HR Advancement Center

1. HR Advancement Center Health Care Labor Trends in the United States

2. Making Non-Clinicians Part of the Health Care Team The Hospital Workforce Where the Most Growth Is: Ambulatory Care

3. Health Care Growing Faster Than Other Industries Source: “Healthcare Metro Monitor Supplement,” Brookings, http://www.brookings.edu/research/reports/2013/07/01-healthcare-metro-monitor; HR Advancement Center analysis. US Employment Growth in Health Care and All Other Industries, 2003-2013 Indexed Employment (2003 Q1 = 100) 125 120 Health CareIndustry 115 110 105 All Other Industries 100 95 2003 2008 2013

4. Expecting Continued Growth in Bulk of Hospital Workforce Source: Bureau of Labor Statistics data; HR Advancement Center analysis. Bureau of Labor Statistics Projected Employment Increase, 2012-2022 General Medical and Surgery Hospitals, Private

5. Growing Demand for Hospitalists Source: Society of Hospital Medicine 2014 Exhibitor and Sponsor Prospectus, available at: http://www.hospitalmedicine2014.org/pdf/HM14_Exhibitor_Prospectus_Final.pdf; Young-Fang Kuoet al., “Growth in the Care of Older Patients by Hospitalists in the United States,” New Engl J Med. 360 (2009):1102-12; HR Advancement Center analysis. Growth in Number of Hospitalists, 2004-2012 29% Increase in odds of receiving care from a hospitalist between 1997 and 2006

6. Don’t Let Projected Employment Growth Obscure Looming Retirements Keep an Eye on Physician Retirement Rates Source: The Physicians Foundation, A Survey of America’s Physicians: Practice Patterns and Perspectives, 2012, accessed April 25, 2013, available at: http://www.physiciansfoundation.org/uploads/default/Physicians_Foundation_2012_Biennial_Survey.pdf; Alliance for Health Reform, Healthcare Workforce: Future Supply and Demand, 2011, accessed March 3, 2013, available at: http://healthinfo.montana.edu/MTHWAC/Health_Care_Workforce_104.pdf; HR Advancement Center interviews and analysis. Age Distribution of US Physicians 33% ” Practicing physicians predicted to retire in the next 10 years Potential Industry-Wide Delays to Retirement “My retirement doesn't look as good as it did. This is similar for a lot of practitioners I know. Many are making decisions to work a bit longer.” ED Physician

7. Many RNs Also Poised to Retire Source: US Department of Health and Human Services, Health Resources and Services Administration, The Registered Nurse Population: Initial Findings from the 2008 National Sample Survey of Registered Nurses, 2010, accessed April 25, 2013, available at: http://bhpr.hrsa.gov/healthworkforce/rnsurveys/rnsurveyinitial2008.pdf; US Department of Health and Human Services, Health Resources and Services Administration, The U.S. Nursing Workforce: Trends in Supply and Education, 2013, accessed May 7, 2013, available at: http://bhpr.hrsa.gov/healthworkforce/reports/ nursingworkforce; HR Advancement Center interviews and analysis. Age Distribution of Practicing Registered Nurses in the US • 2008 1,000,000 RNs that will reach retirement age in the next 10-15 years

8. Making Non-Clinicians Part of the Health Care Team The Hospital Workforce Where the Most Growth Is: Ambulatory Care

9. Deconstructing Health Care Employment Growth Non-Hospital Growth Far Outpacing Hospital Growth Source: Bureau of Labor Statistics data; Advisory Board Daily Briefing analysis. U.S. Employment Growth, 2003-2013 Indexed Employment (2003 Q1 = 100)

10. Where Is the Non-Hospital Growth Occurring? Source: Bureau of Labor Statistics data; HR Advancement Center analysis. Private hospitals. Excluding physician offices, mental health practitioners, and the offices of other health practitioners. Bureau of Labor Statistics Projected Employment Increase, 2012-2022 Ambulatory Health Services2 General Medical and Surgical Hospitals1 Physician Offices Home Health

11. Traditional Primary Care Stretched to the Limit Fewer PCPs Accepting New Patients; Long Wait Times for All Source: Merritt Hawkins & Associates, “2009 Survey of Physician Appointment Wait Times,” available at: www.merritthawkins.com, accessed April 29, 2013; Massachusetts Medical Society, "2012 MMS Patient Access to Care Studies," available at: www.massmed.org, accessed May 1, 2013; Health Care Advisory Board interviews and analysis. Worth the Wait? Primary Care Physicians Accepting New Patients by Insurance Type 20.3 days National average wait time for new patient seeking family practice appointment 45 days Average wait time for new patient seeking family practice appointment in Massachusetts

12. APs Poised to Expand Access, Boost Efficiency Betting on Advanced Practitioners Physician Workforce AP Adoption Well Underway Projected 2005-2025 • Most Practices Employing Advanced Practitioners Demand Supply Source: Dill, Michael J., and Edward S. Salsberg. AAMC Center for Workforce Studies, "The Complexities of Physician Supply and Demand: Projections Through 2025." Last modified November2008. Accessed March 21, 2013. https://members.aamc.org/eweb/upload/The%20Complexities%20of%20Physician%20Supply.pdf; Melissa, Park, Cherry Donald, and Decker Sandra. Centers for Disease Control and Prevention, "NCHS Data Brief No. 69: Nurse Practitioners, Certified Nurse Midwives, and Physician Assistants in Physician Offices." Last modified August 2011. Accessed March 19, 2013. http://www.cdc.gov/nchs/data/databriefs/db69.pdf; Medical Group Strategy Council interviews and analysis.

