managed Primary Care and Wellness Clinics

8. Diverse Settings, Geographic Areas and Demographics Public schools University Housing University Housing Academic Health Centers Mobile Vans Rural Settings

9. NMHC Payer-Mix

10. Most Common Diagnoses in NMHCS • Hypertension • Depression • Diabetes • Child Health Exam • Hyperlipidemia • Adult Health Maintenance Exam • Obesity • URI • Asthma • Normal pregnancy Source: NNCC membership survey data

11. Average Revenue & Cost/Visit Comparisons For NMHCs & FQHCs Revenue Comparisons Cost/Visit Comparisons

12. Nurse-Managed Health Clinics • High patient satisfaction • ER use 15% less than aggregate • Non-maternity hospital days 35-40% less • Specialty care cost 25% less than aggregate • Prescription cost 25% less than aggregate • Nurse-managed health clinics see their members an average of 1.8 times more than other providers 12

13. Data on Cost-Effectiveness NPs provide equivalent quality care to that of physicians at a lower cost* The national average cost of a NP visit was 20% less than a visit to a physician.* Insurance reform in Massachusetts, helped the state realized they could gain a cost savings of $4.2 to $8.4 billion over a 10-year period from increased use of NPs.* A worksite clinic run by an NP resulted in direct medical care cost-savings of nearly $2.18 million over a two-year period.** *Eibner, E et al. (2009). Controlling Health Care Spending in Massachusetts: An Analysis of Options. Rand Health. **Chenoweth, D. et al. (2008). Nurse Practitioner Services: Three-Year Impact on Health Care Costs. Journal of Occupational and Environmental Medicine, 50, 1293-1298.

14. What Patients Saying About NMHCs: • “The preventive part, the education piece has been done outstandingly.” • “It gives you more continuity of care. Because you have your specific provider that sees you on a regular basis they’re quite familiar with your health care needs. • “I mean it’s caring, follow-up. We’ve never had care like that in our 75 years.” • “The other thing is that it is a gateway for complex and advanced care.” • “And they will follow-up and call you. That is like getting the doctor to come out in the middle of the night.” • “It is good because it is a neighborhood clinic and the neighborhood side of it means it is accessible to people.” • “If the clinic was not here it would be a real disaster”

15. Current Data Snapshot on Convenient Care Clinics

16. CCC Background In 2006,150 clinics were open. Clinics were mostly cash-only, offered a very limited scope of services, and were nearly all operated or owned by corporations. Many questioned the viability and legitimacy of the model. Early opposition tried to beat industry back.

17. Accessibility Services primarily provided by NPs Located in retail outlets with retail service hours No appointments necessary – 15-20 minute visits Affordability Transparent pricing; prices are clearly posted Services cost between $40 and $75. CCCs accept insurance Quality Use EMRs Use evidence-based medicine Convenient Care Clinics

18. CCC Services • Work with patients from 18 months through 65+ • Acute care • Immunization • Wellness/preventative services • School, camp and sports physicals • EpiPen Instruction and Prescription • Physical assessments/diagnostic encounters (need specific but general data here) • 20-40 patients/day • Strep testing • Urine analysis • Influenza A and B testing • TB/PPD testing • Chronic disease detection and management • A1C hemoglobin/blood glucose testing • Hypertension analysis • Spirometry screenings • Nebulizer treatments • Injection services • Education and wellness • Smoking Cessation • Weight Management • Diabetes Education • Prescribe medications when necessary

19. Where CCCs Are at Today More than 1,350 clinics with expectations for growth in coming years. Clinic operators consist of hospitals and health systems and corporations, and corporations are increasingly affiliating with health systems. Greater acceptance publicly and support for an emphasis on patient-centered care.

20. What The Research Shows About CCCs Clinics are good for access. Clinics are good for cost reductions. Clinics are good for quality.

21. Improving Access • As many as 60% of clinic patients report not having a PCP (Mehrotra et al., 2008). • 93% of patients report highly on the convenience (Wall Street Journal/Harris Interactive, 2008). • Nearly 30% of the U.S. population lives within a ten-minute drive of a clinic (Rudavsky et al., 2008). • ~12 to 14% of all ED visits can be seen at convenient care clinics (Weinick et al., 2010; Mehrotra et al., 2008).

