By Thomas C. Ricketts and Erin P. Fraher
Reconfiguring Health Workforce
Policy So That Education,
Training, And Actual Delivery
Of Care Are Closely Connected
ABSTRACT There is growing consensus that the health care workforce in
the United States needs to be reconfigured to meet the needs of a health
care system that is being rapidly and permanently redesigned.
Accountable care organizations and patient-centered medical homes, for
instance, will greatly alter the mix of caregivers needed and create new
roles for existing health care workers. The focus of health system
innovation, however, has largely been on reorganizing care delivery
processes, reengineering workflows, and adopting electronic technology
to improve outcomes. Little attention has been paid to training workers
to adapt to these systems and deliver patient care in ever more
coordinated systems, such as integrated health care networks that
harmonize primary care with acute inpatient and postacute long-term
care. This article highlights how neither regulatory policies nor market
forces are keeping up with a rapidly changing delivery system and argues
that training and education should be connected more closely to the
actual delivery of care.
H
ealth care professionals are be-
ing challenged to find new ways
to organize care and develop
systems that hold providers ac-
countable for the quality, cost,
and patient experience of care.1 The once in-
cremental pace of change is accelerating, and
there is evidence that long-standing paradigms
are dramatically shifting.2 For example, the rela-
tively slow acceptance of prepaid and managed
care systems is being replaced by the rapid adop-
tion of bundled and risk-based payment mod-
els.3,4 Early adopters of accountable care organi-
zations (ACOs) are finding that their workforce
is shifting from acute care to community- and
home-based settings with increasing roles for
physicians, nurses, social workers, patient navi-
gators and outreach coordinators, and other
clinicians in providing enhanced care coordina-
tion, better medication management, and im-
proved care transitions.5
The training of health professionals, however,
lags behind these reforms because it remains
largely insulated from change behind the walls
of schools of medicine, dentistry, pharmacy, and
nursing. Medical training is done primarily in
hospitals, while the greatest challenges are
found in coordinating care in multiple out-
patient settings. This article describes how
health workforce policy was done in the past.
It illustrates some of the specific changes under
way and how they are changing the health care
workforce. Further, it suggests that closer links
should be built between the day-to-day caring for
patients and the training of the people who de-
liver that care.
Workforce Policy Center Stage Again
Health workforce policy took center stage in an
earlier Health Affairs thematic issue in 2002.6
Articles in that issue described future efforts to
doi: 10.1377/.
THIS IS THE FEEDBACK I RECEEIVED. Only one patient responded to my.docxjuliennehar
THIS IS THE FEEDBACK I RECEEIVED. Only one patient responded to my post. Hope this helps
Ryan,
Inadequate levels of nursing professionals were first discussed more than 80 years ago (Whelan, n.d.). Recently, scholars have opined many reasons for the shortage of nurses. Factors such as work stress, burnout, violence against healthcare professionals, a lack of qualified nursing instructors, and nurses unable to adapt to changing technology or clinical environments have been addressed (Haddad & Toney-Butler, 2019). As many nurses may attest, doing more with less can lead to mistakes and dissatisfaction with a nursing career. Ultimately, patient care suffers.
Organizations employ various tactics to help strengthen nurse retention. Halter et al. (2017) suggest strong nursing leadership and assigning preceptors to new nurses can help minimize nursing resignation rates. At the writer’s employment, hospital administrators use several ways to retain nurses. Each quarter, a nurse is recognized for outstanding achievement by receiving a certificate, gift card, and editorial mention on the hospital’s intranet. Moreover, the hospital caters lunch for all employees, dayside and nighttime staff, twice a year for meeting quality targets. Also, the hospital uses various national celebration days such as ice cream, donuts, coffee, bagels, and candy to reward all employees. Creating a level of goodwill and institutional collaboration can help retain nurses and improve job satisfaction (Kurnat-Thoma et al., 2017).
Reference
Haddad, L.M., & Toney-Butler, T.J. (2019). Nursing shortage. StatPearls Publishing.
Halter, M., Pelone, F., Boiko, O., Beighton, C., Harris, R., Gale, J., Gourlay, S., & Drennan, V. (2017). Interventions to reduce adult nursing turnover: A systematic review of systematic reviews. The Open Nursing Journal, 11, 108-123. https://doi.org/10.2174/1874434601711010108
Kurnat-Thoma, E., Ganger, M., Peterson, K., & Channell, L. (2017). Reducing annual hospital and registered nurse staff turnover: A 10-element onboarding program intervention. SAGE Open Nursing, 3. https://doi.org/10.1177/2377960817697712
Whelan, J.C. (n.d.). Where did all the nurses go? Retrieved from https://www.nursing.upenn.edu/nhhc/workforce-issues/where-did-all-the-nurses-go/
By Thomas C. Ricketts and Erin P. Fraher
Reconfiguring Health Workforce
Policy So That Education,
Training, And Actual Delivery
Of Care Are Closely Connected
ABSTRACT There is growing consensus that the health care workforce in
the United States needs to be reconfigured to meet the needs of a health
care system that is being rapidly and permanently redesigned.
Accountable care organizations and patient-centered medical homes, for
instance, will greatly alter the mix of caregivers needed and create new
roles for existing health care workers. The focus of health system
innovation, however, has largely been on reorganizing care delivery
processes, reengineering workflows, and adopting electronic technolo ...
The document discusses improving health in communities by aligning incentives to make health profitable. It notes the US healthcare system is strained by chronic conditions exacerbated by an aging population. Experts discuss changing models and behaviors, and how to ensure healthcare reform improves overall community health rather than just preserving existing imbalances. Key ideas discussed include making health states profitable through business models, improving data sharing and transparency, and driving behavioral changes through community efforts.
4 hours ago
Amy Miller
RE: Discussion - Week 7
Collapse
NURS 6050C: Policy and Advocacy for Improving Population Health
Main Question Post. The Patient Protection and Affordable Care Act of 2010 created several positive healthcare policies such as affordable health care, lifting the preexisting health condition clause from health insurance, requiring facilities to make healthcare charges public knowledge, and enforcing healthcare providers to become active in improving quality and health outcomes for patients (Library of Congress, n.d.). The act addressed a combination of the health care drivers of cost, quality, and access. According to a report released by the White House Press Secretary on April 17, 2014, “The Affordable Care Act is working. It is giving millions of middle class Americans the health care security they deserve, it is slowing the growth of health care costs and it has brought transparency and competition to the Health Insurance Marketplace.” (The White House, 2014). However, the price some healthcare providers had to pay a heavy financial - forcing some providers out of business. The negative side of the act is seldom portrayed in the news and media.
Section 3131(a) of the act required payment for home health services to be rebased over a period of four years (Centers for Medicare & Medicaid Services, 2013); resultant in a 2.8% reduction beginning in 2014 for four consecutive years totaling a reduction in payment of 11.6%. The reductions were placed along with mandates for quality reporting, new forms, and new processes resulting in increased administrative overhead costs while shouldering the burden of financial reductions.