13. No Need to Come In? Ongoing Management, Maintenance May Not Require Physical Visit Source: Centers for Disease Control, “National Ambulatory Medical Care Survey 2010 Summary Tables,” available at: http://www.cdc.gov/nchs/data/ahcd/namcs_summary/2010_namcs_web_tables.pdf; Lee T, "Commodifying Content Through IT: Could Physicians Be Next?," available at: www.ihealthbeat.org, accessed April 29, 2013; Health Care Advisory Board interviews and analysis. Major Reason for Office Visit Remote Alternatives Preventive Care Other ” Pre/Post Surgery Mobile Monitoring Email Consultations Chronic Problem (Routine) New Problem Telemedicine Virtual Kiosks Chronic Problem (Flare-Up) Face Time Overrated “…[A] significant part of health care is essentially a content business. Consumers seek answers to clinical questions. Today, that content (or knowledge) primarily resides in the inconvenient and expensive domains of physician office visits.” Thomas Lee, CEO, One Medical Group

14. Virtual Visits Replace Traditional Channels Technology Connects Patients, Providers Source: Health Care Advisory Board interviews and analysis. Relative Value Units. Group Health’s Virtual Care Triage Process Direct Connect technology maps patient's health record to his PCP and directs call to team health coach nurse Patient calls with care question, provides Group Health plan number Health coach nurse able to answer most questions on initial call Physicians reimbursed one-fourth of one RVU1for secure messaging Patient submits question through secure account on MyGroupHealth portal Portal routes e-message to patient's PCP or affiliated care team • Case in Brief: Group Health • Integrated provider and payer network with 250 physicians in 26 clinics in Seattle, Washington • Operates enhanced visit scheduling, phone call triage system, including e-messaging patient portal

15. Making Non-Clinicians Part of the Health Care Team The Hospital Workforce Where the Most Growth Is: Ambulatory Care

16. Community Asthma Coaches at St. Louis Children’s Source: Fisher, E et al, “A Randomized Controlled Evaluation of the Effect of Community Health Workers on Hospitalization for Asthma: The Asthma Coach,” Archives of Pediatric and Adolescent Medicine, 2009;163(3): 225-232; St. Louis Children’s Hospital, St. Louis, MO; Nursing Executive Center interviews and analysis. Non-Clinical Roles Hold Great Potential for Impact • Key Elements of Community Asthma Coaching at St. Louis Children’s 52% Reduction in hospitalizations for coached patients (versus control) Choosing Coaches From Patient Communities An Individualized,Non-Directive Approach • Coaches selected according to the cultural and socioeconomic background of disadvantaged patients • Coaches have personal or family history of asthma • No clinical background required • Coaches trained to advise on navigating the healthcare system and managing asthma • Emphasis on activating parents to take control of children’s health—not for coaches to take control of managing child’s asthma

17. As of 2011. Meals Housing Legal Assistance Transportation Using Students to Provide Community Resources Integration of HealthLeads into PCP Practice Source: HealthLeads, available at: http://www.healthleadsusa.org/; MedInnovation, “The Access Mess: What Doctors Can Do,” available at: http://medinnovationblog.blogspot.com; Health Care Advisory Board interviews and analysis. HealthLeads Alleviates Issues Confounding Clinical Care Common Areas of Focus Case in Brief: HealthLeads • Community resource specialists located in six cities across the country • Staffed by graduate students, non-clinical professionals that connect patients with community resources • Physicians "prescribe" food, fuel assistance, housing, or other resources for patients; HealthLeads volunteers “fill” prescriptions • 9,000 low-income patients and their families have been connected to resources1 Physician “prescribes” HealthLeads for non-clinical needs HealthLeads volunteer provides resources for patient ” • HealthLeads volunteer embedded in clinic connects patient to community resources, follows up • Volunteer is grant-funded, well-connected to community resources Part of the Team “HealthLeads is a part of our team. I can’t do it all. The one social worker we have can’t do it all. We’re just barely staying above water.” Pediatrician, Boston Medical Center

18. Source: Methodist Le Bonheur Healthcare, Memphis, TN; Nursing Executive Center interviews and analysis. Building Supportive Faith-Based Patient Partnerships • Components for Establishing a Congregational Network Clergy members from each congregation recruit individuals to serve as liaisons Convene a steering committee with community faith leaders to define the partnership Hospital navigators build relationships with local congregations to build network Establish agreement for congregations to sign to become part of network Hospital navigators enroll potential patients from the congregations into the patient liaison program Case in Brief: Methodist Le Bonheur Healthcare • Seven-hospital, 1,600-bed health system located in Memphis, Tennessee • Developed the Congregational Health Network (CHN) to leverage the social infrastructure of congregations and provide impactful interventions to congregation members • Clergy members from each congregation in the network identify individuals to serve as liaisons who provide ongoing patient support and act as a bridge between their congregation and the hospital system • Hospital-based navigators visit congregations and register potential patients into the program; upon hospital admission, enrolled members “opt-in” to be paired with liaisons • CHN program has cut readmissions for program participants by 20 percent, reduced mortalities by 50 percent, accrued cost savings of $4 M

19. The Future of Health Care Source: Nursing Executive Center interviews and analysis. Evolving Market Demand Building Long-Term Patient Relationships for Ongoing, Coordinated Care Managing Chronic Care for High-Risk Patients Improving Overall Health and Wellness of the Population Centering Hospital Care on the Patient