22. Decreasing Costs • Costs of care at a convenient care clinic are significantly lower than those at an urgent care center, primary care office, or emergency department (Mehrotra et al., 2009; Thygeson et al., 2008). • Blue Cross and Blue Shield of Minnesota eliminated co-pays for enrollees who used a clinic, citing $1.2 million in cost savings (Minneapolis/St. Paul Business Journal, 2008).

23. Meeting Standards of High Quality • 99.15% of convenient care clinic providers adhered appropriately to diagnostic and treatment guidelines for acute pharyngitis (Woodburn et al., 2007). • Quality scores and rates of preventive care offered are similar for convenient care clinics as for other delivery settings (Mehrotra et al., 2009). • All clinics that are members of the CCA are either certified or accredited by a third party.

24. The Current Crisis in Access to Preventive Care and How NMHCs and CCCs are Responding

25. The Harsh Reality about How Shortage of Providers is Impacting Access • The Association of American Medical Colleges predicts a shortfall of 29,800 primary care physicians by 2015, and 65,800 by 2025 • People are experiencing limited access to routine and preventive care • 70% of Americans can’t get same-day appointments with their PCP • 30% of Americans lack a regular source of primary care • Half of all emergency room visits are non-emergent • The number of uninsured went up in 2011 and 1 in every 8 children are uninsured • Health care costs are rising at unsustainable rates • Consumers are increasingly pressed for time and are demanding convenience

26. Growing numbers of NMHCs and NPs are Helping to Fill Gaps in Care • Approximately 85,000 out of 158,000+ nurse practitioners now provide primary care • NPs are legally authorized to perform the functions of a primary care provider in all 50 states • Approx. 70% of NMHCs offer primary care • “Nurse practitioners are by far the fastest growing group of primary care professionals in the country”* * Statement of A. Bruce Sternward, Health Care Director, U.S. Government Accountability Office, Testimony Before the Committee on Health, Education, Labor and Pensions, U.S. Senate, 2008.

27. NMHCs and Workforce Development NMHCs provide clinical placements for undergraduate and graduate nursing students necessary to increase enrollment in nursing education programs – helping to eliminate shortages in supply of nurses. NMHCs provide primary health care experience with underserved populations. This exposure enhances the chances the students will select to practice in underserved areas. NMHCs give students the unique opportunity to integrate classroom learning with community-based care. 7

28. NMHCs and Workforce Development Source: INC four year membership survey

29. What Students Say About NMHC Clinicals • Emphasis on the community--Community based experiences that were not found in other clinical rotations • Patient diversity emphasized • Addressing health disparities • Ideal setting to teach business and financial concepts • Site consistent with conceptual model of nursing practice presented in the classroom

30. The CCC Industry is also Growing to Meet the Demand for Care Growth in the number of clinics is anticipated in the coming years (Deloitte Center for Health Solutions, 2009). Scope of services is being expanded with an eye towards disease prevention and chronic disease monitoring. More hospitals and health systems now operate clinics than non-hospital companies, though the majority of individual clinics are still operated by non-hospital companies. Growth among hospitals is largely due to perceived benefits of the relationship in supplementing and extending existing care (RAND, 2010).

31. CCCs offer nursing students: Autonomous NP operated clinical experience Exposure to an NP-centric model with NP leadership Opportunity to provide care in an evidenced based practice environment CCCs and Workforce Development

32. Experience in the clinics leads to: Exposure to the importance of clinical, patient/consumer and financial business metrics Career exposure and opportunities Research and project opportunities CCCs and Workforce Development

33. The Role of NMHCs and CCCs in State & Federal Health Care Reform & the National Prevention Strategy

34. Does Coverage = Care? Experiences in Massachusetts suggest not… • Across Mass., wait to see doctors grows: Access to care, insurance law cited for delays (Boston Globe, Sep. 22, 2008) • Numbers dwindle for primary care doctors: Medical students in US choosing other specialties (AP, Sep. 10, 2008) • Workforce Study Confirms Shortage of Primary Care Physicians (Mass. Med. Soc., Aug. 2007)

35. Comparing Two State Approaches • Massachusetts invested in insurance access before ensuring it had the infrastructure to handle increased demand for services. • In Pennsylvania, Governor Rendell learned to invest in health care infrastructure first, setting the stage for insurance reforms in the future.