Initiating a Change in Policy Process
Living in a rural community, I witness firsthand the lack of access to care as there are limited numbers of primary care providers. Couple the limited access to providers with the amount of paperwork and forms that must be signed by a physician and patients are not referred to home health services as often as one should be – the result is the patient presenting to the emergency room or a hospitalization to have one’s health care needs met. Currently, Medicare and Medicaid do not allow physician assistants or advanced practice registered nurses (APRNs) to sign the necessary orders and plan of care for home health services – only a “doctor of medicine, osteopathy, or podiatric medicine” may sign for services (Government Publishing Office, 2014, p. 693). I would like to use the knowledge gained as an APRN to legislate for this mandate to be changed and allow both physician assistants and APRNs to sign for coverage of home health services.
The Kingdon Model would be utilized for the legislation process by finding the three streams of problem, policy, and politics to coordinate with the above-mentioned issue (Milstead, 2019, p. 24). The problem would consist of the burdensome amount of paperwork imposed upon.
DQ 3-2Integrated health care delivery systems (IDS) was develope.docxelinoraudley582231
DQ 3-2
Integrated health care delivery systems (IDS) was developed to initiate excellence health care access and quality of care to entire populations and community by collaborating and coordinating diverse healthcare professionals. Main driving force of IDS is patient centered care by using resources such as collaborating care from physicians and allied health care professionals to construct continuum of care, to deliver care in the most cost-effective way, utilize trained and competent providers by utilizing evidenced -based practice and combine innovation such as EHR (Electronic Health Records) system and team work to produce improved healthcare system.
Excellence in care is attainable by incorporating allied healthcare professional, as high quality care is possible when coordination is unified and covers all areas of responsibilities. For an example-combining resources and coordination of care by involving physicians, dietitian, physical therapy or occupational therapy to work with patient diagnosed with obesity by promoting teamwork approach and ultimately delivering endurance in care and utilizing various resources.
Barriers to IDS can be a huge block in delivering quality care. Among many one limitation is physicians not participating in integrated healthcare system, which disconnect physicians from team based approached by deterring continuous quality improvement (essentialhospitals.org, n.d). This is because, system such as EHR or new innovative quality assurance programs are time consuming and overwhelming, thus decline in physicians support in IDS programs. By implementing user friendly system approach, enforcing focused based care and accepting the necessity of evidenced based practice can improve these barriers. Hence, increasing clinical expertise to produce better service and quality of care in integrated delivery system.
Essentialhospitls.org (n.d). Retrieved from: http://essentialhospitals.org/wp-content/uploads/2013/12/Integrated-Health-Care-Literature-Review-Webpost-8-22-13-CB.pdf
Dq 3-1
1.
In the US, there is not one type of health care system but rather a subset of systems, some of them catering to specific populations. These subsystems include managed care, military, and vulnerable populations. Managed care is a health care delivery system that seeks to achieve efficiency by integrating the basic functions of health care delivery, employs mechanisms to control utilization of medical services, and determines the price at which the services are purchased and how much the providers get paid, military health care system is available free of charge to active duty military personnel and covers preventative and treatment services that are provided by salaried health care personnel and this system combines public health with medical services, and vulnerable population subsystem offers comprehensive medical and enabling services targeted to the needs of vulnerable populations and government health insurance programs provide.
Newark Analysis of a Pertinent Healthcare Issue HW.docxwrite5
1) The document discusses competing needs within healthcare organizations as payment models shift from fee-for-service to value-based. This puts pressure on care quality and resource allocation.
2) Strategies used to address this include establishing separate performance measures for quality and preventative care. This improves primary care coordination but requires additional training and resources.
3) Adopting a strategy that integrates varied healthcare professionals and specialties can improve outcomes but coordinating different performance metrics takes effective administration and financial investment.
The patient-centered medical home (PCMH), an approach designed to rebuild primary care and improve care coordination, has become a major focus of healthcare reform. Thousands of physicians are already participating in medical home pilot projects across the country. Now is the time for practices to investigate the information technology tools that will help them medical home certification requirements.
Running Head HEALTHCARE STAKEHOLDER CONFLICTS1HEALTHCARE .docxcowinhelen
Running Head: HEALTHCARE STAKEHOLDER CONFLICTS
1
HEALTHCARE STAKEHOLDER CONFLICTS
5
Stakeholder Conflicts in Healthcare Visions
Kendra Smith
Grand Canyon University: HCA 675
Introduction
The stakeholders in the healthcare service in any jurisdiction entail the government, the healthcare providers or the physicians, the payers, the patients as well as healthcare professional organizations.
These stakeholders work hand in hand to ensure efficiency and professionalism in healthcare delivery (Blair et al, 1988). They do this by developing succinct policies and effectively implement them for the sole purpose of improving healthcare services. However, there have been serious conflicts in opinion regarding enhancing healthcare service practices and proper administrative mechanisms for the achievement of better services, among the stakeholders.
Conflicts in Health Vision
One of the major health reform visions which have generated considerable debate concerns the accommodation of evidence-driven healthcare service practice, which the government of the United States has instructed all healthcare service providers or organizations to adopt. The major emphasis on this aspect of medicine is the requirement by the government that all healthcare service providers or organizations should document which healthcare services they provide and why they provide such healthcare services to the communit
y.
The argument behind this requirement is that it will enable the government, or it will be generally helpful in gauging the benefits the community gains from such healthcare services. In addition, establishing evidence-driven healthcare practice according to healthcare practitioners will help in identifying specific health problems within a community, and subsequently, design the most appropriate medical response. Some healthcare stakeholders also believe that this is an avenue that the government intends to use in creating and forging a closer working relationship between private and public healthcare providers. However much most stakeholders, both private and public, appreciate this evidence-based healthcare practice, as a vital component in improving healthcare services, the major concern is about how such data should be obtained. Some healthcare providers have reasoned that these data should be generated from the already existing data, due to the costs associated with activities that may lead to acquiring and establishing sound data or information domain. In response to this requirement, most of the healthcare organizations have established community-based information or data collection and management mechanisms, which enable them to collect data concerning community health concerns and threats, then define effective ways of response.
With the introduction and implementation of a series of healthcare reforms in the United States, such as the Obamacare and Trumpcare, there is general expectation that there will be enhanced access to healthcare service ...
THIS IS THE FEEDBACK I RECEEIVED. Only one patient responded to my.docxjuliennehar
THIS IS THE FEEDBACK I RECEEIVED. Only one patient responded to my post. Hope this helps
Ryan,
Inadequate levels of nursing professionals were first discussed more than 80 years ago (Whelan, n.d.). Recently, scholars have opined many reasons for the shortage of nurses. Factors such as work stress, burnout, violence against healthcare professionals, a lack of qualified nursing instructors, and nurses unable to adapt to changing technology or clinical environments have been addressed (Haddad & Toney-Butler, 2019). As many nurses may attest, doing more with less can lead to mistakes and dissatisfaction with a nursing career. Ultimately, patient care suffers.
Organizations employ various tactics to help strengthen nurse retention. Halter et al. (2017) suggest strong nursing leadership and assigning preceptors to new nurses can help minimize nursing resignation rates. At the writer’s employment, hospital administrators use several ways to retain nurses. Each quarter, a nurse is recognized for outstanding achievement by receiving a certificate, gift card, and editorial mention on the hospital’s intranet. Moreover, the hospital caters lunch for all employees, dayside and nighttime staff, twice a year for meeting quality targets. Also, the hospital uses various national celebration days such as ice cream, donuts, coffee, bagels, and candy to reward all employees. Creating a level of goodwill and institutional collaboration can help retain nurses and improve job satisfaction (Kurnat-Thoma et al., 2017).
