Nurse Staffing is Key to Launching Population Health Initiatives

As the Affordable Care Act accelerated the shift of reimbursement models from volume-based to value-based services, the "Triple Aim" gave hospitals a framework in which to work. This conceptual model, introduced by the Institute for Healthcare Improvement, relies on three inter-related elements to optimize healthcare systems: (1) improving the patient experience, (2) lowering the per capita cost of care, and (3) improving the health of populations.¹ Hospitals quickly made great strides with the first two, yet population health initiatives have proved to be more problematic. How can hospitals most effectively work outside their walls to address the socioeconomic, behavioral, and environmental factors that affect the health of patients both before they're ever admitted and after they're discharged? What does it take to make an impact on overall community health?

“Hospitals...need solid staffing strategies to do all this in an era of labor shortages and tight operational budgets."

A report by the Health Research & Educational Trust notes that hospitals need three key elements in place to successfully implement population health management strategies:²

• A capable and qualified workforce that is trained in community and population health
• Health information technologies that generate translatable data and track health trends
• Organizational capacity that includes clinician engagement and formalized community partnerships

In other words, it all comes down to people. Hospitals need human resources to provide inpatient care, coordinate care outside their walls, negotiate partnerships within the community, engage with high-risk patients, implement complex technologies, and crunch data in meaningful ways. And they need solid staffing strategies to do all this in an era of labor shortages and tight operational budgets.

One thing is clear: Nurses will always be crucial to population health efforts. As the largest sector of the healthcare workforce and the frontline caregivers, nurses are vital for their clinical skills and their experience in patient advocacy and education. Even when a hospital's exact path to effective population health management (PHM) has yet to be determined, administrators can start by considering the four nurse staffing issues that are likely to arise in the early stages of their efforts: New care coordination roles, nursing staff turnover, community- based initiatives, and an added reliance on documentation and data.

NEW CARE COORDINATION ROLES REQUIRE CAREFUL WORKFORCE PLANNING

“With a deep database of hard-to-fill specialties, Fastaff can quickly staff even the most critical units to keep them operating at full capacity."

A key theme in PHM is better coordination of care throughout a defined population-whether a minority group that's experiencing health disparities, patients with multiple chronic conditions who use the ER often, or a population of kids with severe asthma. To accomplish this, hospitals are forming multi-disciplinary care teams and creating new job roles for care coordinators, patient navigators, and case managers. Often the starting point is risk stratificationbased on data, with care managers planning a more proactive and involved approach for patients identified to be at high risk for an unwanted outcome.³ Since these new roles are crucial to PHM, there is a consensus by thought leaders that hospitals would be wise to repurpose and train existing nursing staff to fill these positions. A report by Greenway Health says "Often, nurses can be retrained as care managers or care supervisors, which requires a lower capital and time investment than hiring new people."⁴ A report by the Advisory Board Company makes the same point more emphatically, stating:

"There are two components to ensuring that organizations are using their existing workforce in the most effective manner: First, organizations must retrain staff to build the new competencies and skills individuals will need as part of a population health enterprise. Second, organizations must redeploy their highest-performers for new population health roles."⁵

These transitions are a natural way to make use of not only nurses' clinical skills, but their ties to the community and existing relationships with patients. Depending on the needs of the populations it serves, a hospital might find itself transitioning highly specialized nurses into PHM programs. Nurse navigators often have a specific focus area, like cancer, diabetes, or heart disease. Many hospitals are starting PHM efforts with a focus on congestive heart failure, which is the most common reason Medicare patients are admitted to a hospital⁶ and is proved to be managed more effectively with cardiac nurse specialists guiding care.⁷

THE PROBLEM: The downside of deploying staff into new population health roles is the loss of specialized expertise at the bedside and in critical units-in a healthcare environment where the average time to fill an experienced nurse vacancy, regardless of specialty, is 86 days.⁸ Short-staffing can trigger a host of problems, including nurse burnout, patient dissatisfaction, loss of quality, and increased risk of medical errors.