36. Reform in Massachusetts • Since reform in 2006, Massachusetts went from having as many as 650,000 uninsured residents to having less then 168,000 (the lowest rate of uninsured residents in the nation) • But there were not enough primary care providers (PCPs) to fill the need!

37. Reform in Massachusetts In August 2008, S. 2863 was passed (“An act to promote cost containment transparency, and efficiency in the delivery of quality health care”). Intended to address new issues raised by increased access to health insurance Focused on: Health IT Care Coordination Increased utilization of non-physician providers – NPs! Pay-for-Performance

38. Reform in Pennsylvania – RX for PA PA Reform called for approximately 49 statutory/regulatory changes to allow NPs to practice to the full extent of their scope of practice. NPs in PA can now: • Make respiratory and occupational therapy referrals • Perform disability assessments for the program providing Temporary Assistance to Needy Families (TANF) • Issue homebound schooling certifications • Perform and sign the initial assessment of methadone treatment evaluations Order home health and hospice care Order durable medical equipment Issue oral orders to the extent permitted by the state’s health care facilities Make physical therapy and dietitian referrals

39. Reform in Pennsylvania Pennsylvania Governor Edward G. Rendell signs first pieces of the “Prescription for Pennsylvania” health care reform plan into law at the University of Pennsylvania School of Nursing, July 2007.

40. Policy Gains on the Federal Level • In 2009 NNCC introduced a bill to create a federal grant program for NMHCs • In the House, the bill was introduced by Lois Capps (D-CA) and Lee Terry (R-NE) • In the Senate, the bill was introduced by Daniel Inouye (D-HI) and Lamar Alexander (R-TN) • In 2010 the bill became law when it was inserted into the Affordable Care Act • Where did that get us?

41. Policy Gains on the Federal Level NMHCs Defined in Federal Law - ACA Definition: • “A nurse managed health clinic is a nurse practice arrangement, managed by advanced practice nurses, that provides primary care or wellness services to underserved or vulnerable populations and that is associated with a school, college, university or department of nursing, federally qualified health center, or independent nonprofit health or social services agency.” NMHC Grant Program Created: • Provided $15 million to 10 NMHCs in 2010 • Congress has never appropriated funding

42. CCCs and Health Care Reform Clinics Provide Opportunities in Response to Health Reform Access points for ~30 million more insured. Being included in medical home/accountable care organization concepts as alternative/complimentary delivery sites Focus on preventive and wellness focused healthcare Retail clinics engage in creative partnerships (employers, community health centers, private sector, payors)

43. The National Prevention Strategy Borrowed from: National Prevention Council, National Prevention Strategy, Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General, 2011.

44. National Prevention Strategy The National Prevention Strategy’s overarching goal is to increase the number of Americans who are healthy at every stage of life.

45. National Prevention Strategy Strategic Directions of the National Prevention Strategy: • Healthy and Safe Community Environments: Create, sustain, and recognize communities that promote health and wellness through prevention. • Clinical and Community Preventive Services: Ensure that prevention-focused health care and community prevention efforts are available, integrated, and mutually reinforcing. • Empowered People: Support people in making healthy choices. • Elimination of Health Disparities: Eliminate disparities, improving the quality of life for all Americans.

46. NMHCs and the National Prevention Strategy NMHCs focus on all seven of the NPS priorities: • Tobacco Free Living • Preventing Drug Abuse &Excessive Alcohol Use • Healthy Eating • Active Living • Injury and Violence Free Living • Reproductive and Sexual Health • Mental and Emotional Well-Being

47. Retail Health and the National Prevention Strategy CCCs focus on many of the NPS priorities through education, like: • Tobacco Free Living • Healthy Eating • Active Living • Injury and Violence Free Living

48. Challenges and Opportunities for NMHCs

49. Nurse-led Primary Health Care is the Model for the Future of Nursing Report … • Report Recommendations • Nurses should practice to the full extent of their education and training • Preparing and Enabling Nurses to Lead Change and Advance Health • Nurses should be full partners, with physicians and other health professionals, in redesigning healthcare in the United States

50. Opportunities for the Future • More to do than Traditional Policy Work • Change insurer credentialing and contracting policies • Highmark, Aetna, others, have done the right thing • But about 50% of insurers are still not contracting with NPs • Support other existing nurse-led practice models • CCCs, School-based centers and private practices • Push to ensure NMHCs are included in state and federal patient centered medical home demonstration projects and insurance exchanges