Reference
Haddad, L.M., & Toney-Butler, T.J. (2019). Nursing shortage. StatPearls Publishing.
Halter, M., Pelone, F., Boiko, O., Beighton, C., Harris, R., Gale, J., Gourlay, S., & Drennan, V. (2017). Interventions to reduce adult nursing turnover: A systematic review of systematic reviews. The Open Nursing Journal, 11, 108-123. https://doi.org/10.2174/1874434601711010108
Kurnat-Thoma, E., Ganger, M., Peterson, K., & Channell, L. (2017). Reducing annual hospital and registered nurse staff turnover: A 10-element onboarding program intervention. SAGE Open Nursing, 3. https://doi.org/10.1177/2377960817697712
Whelan, J.C. (n.d.). Where did all the nurses go? Retrieved from https://www.nursing.upenn.edu/nhhc/workforce-issues/where-did-all-the-nurses-go/
By Thomas C. Ricketts and Erin P. Fraher
Reconfiguring Health Workforce
Policy So That Education,
Training, And Actual Delivery
Of Care Are Closely Connected
ABSTRACT There is growing consensus that the health care workforce in
the United States needs to be reconfigured to meet the needs of a health
care system that is being rapidly and permanently redesigned.
Accountable care organizations and patient-centered medical homes, for
instance, will greatly alter the mix of caregivers needed and create new
roles for existing health care workers. The focus of health system
innovation, however, has largely been on reorganizing care delivery
processes, reengineering workflows, and adopting electronic technolo ...
The document discusses improving health in communities by aligning incentives to make health profitable. It notes the US healthcare system is strained by chronic conditions exacerbated by an aging population. Experts discuss changing models and behaviors, and how to ensure healthcare reform improves overall community health rather than just preserving existing imbalances. Key ideas discussed include making health states profitable through business models, improving data sharing and transparency, and driving behavioral changes through community efforts.
4 hours ago
Amy Miller
RE: Discussion - Week 7
Collapse
NURS 6050C: Policy and Advocacy for Improving Population Health
Main Question Post. The Patient Protection and Affordable Care Act of 2010 created several positive healthcare policies such as affordable health care, lifting the preexisting health condition clause from health insurance, requiring facilities to make healthcare charges public knowledge, and enforcing healthcare providers to become active in improving quality and health outcomes for patients (Library of Congress, n.d.). The act addressed a combination of the health care drivers of cost, quality, and access. According to a report released by the White House Press Secretary on April 17, 2014, “The Affordable Care Act is working. It is giving millions of middle class Americans the health care security they deserve, it is slowing the growth of health care costs and it has brought transparency and competition to the Health Insurance Marketplace.” (The White House, 2014). However, the price some healthcare providers had to pay a heavy financial - forcing some providers out of business. The negative side of the act is seldom portrayed in the news and media.
Section 3131(a) of the act required payment for home health services to be rebased over a period of four years (Centers for Medicare & Medicaid Services, 2013); resultant in a 2.8% reduction beginning in 2014 for four consecutive years totaling a reduction in payment of 11.6%. The reductions were placed along with mandates for quality reporting, new forms, and new processes resulting in increased administrative overhead costs while shouldering the burden of financial reductions.
Initiating a Change in Policy Process
Living in a rural community, I witness firsthand the lack of access to care as there are limited numbers of primary care providers. Couple the limited access to providers with the amount of paperwork and forms that must be signed by a physician and patients are not referred to home health services as often as one should be – the result is the patient presenting to the emergency room or a hospitalization to have one’s health care needs met. Currently, Medicare and Medicaid do not allow physician assistants or advanced practice registered nurses (APRNs) to sign the necessary orders and plan of care for home health services – only a “doctor of medicine, osteopathy, or podiatric medicine” may sign for services (Government Publishing Office, 2014, p. 693). I would like to use the knowledge gained as an APRN to legislate for this mandate to be changed and allow both physician assistants and APRNs to sign for coverage of home health services.
The Kingdon Model would be utilized for the legislation process by finding the three streams of problem, policy, and politics to coordinate with the above-mentioned issue (Milstead, 2019, p. 24). The problem would consist of the burdensome amount of paperwork imposed upon.
DQ 3-2Integrated health care delivery systems (IDS) was develope.docxelinoraudley582231
DQ 3-2
Integrated health care delivery systems (IDS) was developed to initiate excellence health care access and quality of care to entire populations and community by collaborating and coordinating diverse healthcare professionals. Main driving force of IDS is patient centered care by using resources such as collaborating care from physicians and allied health care professionals to construct continuum of care, to deliver care in the most cost-effective way, utilize trained and competent providers by utilizing evidenced -based practice and combine innovation such as EHR (Electronic Health Records) system and team work to produce improved healthcare system.
Excellence in care is attainable by incorporating allied healthcare professional, as high quality care is possible when coordination is unified and covers all areas of responsibilities. For an example-combining resources and coordination of care by involving physicians, dietitian, physical therapy or occupational therapy to work with patient diagnosed with obesity by promoting teamwork approach and ultimately delivering endurance in care and utilizing various resources.
Barriers to IDS can be a huge block in delivering quality care. Among many one limitation is physicians not participating in integrated healthcare system, which disconnect physicians from team based approached by deterring continuous quality improvement (essentialhospitals.org, n.d). This is because, system such as EHR or new innovative quality assurance programs are time consuming and overwhelming, thus decline in physicians support in IDS programs. By implementing user friendly system approach, enforcing focused based care and accepting the necessity of evidenced based practice can improve these barriers. Hence, increasing clinical expertise to produce better service and quality of care in integrated delivery system.
Essentialhospitls.org (n.d). Retrieved from: http://essentialhospitals.org/wp-content/uploads/2013/12/Integrated-Health-Care-Literature-Review-Webpost-8-22-13-CB.pdf
Dq 3-1
1.
In the US, there is not one type of health care system but rather a subset of systems, some of them catering to specific populations. These subsystems include managed care, military, and vulnerable populations. Managed care is a health care delivery system that seeks to achieve efficiency by integrating the basic functions of health care delivery, employs mechanisms to control utilization of medical services, and determines the price at which the services are purchased and how much the providers get paid, military health care system is available free of charge to active duty military personnel and covers preventative and treatment services that are provided by salaried health care personnel and this system combines public health with medical services, and vulnerable population subsystem offers comprehensive medical and enabling services targeted to the needs of vulnerable populations and government health insurance programs provide.
Newark Analysis of a Pertinent Healthcare Issue HW.docxwrite5
1) The document discusses competing needs within healthcare organizations as payment models shift from fee-for-service to value-based. This puts pressure on care quality and resource allocation.
2) Strategies used to address this include establishing separate performance measures for quality and preventative care. This improves primary care coordination but requires additional training and resources.
3) Adopting a strategy that integrates varied healthcare professionals and specialties can improve outcomes but coordinating different performance metrics takes effective administration and financial investment.
The patient-centered medical home (PCMH), an approach designed to rebuild primary care and improve care coordination, has become a major focus of healthcare reform. Thousands of physicians are already participating in medical home pilot projects across the country. Now is the time for practices to investigate the information technology tools that will help them medical home certification requirements.