THE SOLUTION: As nurses are transitioned to care coordination teams, the hospital can partner with Fastaff to guarantee continuous coverage. Fastaff nurses arrive ready to hit the ground running, with minimal orientation- our experienced nurses have an average of seven years tenure with our company. With a deep database of hard- to-fill specialties, Fastaff can quickly staff even the most critical units to keep them operating at full capacity. The Fastaff Rapid Response® travel nurse solution has the advantage of a 48-hour work week model with no overtime charges to the facility. Fastaff prioritizes high-quality clinical care: in the past two years, 99 percent of survey respondents reported satisfaction with our nurses' clinical competence. As care delivery methods have continued to evolve, Fastaff has adapted to our client's needs by developing flexible staffing solutions.

WIDESPREAD PHM EFFORTS MAY INCREASE NURSING STAFF TURNOVER

Hospitals are not alone in their efforts to better coordinate care and manage population health. Private payers are hiring nurses at unprecedented rates to coordinate the care of patients enrolled in their health plans, better manage chronic disease, and staff 24-hour patient phone lines in an effort to reduce unnecessary ER visits.

Forbes reported that UnitedHealth Group hired 7,000 nurses between 2005-2015, Cigna increased employment of nurses sixfold in the same time frame, and Humana reported it employed over 10,500 nurses in 2015.⁹

“Once a hospital is able to recruit, hire, and train a new full-time employee, it can cancel Fastaff nurses with a four-shift notice without penalties."

Accountable care organizations (ACOs) also hire care coordinators to help lower costs,¹⁰ and 16.6 percent of physician practices now employ care coordinators.¹¹ Additionally, since 2015, cancer centers have been required to have oncology nurse navigators on staff, in order to maintain accreditation.¹²

THE PROBLEM: As other organizations step up their PHM efforts, they hire from the pool of experienced RNs currently working at hospitals. These jobs may be highly attractive to nurses who are ready to leave the bedside and work more regular hours, with weekends and holidays off. As nurses move into new care coordination jobs with payers and ACOs, hospitals may experience more staff turnover-and greater recruitment and retention headaches. Heavy turnover among nursing staff, including the rapid retirement of highly experienced baby boomers, can lead to mandatory overtime, with all its associated problems.

THE SOLUTION: Hospitals losing nurses to payers or other organizations can rely on Fastaff for one-of-a-kind guaranteed delivery of replacement nursing staff. Fastaff can staff all critical units, even those in hard-to-fill specialties, while recruitment efforts are underway. Fastaff's in-house team of experts responds with urgency to all requests, and can usually present qualified candidates within two days. Once a hospital is able to recruit, hire, and train a new full-time employee, it can cancel Fastaff nurses with a four-shift notice without penalties. Fastaff's flexible-length assignments, even as short as two weeks, provide hospitals the ability to achieve full nurse utilization and eliminate non-productive hours.

SHORT-TERM COMMUNITY-BASED INITIATIVES TAKE NURSES AWAY FROM THE BEDSIDE

Hospitals are now partnering with government agencies, payers, non-profits, schools, chambers of commerce, and other organizations to address population health issues. They can implement community-based projects that encourage healthier lifestyles and proactive disease prevention measures, including educational programs, screenings, health fairs, exercise classes, and even sponsorship of a farmers' market. Non-profit hospitals that receive significant tax savings are required to conduct a community health needs assessment (CHNA) every three years and report their annual spending on community benefits to the IRS-historically this was mainly unreimbursed charity care, but under the ACA the IRS has allowed hospitals to report community initiatives that improve the social determinants of health.¹³

Community-based initiatives can help to reduce health disparities in low-income, rural, or ethnic populations. They can address smoking cessation, obesity, nutritional deficiencies, and chronic disease self-management. As hospitals offer more community-based programs that support patients after discharge or help to prevent readmissions, they may need to dispatch specialized nurses into the community. For example, in an area where a CHNA has identified infant or maternal mortality as a high-priority problem, a hospital might coordinate home visits for new or expecting parents, conducted by nurses with experience in labor & delivery, postpartum care, or neonatal care.

