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AAACN AAACN
April 2008April 2008
Mary Ramos, PhD, RNMary Ramos, PhD, RN
The Role of Military The Role of Military Ambulatory Care Nurses Ambulatory Care Nurses in Facilitating the Best in Facilitating the Best Evidence-based CareEvidence-based Care
Military Health System New to Military Health System New to Provision of Broad-based CareProvision of Broad-based Care
Until 1880s cared only for SoldiersUntil 1880s cared only for Soldiers After 1884 Medical Officers and After 1884 Medical Officers and
Contract Surgeons cared for families Contract Surgeons cared for families free of charge as possiblefree of charge as possible
World War II presented huge burden World War II presented huge burden of obstetrical careof obstetrical care
December 7, 1956: Dependents December 7, 1956: Dependents Medical Care ActMedical Care Act
CHAMPUS: 1967CHAMPUS: 1967
The 1960sThe 1960s
CHAMPUS provided ambulatory and CHAMPUS provided ambulatory and psychiatric care for all family psychiatric care for all family members and retirees by 1967: members and retirees by 1967: Modified HMO/PPOModified HMO/PPO
About 30 HMOs in commercial sectorAbout 30 HMOs in commercial sector Beginning awareness of financial risk Beginning awareness of financial risk
in provision of health carein provision of health care– Utilization ReviewUtilization Review– Cost ContainmentCost Containment
1980s1980s
Fee for Service Decreasingly Feasible Fee for Service Decreasingly Feasible in Community-based Carein Community-based Care
Growth of Managed Care Growth of Managed Care EnvironmentEnvironment
CHAMPUS Reform Initiative in MilitaryCHAMPUS Reform Initiative in Military TRICARETRICARE
Military Health Care in 2008Military Health Care in 2008
TRICARE-contractedTRICARE-contracted Network-dependentNetwork-dependent AmbulatoryAmbulatory Cost-focusedCost-focused Resource-strainedResource-strained Complex SystemsComplex Systems High TechnologyHigh Technology High ExpectationsHigh Expectations Outcomes Measured and ComparedOutcomes Measured and Compared
Key to Maximizing Quality of Key to Maximizing Quality of CareCare
Attention to ProcessesAttention to Processes Balanced Team ApproachBalanced Team Approach Patient FocusPatient Focus Data-based Decision-makingData-based Decision-making
– Evidence-based PracticesEvidence-based Practices– Clinical Practice GuidelinesClinical Practice Guidelines– Using Available DataUsing Available Data
The Best Position to Facilitate The Best Position to Facilitate Change: NursesChange: Nurses
Providers Look at One Patient at a Providers Look at One Patient at a TimeTime
Providers Should be Seeing PatientsProviders Should be Seeing Patients Providers Need System SupportProviders Need System Support
Nurses Can Be System ThinkersNurses Can Be System Thinkers Nurses Can Provide DataNurses Can Provide Data Nurses Can Support Providers in Nurses Can Support Providers in
Improving Population Health Through Improving Population Health Through Data-based Decision-makingData-based Decision-making
Clinical Practice GuidelinesClinical Practice Guidelines
Evidence-basedEvidence-based Algorithmic: Decision MatricesAlgorithmic: Decision Matrices Outcomes-focusedOutcomes-focused Bring Best Practices to the PatientBring Best Practices to the Patient Decrease Unwanted VariationDecrease Unwanted Variation Free Providers to Concentrate on Free Providers to Concentrate on
What Cannot be “Automatic”What Cannot be “Automatic”
https://qmo.amedd.army.mil/pguide.htm
https://qmo.amedd.army.mil/CPGShoppingCart/entry.aspx?link=/CPGShoppingCart/default.aspx
Diabetes Clinical Practice Diabetes Clinical Practice Guideline RecommendationsGuideline Recommendations
A1C At Least AnnuallyA1C At Least Annually Foot Exam AnnuallyFoot Exam Annually Dilated Eye Exam AnnuallyDilated Eye Exam Annually Track LipidsTrack Lipids Influenza/PNX VaccineInfluenza/PNX Vaccine Microalbumin CheckMicroalbumin Check
Provider Decisions?Provider Decisions?