Running Head HEALTHCARE STAKEHOLDER CONFLICTS1HEALTHCARE .docxcowinhelen
Running Head: HEALTHCARE STAKEHOLDER CONFLICTS
1
HEALTHCARE STAKEHOLDER CONFLICTS
5
Stakeholder Conflicts in Healthcare Visions
Kendra Smith
Grand Canyon University: HCA 675
Introduction
The stakeholders in the healthcare service in any jurisdiction entail the government, the healthcare providers or the physicians, the payers, the patients as well as healthcare professional organizations.
These stakeholders work hand in hand to ensure efficiency and professionalism in healthcare delivery (Blair et al, 1988). They do this by developing succinct policies and effectively implement them for the sole purpose of improving healthcare services. However, there have been serious conflicts in opinion regarding enhancing healthcare service practices and proper administrative mechanisms for the achievement of better services, among the stakeholders.
Conflicts in Health Vision
One of the major health reform visions which have generated considerable debate concerns the accommodation of evidence-driven healthcare service practice, which the government of the United States has instructed all healthcare service providers or organizations to adopt. The major emphasis on this aspect of medicine is the requirement by the government that all healthcare service providers or organizations should document which healthcare services they provide and why they provide such healthcare services to the communit
y.
The argument behind this requirement is that it will enable the government, or it will be generally helpful in gauging the benefits the community gains from such healthcare services. In addition, establishing evidence-driven healthcare practice according to healthcare practitioners will help in identifying specific health problems within a community, and subsequently, design the most appropriate medical response. Some healthcare stakeholders also believe that this is an avenue that the government intends to use in creating and forging a closer working relationship between private and public healthcare providers. However much most stakeholders, both private and public, appreciate this evidence-based healthcare practice, as a vital component in improving healthcare services, the major concern is about how such data should be obtained. Some healthcare providers have reasoned that these data should be generated from the already existing data, due to the costs associated with activities that may lead to acquiring and establishing sound data or information domain. In response to this requirement, most of the healthcare organizations have established community-based information or data collection and management mechanisms, which enable them to collect data concerning community health concerns and threats, then define effective ways of response.
With the introduction and implementation of a series of healthcare reforms in the United States, such as the Obamacare and Trumpcare, there is general expectation that there will be enhanced access to healthcare service ...
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Building Clinical Integration as a Foundation to Become a Successful ACOPhytel
More and more healthcare organizations are recognizing that clinical integration of providers is a prerequisite to care coordination, population health management, and accountable care organizations. They also know that patient centered medical homes—the building blocks of ACOs—can thrive only in patient-centered medical neighborhoods where specialists collaborate with primary care physicians. For this cooperation to be truly effective, all of these providers must be clinically integrated. This paper explains the components of clinical integration and summarizes the kinds of information technology required for its implementation. Case studies of organizations that are building the necessary infrastructure are also included.
2013 community health workers nej mp1305636Roger Zapata
This document discusses the potential for community health workers (CHWs) to improve health outcomes and reduce costs in the United States. It makes three key points:
1) CHWs have been shown to be effective in improving health in multiple areas like maternal/child health and chronic disease management in other countries. Expanding CHWs in the US could improve health and create new jobs.
2) There are three models for organizing CHWs in the US - as extensions of hospitals, through community non-profits, or through dedicated management organizations. More research is needed but CHW programs have shown potential to reduce costs for Medicaid/Medicare patients.
3) Policy changes like developing the evidence base on CH
Chapter 4 Information Systems to Support Population Health Managem.docxketurahhazelhurst
Chapter 4 Information Systems to Support Population Health Management Learning Objectives To be able to understand the data and information needs of health systems in managing population health effectively under value-based payment models. To be able to discuss key health IT tools and strategies for population health management including EHRs, registries, risk stratification, patient engagement, and outreach, care coordination and management, analytics, health information exchange, and telemedicine and telehealth. To be able to discuss the application and use of data analytics to monitor, predict, and improve performance. The enactment of the Affordable Care Act (ACA) brought about sweeping legislation intended to reduce the numbers of uninsured and make health care accessible to all Americans. It also ushered in an era in which changing reimbursement and care delivery models are driving providers from the current fragmented system focused on volume-based services to an outcomes orientation. As a result, the health care system now taking shape is one in which value-based payment models financially reward patient-centered, coordinated, accountable care. Against this backdrop, providers' increasing use of evidence-based medicine and growing capabilities in managing volumes of clinical evidence through sophisticated health IT systems will mean that treatments can be tailored for the individual and interventions can be made earlier to keep patients well. Furthermore, patient engagement is fast becoming a critical component in the care process, particularly in the area of population health management (PHM). Health care providers' interest in improving population health appears to be increasing because of the sudden ubiquity of the phrase, because many are participating in accountable care organizations (ACOs), and because even hospitals not participating in an ACO increasingly have incentives to reduce their number of potentially unavoidable admissions, readmissions, and emergency department visits (Casalino, Erb, Joshi, & Shortell, 2015). In this chapter we'll not only seek a common understanding of PHM but also explore how the advent of shared accountability financial arrangements between providers and purchasers of care has created significant focus on PHM. We'll also review the core processes associated with accountable care and examine the strategic IT investments and data management capabilities required to support population health management and enable a successful transition from volume-based to value-based care. PHM: Key to Success Although the ACO model is still new and evolving, approximately 750 ACOs are in operation today, covering some 23.5 million lives under Medicare, Medicaid, and private insurers. Although not all ACOs have demonstrated success in delivering better health outcomes at a lower cost, many have achieved promising results (Houston & McGinnis, 2016). As such, significant ACO growth is expected. In fact, it is predicte ...
Regulatory reforms and advances in technology are enabling a shift from reactive, provider-centric healthcare to proactive, population-based healthcare management. This involves collecting and analyzing patient data from multiple sources to better understand patient needs, identify patterns, and implement preventative programs and automated interventions. The goal is to improve health outcomes and reduce costs by keeping populations healthy and minimizing expensive medical procedures. Healthcare organizations must adopt new data-driven care models, tools, and workflows to effectively manage population health.
This document discusses the history of the healthcare system in the US and the changing role of physicians within that system. It notes that physicians originally had close personal relationships with patients but that hospitals and specialization led to more fragmented care. Government programs like Medicare and the rise of managed care further changed the physician role by increasing administrative duties. The document examines the current medical school curriculum, noting a lack of leadership and management training. It discusses some programs that do offer such training but notes they are electives, not mandatory. The document concludes there are gaps in preparing physicians for the changing healthcare system and future skills needed in areas like business, communication, and leadership.
This document discusses population health and the need for healthcare providers to shift from a volume-based to a value-based reimbursement model. It defines population health as "the science and art of preventing disease, prolonging life, and promoting health through the organized efforts and informed choices of society, organizations, public and private communities, and individuals." The document states that leveraging automation, analytics, and historical data can help improve delivery of care to groups with similar needs and support the shift to more population-centric care. It also discusses using predictive analytics to identify high-risk patients, plan interventions, and ensure medication adherence to contain costs and mitigate risks.
PHM Tools and Strategies to Support Care Coordination infomc
This document discusses population health management tools and strategies to support care coordination. It describes how InfoMC's InSpotlight tools can help identify at-risk individuals in a population for improved health outcomes through targeted care coordination. The tools aggregate data from multiple sources to stratify populations and identify factors contributing to poor health. This supports effective care plans and workflows to better integrate physical and behavioral healthcare across providers.