“With Fastaff, hospitals can customize the assignment length, based on what’s needed during community- based PHM projects."

THE PROBLEM: Short-term, temporary, or sporadic community-based PHM programs can leave nursing units short-staffed as nurses with strong ties to the community work on projects outside the hospital or make home visits. This can be especially problematic in critical units that have unpredictable patient volumes. It can also lead to the expense of overtime as other staff nurses fill in the empty shifts.

THE SOLUTION: Hospitals with short-term needs for replacement staff can rely on Fastaff to supply travel nurses to cover open shifts. Fastaff's flexible-length assignments allow facilities to use nurses for as little or as much time is needed, with no cancellation penalties, as short as two-week assignments. With Fastaff, hospitals can customize the assignment length, based on what's needed during community-based PHM projects. As the pioneer and industry leader in Rapid Response® travel nurse staffing solutions, Fastaff has more than 25 years of experience with delivering nurses to hospitals nationwide. More than half of the nurses in Fastaff's deep database work in a hard-to-fill specialty, guaranteeing coverage in the most critical units: NICU, PICU, CVOR, IR, L&D, PER, PED, Cath Lab, OR, ICU, ER, Psych and more.

“Fastaff is a trusted partner in new technology initiatives, allowing hospitals to fully train staff nurses through uninterrupted education sessions while Fastaff travel nurses provide expert bedside care."

POPULATION HEALTH MANAGEMENT RELIES ON DOCUMENTATION AND DATA

Clinical and claims data are so essential to PHM that one definition of population health is the aggregation and analysis of patient data to impact the health outcomes of a group of individuals, including the distribution of such outcomes within  the group.¹⁴ Care managers rely on the ability to run detailed reports for risk stratification-the statistical process that can determine which patients are most likely to have unwanted outcomes (e.g., readmission, ER visit, complications of diabetes, etc.) They need to quickly identify patients who are overdue for screening procedures like mammograms and colonoscopies, or patients with metrics like a high A1C level that indicate an intervention is required.

Care coordination across a large health system might also depend on technology that allows for health information exchange (HIE), defined as the sharing of health information electronically across organizations within a region, community, or hospital system.¹⁵ As a central tenet of PHM is providing patients with the tools needed to self-manage care, patient portals are proving to be a valuable tech strategy for patient engagement within the PHM framework.¹⁶ And hospitals that are tracking their alignment with CMS quality measures and regional or national benchmarks need sophisticated reporting tools to address every detail.¹⁷

This need for technology and data means hospitals are upgrading EMR systems or adding additional modules. They are searching for ways to compile and match patient data from multiple, disparate systems, and adjusting workflows to ensure that documentation happens at the appropriate time and place.¹⁸

THE PROBLEM: As the use of technology expands and hospitals become more reliant on documentation for reporting, risk stratification, and claims, it is essential that staff is well trained on IT systems. Nurses may need detailed training on EMR fields to capture during charting, for claims or for later analytical processes related to PHM. Training sessions and meetings can take nurses off the floor, possibly affecting patient care. When hospitals have to split nursing staff between multiple training sessions to ensure adequate staffing, the IT training may drag on for weeks or months.

THE SOLUTION: Fastaff has covered hospitals nationwide during EMR conversions and upgrades. Fastaff is a trusted partner in new technology initiatives, allowing hospitals to fully train staff nurses through uninterrupted education sessions while Fastaff travel nurses provide expert bedside care. While travel nursing is often seen as an expensive proposition, Fastaff's flexible-length assignment model allows nurses to be deployed only for the time needed, rather than for the fixed 13-week assignment that is common among other agencies. It just takes one call to activate the Fastaff Rapid Response® process.

FASTAFF RAPID RESPONSE® TRAVEL NURSE STAFFING

As hospitals expand their efforts to manage population health, staffing strategies are key. When nurses are reassigned, leave the organization, or need to spend time out in the community or in a training session, operating  with lean staffing can pose severe risk to a facility. Adding experienced nurses to existing core staff not only provides continuous, high-quality care, but also allows appropriate relief and rest for core staff throughout the PHE duration. Nearly 75 percent of completed Fastaff assignments require nurses in a hard-to-fill specialty. Fastaff understands the dilemmas facing hospitals today in terms of recruiting and retaining nurses while staffing new roles in care coordination and population health management.