Research-basedResearch-based Universally AcceptedUniversally Accepted Patient Should be Involved in PlanningPatient Should be Involved in Planning
– Timing for A1CTiming for A1C– Relationship of Diet and Exercise to A1CRelationship of Diet and Exercise to A1C– Patient Ability to Assess FeetPatient Ability to Assess Feet– Importance of Eye ExamImportance of Eye Exam– Diabetes and Kidney FunctionDiabetes and Kidney Function
Using Data in Clinical Using Data in Clinical SettingsSettings
AggregationAggregation AnalysisAnalysis ActionAction
AggregationAggregation
Aggregation is putting individual Aggregation is putting individual numbers into sets that “fit” questionsnumbers into sets that “fit” questions
The questions, then, must come firstThe questions, then, must come first
Know Your EnrolleesKnow Your Enrollees
How Many EnrolleesHow Many Enrollees By Benefit CategoryBy Benefit Category By Age Group and GenderBy Age Group and Gender By Function and ActivityBy Function and Activity By ConditionBy Condition
Know Your ProvidersKnow Your Providers
How Many ProvidersHow Many Providers By Category By Category
– Primary Care vs. SpecialtyPrimary Care vs. Specialty– Physician vs. NP and othersPhysician vs. NP and others
By Population Benefit CategoryBy Population Benefit Category By Population Age Group and Gender By Population Age Group and Gender By Deployment StatusBy Deployment Status By Population ConditionBy Population Condition
Formulate QuestionsFormulate Questions
How many patients with asthma?How many patients with asthma?How many of those have had ED How many of those have had ED visits for asthma?visits for asthma?How many of them are on inhaled How many of them are on inhaled steroid medication?steroid medication?
All answers readily available through All answers readily available through the MHSPHPthe MHSPHP
Patient-level DataPatient-level DataAge BenCat PCM
Name
Provider Group
Hosp OP Visits ER Disp Ctrl Rx Ctrl Drug Name
40 ADA QR PCMA 0 3 0 6 30-Oct-07 ADVAIR DISKUS
35 ADA QR PCMA 0 1 0 5 4-May-07 ADVAIR DISKUS
49 ADA QR PCMA 0 1 0 7 22-Oct-07 ADVAIR DISKUS
34 ADA QR PCMA 0 0 0 4 13-Sep-07 ADVAIR DISKUS
47 ADA QR PCMA 0 0 0 5 3-Sep-07 ADVAIR DISKUS
51 ADA QR PCMA 0 0 0 4 22-Oct-07 ADVAIR DISKUS
47 ADA QR PCMA 0 4 0 21 28-Sep-07 ADVAIR DISKUS
42 ADAF QR PCMA 0 1 0 11 31-Jul-07 ADVAIR DISKUS
39 ADAF QR PCMA 0 0 0 8 13-Aug-07 ADVAIR DISKUS
46 ADAF QR PCMA 0 1 0 4 19-Sep-07 ADVAIR DISKUS
51 ADAF QR PCMA 0 1 0 5 13-Sep-07 ADVAIR DISKUS
41 ADAF QR PCMA 0 1 0 13 11-Oct-07 FLOVENT HFA
36 ADAF QR PCMA 0 0 0 17 10-Sep-07 SINGULAIR
26 ADAF QR PCMA 0 14 0 7 26-Sep-07 SINGULAIR
https://pophealth.afms.mil/tsphp/login/login.cfm
MTF-level DataMTF-level Data
https://cms.mods.army.mil/cms/secured/stoplights_frameset.aspx?metricCategoryCd=POPH
AnalysisAnalysis
Without analysis, numbers are just Without analysis, numbers are just data – not informationdata – not information
Without analysis, we DRIPWithout analysis, we DRIP Analysis is interpreting numbers to Analysis is interpreting numbers to
answer questionsanswer questions The questions, then, must come firstThe questions, then, must come first
AnalysisAnalysis
Analyze data sets separatelyAnalyze data sets separately– ORYXORYX– HEDISHEDIS– Other Applicable DataOther Applicable Data
Analyze data sets togetherAnalyze data sets together– ED Utilization against Portal Asthma ED Utilization against Portal Asthma
datadata– Inpatient days for diabetes patientsInpatient days for diabetes patients– Readmission for CHF and ORYX Readmission for CHF and ORYX
discharge education datadischarge education data
ORYX Analysis ToolsORYX Analysis Tools
www.mhs-cqm.infowww.mhs-cqm.info– MTF comparison chartsMTF comparison charts– Can be edited to address local issuesCan be edited to address local issues
www.hcdinc.comwww.hcdinc.com– Process Control Charts (Consistency)Process Control Charts (Consistency)– Comparison Charts (Observed vs. Comparison Charts (Observed vs.