Running Head STRATEGIC ALLIANCE 1STRATEGIC AL.docxtodd521
Running Head: STRATEGIC ALLIANCE 1
STRATEGIC ALLIANCE3
Strategic Alliance in Health Care
Strategic alliance in health care arises about with accountable care in organization as related reforms aims to increase coordination between health care providers. Due to the uneven nature of health care system. Strategic alliance in health care along with successful coordination will pivot in large part on the ability of health care organization to successful partner across organizational boundaries. Furthermore, under Medicare partnership accountable care organization has lower quality enactment. This is arrived at by the use of qualitative interviews released that providers are motivated to partner for resource complementarity, risk lessening and legislative requirements. By way of conjointly bringing together official as well casual responsibility device. Strategic alliance in health care may provide an important window to screen a potential wave of health care consolidation or in contrast new models of independent providers’ successfully coordinating patient care.
There has been development in the number of physicians joining the practices and physician practice joining hospital and health care system. As result coordination of clinical care often requires working transversely in organizational boundaries. This is predominantly true when providing care to intricate or high need patients who often require attention for post- acute care facilities such as skilled nursing facilities, rehabilitation centers and home health agencies strategic alliance in health care aims to encourage coordinating through financial incentive and rewards for meeting quality performance targets and total cost of care benchmarks. With required dynamic trust of association. So as to meet desired cost and quality objective. Strategic alliance in health care is recognized arrangements between two or more independent organization to succeed shared or harmonious goals. This is substantial growth in such relationships in health care sector. Notably, these arrangements between autonomous organizations are non-ownership relation based. The primary motivation for this strategic alliance in health lie in understanding needs for resources and capabilities needs to frontier transaction cost and the need to respond to external requirements from Medicare. The benefit of the strategic alliance in health care contribution risk or gaining resources, personnel benefits including improved staffing and management capabilities and organization benefits including growth, opportunities to learn and gain new proficiencies and mutual support and group collaboration.
Numerous methods have been used hence mixed method analysis which involves survey data, performance data, and semi-structured interviews. Questions examined involved to what range is strategic alliance in health benefit to the health sector organization, second how is strategic alliance performance in different organ.
This monograph provides an assessment of the current hospital-physician landscape and outlines an innovative vehicle for advancing hospital-physician relationships that has the potential to improve care delivery and coordination, clinical quality, and patient cost. Our findings and recommendations address:• Changes in the market place.• The concept of an integrated medical staff model.• The role of operational clinical integration, enabled by an Electronic Medical• Record, toward creating virtual medical staffs.• Benefits to the hospital, physicians, patients and community.• What boards and senior management can do to move toward the model.
Submission Id ab299d7c-b547-4cf3-958a-07922ca71f2765 SIM.docxdeanmtaylor1545
Submission Id: ab299d7c-b547-4cf3-958a-07922ca71f27
65% SIMILARITY SCORE 12 CITATION ITEMS 20 GRAMMAR ISSUES 0 FEEDBACK COMMENT
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Inst itut ion 65%
Patience Nehikhare
healthcaredeliverysystemchanges.docx
Summary
1175 Words
Running Head: HEALTHCARE DELIVERY SYSTEM
THE U.S. HEALTHCARE DELIVERY SYSTEM 2
Healthcare Delivery System
Patience Nehikhare
Grand Canyon University
December 22, 2019
The U.S. Healthcare Delivery System
There is a rapid change within the healthcare system in the United States. The
changes that have occurred were made for the purpose of improving quality,
rewarding value and not volume, as well as integrating and coordinating the care
(Seshamani & Sen, 2018). As such, this paper will seek to put into consideration
current healthcare laws within the U.S. and the nurse’s role within this continuously
changing environment; the manner in which quality measures and pay for performance
affect patient outcomes. Furthermore, the emerging trends in the healthcare system,
professional nursing leadership, and management roles will be discussed.
The Emerging Health Care Laws and their Effects on Nursing Practice
One of the most crucial healthcare legislat ions that has been enacted in the United
States since the inception of Medicare and Medicaid in 1965 is the Affordable Care
Act (Obama, 2016). The ACA was enacted in 2010. Issues relat ing to affordability,
ease of access, and the care quality within the United States healthcare system were
some of the driving factors that formed the list of many t ime spanning challenges
that compiled the init iat ion of this legislat ion. Between 2010 to 2015 there was a
decrease in the number of uninsured cit izens in the U.S. by forty three percent as an
effect of the Affordable Care Act.
The payment systems in healthcare are undergoing some changes and the access to
care has also improved (Obama, 2016). The ACA promotes preventive healthcare
models that put emphasis on quality care, primary care, and the funding of community
health init iat ives (Lathrop and Hodnicki, 2014). Millions of previously uninsured cit izens
are also provided insurance coverage and also some healthcare areas that need
reforms so as to meet the needs of patients’ improved healthcare outcomes are
highly focused by the act. The act has an effect on nursing practice in several ways.
The first effect is that the act creates a high demand for healthcare professionals
that are sufficiently trained to provide healthcare services that are up to the acts’
standards. The second effect is that Advanced Practice Registered Nurses (APRNs)
who hold the Doctor of Nursing Practice (DNP) are required to be prepared so that
they can meet the increased needs through the provision of leadership skills in
community health centers. These professionals are also held accountable for direct ing
and advocating for future init iates as well as ser.
2015 05 01 Pop Health - Laying the Foundation (00000002)Dana Alexander
This document discusses population health management and outlines four key aspects: data control and governance, population management and risk stratification, care management, and patient engagement. It summarizes the challenges of collecting and analyzing large amounts of patient data from electronic health records, developing risk profiles of patient subgroups, implementing targeted care models, and encouraging patient accountability through new technologies. The overall goal is for healthcare organizations to successfully address these areas and achieve true population health management.
Three key trends are forcing a change in today's health models: 1) Rising chronic diseases among both young and old are driving up health costs and creating future liabilities. 2) Technology is enabling mass customization of healthcare similar to other industries. 3) Broader factors like behavior, socioeconomics, and genetics are recognized as influencing health beyond medical care. To address these issues, health will be customized around six vectors: incentives, regulations, funding, patient communication, information technology, and workforce models to personalize diagnosis, care and cure for individuals.
35NURSING ECONOMIC$/January-February 2011/Vol. 29/No. 1
T
HE WORLD OF ARISTOTLE AND
Ptolemy believed that Earth
was positioned at the cen-
ter of the universe. Thanks
to Galileo and Copernicus’s studies
in the 16th century, we know this
is not true and that the sun is the
center of our universe. Pers -
pectives of health care have
undergone similar, radical changes
in perception. For centuries we
had a hospital-centric view; an
illness-based model, where the majority of care was
provided in hospitals, when we were ill. In the last
few decades, that model has migrated to a more con-
tinuum of care view; a wellness/health maintenance
model, where emphasis of care is outside the hospital
in other venues such as outpatient, ambulatory/clin-
ic, and home care (see Figure 1).