Contact our Client Services team to discuss how Fastaff can help implement your population health initiatives – email HelpNow@Fastaff.com to get started.

Kim Windsor, DHA, MSN, MBA, RN

With a well-rounded career in various aspects of healthcare, Dr. Windsor has become a prominent force in clinical operations, hospital administration, risk management, human resources and staffing. Evolving from a staff nurse to the vice president of nursing for a major health system for nearly nine years, Dr. Windsor provided leadership for critical care, operating room, emergency department, pharmacy and medical/ surgical units. As the vice president of human resources, Dr. Windsor's experience spanned to cover employee relations, compensation, talent management, benefits and occupational health. With more than 13 years in the staffing industry, Dr. Windsor applied her clinical and human resources expertise to provide insight into identifying quality nursing solutions for hospital systems nationwide. Dr. Windsor is accomplished in her implementation of credentialing standards to meet or exceed qualifications by the Joint Commission, as well as program integrity, risk and managed service programs.

1. Stiefel M, Nolan K. A Guide to Measuring the Triple Aim: Population Health, Experience of Care, and Per Capita Cost. IHI Innovation Series white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement: 2012. (Available on www.IHI.org)
2. Association for Community Health Improvement. (2013, December). Trends in hospital-based population health infrastructure: Results from an Association for Community Health Improvement and American Hospital Association survey. Chicago: Health Research & Educational Trust. Accessed at www.healthycommunities.org.
3. Greenway Health. Population Health Best Practices Guide. Accessed at https://www.greenwayhealth.com/wp-content/ uploads/2015/09/070106-041_Greenway_Health_Population_Health_091615Final.pdf.
4. Ibid.
5. Health Care Advisory Board. (2013). Playbook for Population Health: Building the High-Performance Care Management Network. Published by the Advisory Board Company.
6. H.M. Krumholz et al., "Readmission after Hospitalization for Congestive Heart Failure among Medicare Beneficiaries," Archives of Internal Medicine 157, no. 1 (1997): 99-104.
7. Grange, J. (2005). "The role of nurses in the management of heart failure." Heart, 91(Suppl 2), ii39-ii42. http://doi.org/10.1136/ hrt.2005.062117
8. Nursing Solutions, Inc. 2017 National Health Care Retention & RN Staffing Report.
9. Japsen, Bruce. "Health Insurers Hire Thousands Of Nurses To Coordinate Care." Forbes.com. September 25, 2015. https://www.forbes. com/sites/brucejapsen/2015/09/25/health-insurers-hire-thousands-of-nurses-amid-shift-to-value-based-care/#60ddbf876d9d
10. Punke, Heather. "3 Strategies Driving ACO Success." Becker's Hospital Review, September 13, 2013.
11. http://www.physicianspractice.com/staff-salary-survey/2017-staff-salary-survey-results-national
12. American College of Surgeons. Cancer Program Standards: Ensuring Patient-Centered Care. 2016 edition.
13. Crossley, Mary, Elizabeth Tobin Tyler, and Jennifer L. Herbst. "Tax-Exempt Hospitals and Community Health Under the Affordable Care Act: Identifying and Addressing Unmet Legal Needs as Social Determinants of Health." Public Health Reports 131.1 (2016): 195-199. Print
14. Greenway Health. Population Health Best Practices Guide. Accessed at https://www.greenwayhealth.com/wp-content/ uploads/2015/09/070106-041_Greenway_Health_Population_Health_091615Final.pdf.
15. Bipartisan Policy Center Task Force on Delivery System Reform and Health IT. Transforming Health Care: The Role of Health IT. (2012)
16. Ibid.
17. Ibid.
18. Bipartisan Policy Center Task Force on Delivery System Reform and Health IT. Transitioning from Volume to Value: Consolidation and Alignment of Quality Measures. (April, 2015)