Geographic Variation/Health Care Spending/High Value Care: Nursing’s Perspective

1. Geographic Variation/Health Care Spending/High Value Care:Nursing’s Perspective Eileen M. Sullivan-Marx, PhD, RN, FAAN Associate Dean for Practice & Community 2010-11 Health & Aging Policy Fellow University of Pennsylvania School of Nursing

2. Acknowledgements • American Political Science Association • Atlantic Philanthropies • McMenamin, P. (2010). Some utilization and revenue variations in the direct billing Medicare Part B practices of APRNs. Unpublished draft. Senior Policy Fellow, American Nurses Association.

3. Consideration of Nursing Issues • Nurse Workforce • Advanced Practice Registered Nurses • Nurse Innovation Models • Programs for All-Inclusive Care of Elders (PACE)

4. U. S. Registered Nurses • Licensed by state • 3,063,163 RNs; 5.3% increase from 2004 • Licensing Exam- NCLEX • London, Hong Kong • 884 per 100,000 persons • Most employed in hospitals • 8% with advanced degrees • 50% with BSN • 88.4% white, 94.3% women • http://bhpr.hrsa.gov/healthworkforce/rnsurvey/initialfindings2008.pdf

5. U.S. Nurse Shortage • By 2020, the demand for RNs will be 2.8 million equaling a shortage rate of 29% Bureau of Health Professions, July, 2002

6. Nurse Workforce

7. Future of Nursing ReportRWJ/IOM 2010 • Nurses should practice to full extent of education • Education should work together for seamless nurse career ladder – 80% BSN by 2020 • Nurses should be full partners in redesigning health care • Effective workforce planning and policy making require better data collection and information infrastructure.

8. Recommendations to Position the Future for Community Nurse Careers • Establish professional nursing roles in places where society lives/works • Students can learn and seek jobs in these settings • Maximize benefits / Minimize costs • Reframe care not by place but by skills and service • Enable nurses to control practice • Payment of nursing care needs to be visible, transparent, fair, and based on outcome incentives • Foster and recognize independent decision-making by basic and advanced practice nurses • Eliminate “medical” decision making orders, payment convolutions • Establish quality in community care as a core competency for all nurses • Embrace family/patient centered care within a team of providers with nurses as leaders in care • Lead the return and renewal of public health nursing

9. Advanced practice registered nurses

10. Workforce • Nurse Practitioners • 46, 328 (1992) • 63, 191 (1996) • 85, 000 (2000) • 141,209 (2004) • 138,558 (2008)

11. Visibility in Payment: Data Accuracy • Lack of consistent visibility of APRNs in Medicare Fee Schedule • Direct to APRN @ 85% physician rate • “Incident to” Billing • Nursing Home Admission • PACE, Home Care

13. Spending Variations by State

14. Spending Variations by State: CNMs and CNSs

24. Nurse innovation models

26. Living Independently for Elders (LIFE) Nurse Led Integrated Model of Care In-Home Services Day Health Care Center & Social Services Primary Care & Pharmacy Services Interdisciplinary Team Acute Hospital Care Transportation Services MEMBER/FAMILY Skilled Nursing Facility Care Rehabilitative & Activity Services Specialty – Behavioral Health, Podiatry, Dentistry

27. LIFE Nursing Professional Model • Owned and operated – Penn School of Nursing • Director of Nursing & Member Services • Primary Care – Nurse Practitioners • Geropsychiatric Nurse • Home Health Nurse Practitioner • Home Care Nurses • Day Center Triage Nurses

28. Community Survival with In-Home LTC Services in a 5-year Inception Cohort (2001-2005)

29. Summary • Variation in distribution of nurse workforce • Address visibility and data accuracy for APRNs in Medicare and private insurer payment systems • Consider Future of Nursing Recommendations • Include Nurse Innovative Models that Address High-Value Care • PACE model at Penn Nursing (LIFE) • Nurse Managed Centers • Transitional Care Model