But as we all know, this is still not where we need
to be to support the highest quality care at the right
cost. Despite a focus on moving care out of the hospi-
tals, one only needs to think about the process of
medication reconciliation between care venues to
realize the lack of seamless integration of care deliv-
ery and the challenges of supporting interoperability
across the continuum. Hence, here I am proposing the
patient centric view, where the patient actively partic-
ipates in his or her care and we look at delivering care
from a patient’s point of view. This allows us to break
down some of the barriers we have struggled with on
our journeys to promote higher quality care through
the use of health information technology (HIT). Now
we need to consider how the health care system
should revolve around the patient, rather than the
patient rotating around the hospital. Considering a
patient-centric point of view when implementing and
optimizing the use of HIT provides new perspectives
on the meaning of “integrated” health care.
Patient-Centric Care
It might seem odd that a health care organization
needs to be reminded to involve the patient in his or
her care. After all, this approach would certainly be
supported from a patient’s perspective. And, of
course, the health care industry has compelling rea-
sons to incorporate a strong customer and service
focus in order to improve patient satisfaction and
impact patient loyalty. But as health care systems
Patient as Center of the Health Care Universe:
A Closer Look at Patient-Centered Care
JUDY MURPHY, RN, FACMI, FHIMSS, is Vice President-
Information Services, Aurora Health Care, Milwaukee, WI; a
HIMSS Board Member; Co-Chair of the Alliance for Nursing
Informatics; a member of the federal HIT Standards Committee;
and is a Nursing Economic$ Editorial Board Member. Comments
and suggestions can be sent to [email protected]
EXECUTIVE SUMMARY
We need to consider how the health care system
should revolve around the patient, rather than the
patient rotating around the hospital.
Considering a patient-centric point of view when
implementing and optimizing the use of health infor-
mation technology (HIT) provides new perspect.
35NURSING ECONOMIC$/January-February 2011/Vol. 29/No. 1
T
HE WORLD OF ARISTOTLE AND
Ptolemy believed that Earth
was positioned at the cen-
ter of the universe. Thanks
to Galileo and Copernicus’s studies
in the 16th century, we know this
is not true and that the sun is the
center of our universe. Pers -
pectives of health care have
undergone similar, radical changes
in perception. For centuries we
had a hospital-centric view; an
illness-based model, where the majority of care was
provided in hospitals, when we were ill. In the last
few decades, that model has migrated to a more con-
tinuum of care view; a wellness/health maintenance
model, where emphasis of care is outside the hospital
in other venues such as outpatient, ambulatory/clin-
ic, and home care (see Figure 1).
But as we all know, this is still not where we need
to be to support the highest quality care at the right
cost. Despite a focus on moving care out of the hospi-
tals, one only needs to think about the process of
medication reconciliation between care venues to
realize the lack of seamless integration of care deliv-
ery and the challenges of supporting interoperability
across the continuum. Hence, here I am proposing the
patient centric view, where the patient actively partic-
ipates in his or her care and we look at delivering care
from a patient’s point of view. This allows us to break
down some of the barriers we have struggled with on
our journeys to promote higher quality care through
the use of health information technology (HIT). Now
we need to consider how the health care system
should revolve around the patient, rather than the
patient rotating around the hospital. Considering a
patient-centric point of view when implementing and
optimizing the use of HIT provides new perspectives
on the meaning of “integrated” health care.
Patient-Centric Care
It might seem odd that a health care organization
needs to be reminded to involve the patient in his or
her care. After all, this approach would certainly be
supported from a patient’s perspective. And, of
course, the health care industry has compelling rea-
sons to incorporate a strong customer and service
focus in order to improve patient satisfaction and
impact patient loyalty. But as health care systems
Patient as Center of the Health Care Universe:
A Closer Look at Patient-Centered Care
JUDY MURPHY, RN, FACMI, FHIMSS, is Vice President-
Information Services, Aurora Health Care, Milwaukee, WI; a
HIMSS Board Member; Co-Chair of the Alliance for Nursing
Informatics; a member of the federal HIT Standards Committee;
and is a Nursing Economic$ Editorial Board Member. Comments
and suggestions can be sent to [email protected]
EXECUTIVE SUMMARY
We need to consider how the health care system
should revolve around the patient, rather than the
patient rotating around the hospital.
Considering a patient-centric point of view when
implementing and optimizing the use of health infor-
mation technology (HIT) provides new perspect ...
Why Electronic Health Records are Ill Suited for Population Health 012616infomc
Electronic health records are ill-suited for population health management for several reasons. EHRs were designed to manage patient data within individual healthcare systems and have limited ability to track health information from outside sources or support integrated care across multiple providers. Population health management requires more sophisticated technology that can perform functions like enrollment tracking, provider networking, utilization review, claims processing, and quality reporting that are beyond the scope of most EHRs. While EHRs are important for individual medical practices, organizations taking on financial risk for patient populations need systems designed for the specific demands of population health management.
Why Electronic Health Records are Ill Suited for Population Healthinfomc
Electronic health records are ill-suited for population health management for several reasons. EHRs were designed to manage patient data within individual healthcare systems and have limited ability to track health information from outside sources or support integrated care across multiple providers. Population health management requires more sophisticated technology that can perform tasks like enrollment tracking, provider networking, utilization review, and claims adjudication across different clinical systems. While EHRs are important for individual medical practices, organizations taking on financial risk for patient populations need systems with greater functionality for care coordination, quality monitoring, and financial reporting at a population level.
1) The document discusses how health information technology (HIT), such as electronic health records (EHRs) and health information exchanges (HIEs), has the potential to influence health reform efforts in the United States by reducing costs, increasing access to care, and improving quality of care.
2) The Affordable Care Act includes provisions and financial incentives to encourage widespread adoption of EHRs and use of HIT. Meaningful use criteria aim to ensure EHRs improve safety, quality, and coordination of care.
3) HIT such as EHRs and HIEs could transform healthcare by giving providers access to complete patient information, reducing medical errors, duplicative tests, and costs
In the coming years the United States will find themselves going through a number of changes within the Social Security Administration which will affect the Health Care Industry as we know it “Hospital size has long been an area of discussion and debate in the U.S. healthcare industry. Questions have consistently focused on cost management or efficiency in large versus small hospitals. A persistent question among researchers is whether efficiencies are associated with larger facilities through economies of scale, or if there are alternate scenarios that play a significant part in hospital cost and efficiency” (2009, JHM). Since the Affordable Health Care Act was established it made obtaining health care much more affordable and accessible, but at the same time there has to be some cut back.
Calculus Quiz 2 (Derivatives)Covers Units 9-13. This is a 10 quest.docxclairbycraft
Calculus Quiz 2 (Derivatives)
Covers Units 9-13. This is a 10 question, 10 point quiz consisting of multiple choice and calculated numeric answers.
You should complete the homework over these units before beginning the quiz.
You should complete the by
Thursday, November 12.
YOU MAY ATTEMPT THE QUIZ up to 3 timesIF YOU WISH to improve your score.
.
Calculus IDirections (10 pts. each) Answer each of the followin.docxclairbycraft
Calculus I
Directions: (10 pts. each) Answer each of the following questions below. In order to receive ANY credit for a question, you must SHOW YOUR WORK using proper notation and clear and concise logic. You're graded on both the accuracy of your answers AND your explanations that sufficiently support your answers. Unless otherwise stated, you're to give the EXAXCT VALUES of answers instead of decimal approximations. In order to receive ANY credit for any applied/word problem (i.e. Problems #29 - ), you MUST declare a variable (unless the variable(s) have already been declared in the problem) and set up and solve an appropriate mathematical expression that can be used to answer the question. Proper units must also be included in answers to applied problems. NO CREDIT WILL BE GIVEN FOR EITHER GUESSING OR CHECKING POSSIBLE ANSWERS WITHOUT SOLVING THE PROBLEM. YOU CANNOT USE CALCULUS TO SOLVE THESE PROBLEMS.