Benchmark)Benchmark)– Quality Reports (TJC Quality Check)Quality Reports (TJC Quality Check)
ActionAction
Having data is not enoughHaving data is not enough Everyone is involved in incorporating Everyone is involved in incorporating
data into every day decision-making data into every day decision-making and strategic planning to modify and strategic planning to modify processes to enhance and optimize processes to enhance and optimize patient care and patient safetypatient care and patient safety
Get your findings out of the office Get your findings out of the office and into the fieldand into the field
Talk to the delivery teams about Talk to the delivery teams about creative ways to improve numberscreative ways to improve numbers
Use data to feed and nourish quality Use data to feed and nourish quality improvement effortsimprovement efforts
Cross-pollinateCross-pollinate
Ambulatory Nursing Ambulatory Nursing InterventionsInterventions
Design Systems to Support Care Design Systems to Support Care DeliveryDelivery– HuddlesHuddles– Order SetsOrder Sets– Availability of DataAvailability of Data
Integrated TeamsIntegrated Teams Patient PartnershipsPatient Partnerships Case Management and Continuity of Case Management and Continuity of
CareCare
Best PracticesBest Practices
Mammography Self-referralMammography Self-referral Integrated Diabetes CareIntegrated Diabetes Care
– Classes to Fit Patient PreferencesClasses to Fit Patient Preferences– Comprehensive Cardiac Risk ManagementComprehensive Cardiac Risk Management– Interdisciplinary ApproachesInterdisciplinary Approaches
Comprehensive Asthma CareComprehensive Asthma Care– Integration with School NursesIntegration with School Nurses– Involvement of ED Involvement of ED – Diagnostic and Coding Issues AddressedDiagnostic and Coding Issues Addressed
Expanded Roles for Nurses in Expanded Roles for Nurses in Ambulatory CareAmbulatory Care
Active Partnerships with Case and Active Partnerships with Case and Disease ManagersDisease Managers
Identifying and Eliminating “Silos” in Identifying and Eliminating “Silos” in Preventative Care ServicesPreventative Care Services
Richer Mix of Professional NursesRicher Mix of Professional Nurses Nurses More Involved in Direct Patient Nurses More Involved in Direct Patient
CareCare Larger Voice in Administrative Decision-Larger Voice in Administrative Decision-
making and Systems Designmaking and Systems Design
Golden Opportunities for Golden Opportunities for NursesNurses
Advocate for Patient-friendly SystemsAdvocate for Patient-friendly Systems Expand Responsibility and Expand Responsibility and
PartnershipsPartnerships Assume Responsibility for Optimal Assume Responsibility for Optimal
Patient WellnessPatient Wellness Assist Military in Designing Assist Military in Designing
Delivery Systems Delivery Systems for the 21for the 21stst Century Century