Finally, write ONLY FINAL ANSWERS ON THESE PAGES; you must show your work both according to homework guidelines and on YOUR OWN PAPER.
SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question.
Multiply or divide as indicated. Write your answer in factored form.
1) x22 - 9x + 14 · xx22 -- 1618x x ++ 4877 1)
2)
x
-
12
x
+
32
Simplify the complex rational expression.
4
x
2
-
4
x
-
32
-
1
x
-
8
2)
1 + 1 x + 4
Find the difference quotient for the function and simplify it.
3) g(x) = 6x2 + 14x - 1 3)
Find the domain and range of the function. Write your answers using interval notation.
4)
g(z)
=
16
-
z
2
4)
Find a formula for the function graphed.
5) 5)
Determine if the function is even, odd, or neither. You must use algebra to justify your answer; otherwise, no full credit will be given. NO CREDIT is given for an answer without a mathematical explanation.
6) f(x) = x -+7 9 6)
State the domain of the composition.
7)
(
g
H
h)(x) with g(x)
=
x
+
5
and h(x)
=
8
x
+
7
7)
Compute
f(x
+
h)
-
f(x)
h
(h
J
0) for the given function
.
8) f(x) = 4x - 8 8)
9)
f(x)
=
5
x
2
+
6
x
9)
10)
f(x)
=
1
9
x
10)
Solve the equation by multiplying both sides by the LCD.
11) 32x - x 3+ 1 = 1 11)
12)
Solve the equation.
x
+
6
+
2
-
x
=
4
12)
13)
(
4
x
-
2
)
/
3
2
+
6
=
15
13)
14)
3
x
+
4
=
x
-
1
14)
Find the real solutions of the equation by factoring.
15) x3 + 8x2 - x - 8 = 0 15)
Solve the equation by making an appropriate substitution.
16) (x2 - 2x)2 - 11(x2 - 2x) + 24 = 0 16)
Solve the logarithmic equation.
17) log2(x + 7) + log2(x - 7) = 2 17)
Solve the exponential equation. Express the solution set in terms of natural logarithms.
18) 4x + 4 = 52x + 5 18)
Solve the inequality and express the solution in interval notation.
19) 7Ax - 1A L 2 19)
Solve the inequality. Write your answer using interval notation.
20) x 18- 5 > x 15+ 1 20)
Write the equation as f(x) = a(x - h)2 + k. Identify the vertex, range, and axis of symmetry of the function.
21) f(x) = x2 + 5x + 2 21)
23) log
F.
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Building Clinical Integration as a Foundation to Become a Successful ACOPhytel
More and more healthcare organizations are recognizing that clinical integration of providers is a prerequisite to care coordination, population health management, and accountable care organizations. They also know that patient centered medical homes—the building blocks of ACOs—can thrive only in patient-centered medical neighborhoods where specialists collaborate with primary care physicians. For this cooperation to be truly effective, all of these providers must be clinically integrated. This paper explains the components of clinical integration and summarizes the kinds of information technology required for its implementation. Case studies of organizations that are building the necessary infrastructure are also included.
2013 community health workers nej mp1305636Roger Zapata
This document discusses the potential for community health workers (CHWs) to improve health outcomes and reduce costs in the United States. It makes three key points:
1) CHWs have been shown to be effective in improving health in multiple areas like maternal/child health and chronic disease management in other countries. Expanding CHWs in the US could improve health and create new jobs.
2) There are three models for organizing CHWs in the US - as extensions of hospitals, through community non-profits, or through dedicated management organizations. More research is needed but CHW programs have shown potential to reduce costs for Medicaid/Medicare patients.
3) Policy changes like developing the evidence base on CH
Chapter 4 Information Systems to Support Population Health Managem.docxketurahhazelhurst
Chapter 4 Information Systems to Support Population Health Management Learning Objectives To be able to understand the data and information needs of health systems in managing population health effectively under value-based payment models. To be able to discuss key health IT tools and strategies for population health management including EHRs, registries, risk stratification, patient engagement, and outreach, care coordination and management, analytics, health information exchange, and telemedicine and telehealth. To be able to discuss the application and use of data analytics to monitor, predict, and improve performance. The enactment of the Affordable Care Act (ACA) brought about sweeping legislation intended to reduce the numbers of uninsured and make health care accessible to all Americans. It also ushered in an era in which changing reimbursement and care delivery models are driving providers from the current fragmented system focused on volume-based services to an outcomes orientation. As a result, the health care system now taking shape is one in which value-based payment models financially reward patient-centered, coordinated, accountable care. Against this backdrop, providers' increasing use of evidence-based medicine and growing capabilities in managing volumes of clinical evidence through sophisticated health IT systems will mean that treatments can be tailored for the individual and interventions can be made earlier to keep patients well. Furthermore, patient engagement is fast becoming a critical component in the care process, particularly in the area of population health management (PHM). Health care providers' interest in improving population health appears to be increasing because of the sudden ubiquity of the phrase, because many are participating in accountable care organizations (ACOs), and because even hospitals not participating in an ACO increasingly have incentives to reduce their number of potentially unavoidable admissions, readmissions, and emergency department visits (Casalino, Erb, Joshi, & Shortell, 2015). In this chapter we'll not only seek a common understanding of PHM but also explore how the advent of shared accountability financial arrangements between providers and purchasers of care has created significant focus on PHM. We'll also review the core processes associated with accountable care and examine the strategic IT investments and data management capabilities required to support population health management and enable a successful transition from volume-based to value-based care. PHM: Key to Success Although the ACO model is still new and evolving, approximately 750 ACOs are in operation today, covering some 23.5 million lives under Medicare, Medicaid, and private insurers. Although not all ACOs have demonstrated success in delivering better health outcomes at a lower cost, many have achieved promising results (Houston & McGinnis, 2016). As such, significant ACO growth is expected. In fact, it is predicte ...
Regulatory reforms and advances in technology are enabling a shift from reactive, provider-centric healthcare to proactive, population-based healthcare management. This involves collecting and analyzing patient data from multiple sources to better understand patient needs, identify patterns, and implement preventative programs and automated interventions. The goal is to improve health outcomes and reduce costs by keeping populations healthy and minimizing expensive medical procedures. Healthcare organizations must adopt new data-driven care models, tools, and workflows to effectively manage population health.
This document discusses the history of the healthcare system in the US and the changing role of physicians within that system. It notes that physicians originally had close personal relationships with patients but that hospitals and specialization led to more fragmented care. Government programs like Medicare and the rise of managed care further changed the physician role by increasing administrative duties. The document examines the current medical school curriculum, noting a lack of leadership and management training. It discusses some programs that do offer such training but notes they are electives, not mandatory. The document concludes there are gaps in preparing physicians for the changing healthcare system and future skills needed in areas like business, communication, and leadership.
This document discusses population health and the need for healthcare providers to shift from a volume-based to a value-based reimbursement model. It defines population health as "the science and art of preventing disease, prolonging life, and promoting health through the organized efforts and informed choices of society, organizations, public and private communities, and individuals." The document states that leveraging automation, analytics, and historical data can help improve delivery of care to groups with similar needs and support the shift to more population-centric care. It also discusses using predictive analytics to identify high-risk patients, plan interventions, and ensure medication adherence to contain costs and mitigate risks.
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Running Head STRATEGIC ALLIANCE 1STRATEGIC AL.docxtodd521
Running Head: STRATEGIC ALLIANCE 1
STRATEGIC ALLIANCE3
Strategic Alliance in Health Care
Strategic alliance in health care arises about with accountable care in organization as related reforms aims to increase coordination between health care providers. Due to the uneven nature of health care system. Strategic alliance in health care along with successful coordination will pivot in large part on the ability of health care organization to successful partner across organizational boundaries. Furthermore, under Medicare partnership accountable care organization has lower quality enactment. This is arrived at by the use of qualitative interviews released that providers are motivated to partner for resource complementarity, risk lessening and legislative requirements. By way of conjointly bringing together official as well casual responsibility device. Strategic alliance in health care may provide an important window to screen a potential wave of health care consolidation or in contrast new models of independent providers’ successfully coordinating patient care.
There has been development in the number of physicians joining the practices and physician practice joining hospital and health care system. As result coordination of clinical care often requires working transversely in organizational boundaries. This is predominantly true when providing care to intricate or high need patients who often require attention for post- acute care facilities such as skilled nursing facilities, rehabilitation centers and home health agencies strategic alliance in health care aims to encourage coordinating through financial incentive and rewards for meeting quality performance targets and total cost of care benchmarks. With required dynamic trust of association. So as to meet desired cost and quality objective. Strategic alliance in health care is recognized arrangements between two or more independent organization to succeed shared or harmonious goals. This is substantial growth in such relationships in health care sector. Notably, these arrangements between autonomous organizations are non-ownership relation based. The primary motivation for this strategic alliance in health lie in understanding needs for resources and capabilities needs to frontier transaction cost and the need to respond to external requirements from Medicare. The benefit of the strategic alliance in health care contribution risk or gaining resources, personnel benefits including improved staffing and management capabilities and organization benefits including growth, opportunities to learn and gain new proficiencies and mutual support and group collaboration.
Numerous methods have been used hence mixed method analysis which involves survey data, performance data, and semi-structured interviews. Questions examined involved to what range is strategic alliance in health benefit to the health sector organization, second how is strategic alliance performance in different organ.
This monograph provides an assessment of the current hospital-physician landscape and outlines an innovative vehicle for advancing hospital-physician relationships that has the potential to improve care delivery and coordination, clinical quality, and patient cost. Our findings and recommendations address:• Changes in the market place.• The concept of an integrated medical staff model.• The role of operational clinical integration, enabled by an Electronic Medical• Record, toward creating virtual medical staffs.• Benefits to the hospital, physicians, patients and community.• What boards and senior management can do to move toward the model.
Submission Id ab299d7c-b547-4cf3-958a-07922ca71f2765 SIM.docxdeanmtaylor1545
Submission Id: ab299d7c-b547-4cf3-958a-07922ca71f27
65% SIMILARITY SCORE 12 CITATION ITEMS 20 GRAMMAR ISSUES 0 FEEDBACK COMMENT
Internet Source 0%
Inst itut ion 65%
Patience Nehikhare
healthcaredeliverysystemchanges.docx
Summary
1175 Words
Running Head: HEALTHCARE DELIVERY SYSTEM
THE U.S. HEALTHCARE DELIVERY SYSTEM 2
Healthcare Delivery System
Patience Nehikhare
Grand Canyon University
December 22, 2019
The U.S. Healthcare Delivery System
There is a rapid change within the healthcare system in the United States. The
changes that have occurred were made for the purpose of improving quality,
rewarding value and not volume, as well as integrating and coordinating the care
(Seshamani & Sen, 2018). As such, this paper will seek to put into consideration
current healthcare laws within the U.S. and the nurse’s role within this continuously
changing environment; the manner in which quality measures and pay for performance
affect patient outcomes. Furthermore, the emerging trends in the healthcare system,
professional nursing leadership, and management roles will be discussed.
The Emerging Health Care Laws and their Effects on Nursing Practice
One of the most crucial healthcare legislat ions that has been enacted in the United
States since the inception of Medicare and Medicaid in 1965 is the Affordable Care
Act (Obama, 2016). The ACA was enacted in 2010. Issues relat ing to affordability,
ease of access, and the care quality within the United States healthcare system were
some of the driving factors that formed the list of many t ime spanning challenges
that compiled the init iat ion of this legislat ion. Between 2010 to 2015 there was a
decrease in the number of uninsured cit izens in the U.S. by forty three percent as an
effect of the Affordable Care Act.
The payment systems in healthcare are undergoing some changes and the access to
care has also improved (Obama, 2016). The ACA promotes preventive healthcare
models that put emphasis on quality care, primary care, and the funding of community
health init iat ives (Lathrop and Hodnicki, 2014). Millions of previously uninsured cit izens
are also provided insurance coverage and also some healthcare areas that need
reforms so as to meet the needs of patients’ improved healthcare outcomes are
highly focused by the act. The act has an effect on nursing practice in several ways.
The first effect is that the act creates a high demand for healthcare professionals
that are sufficiently trained to provide healthcare services that are up to the acts’
standards. The second effect is that Advanced Practice Registered Nurses (APRNs)
who hold the Doctor of Nursing Practice (DNP) are required to be prepared so that
they can meet the increased needs through the provision of leadership skills in
community health centers. These professionals are also held accountable for direct ing
and advocating for future init iates as well as ser.
2015 05 01 Pop Health - Laying the Foundation (00000002)Dana Alexander
This document discusses population health management and outlines four key aspects: data control and governance, population management and risk stratification, care management, and patient engagement. It summarizes the challenges of collecting and analyzing large amounts of patient data from electronic health records, developing risk profiles of patient subgroups, implementing targeted care models, and encouraging patient accountability through new technologies. The overall goal is for healthcare organizations to successfully address these areas and achieve true population health management.
Three key trends are forcing a change in today's health models: 1) Rising chronic diseases among both young and old are driving up health costs and creating future liabilities. 2) Technology is enabling mass customization of healthcare similar to other industries. 3) Broader factors like behavior, socioeconomics, and genetics are recognized as influencing health beyond medical care. To address these issues, health will be customized around six vectors: incentives, regulations, funding, patient communication, information technology, and workforce models to personalize diagnosis, care and cure for individuals.
35NURSING ECONOMIC$/January-February 2011/Vol. 29/No. 1
T
HE WORLD OF ARISTOTLE AND
Ptolemy believed that Earth
was positioned at the cen-
ter of the universe. Thanks
to Galileo and Copernicus’s studies
in the 16th century, we know this
is not true and that the sun is the
center of our universe. Pers -
pectives of health care have
undergone similar, radical changes
in perception. For centuries we
had a hospital-centric view; an
illness-based model, where the majority of care was
provided in hospitals, when we were ill. In the last
few decades, that model has migrated to a more con-
tinuum of care view; a wellness/health maintenance
model, where emphasis of care is outside the hospital
in other venues such as outpatient, ambulatory/clin-
ic, and home care (see Figure 1).
But as we all know, this is still not where we need
to be to support the highest quality care at the right
cost. Despite a focus on moving care out of the hospi-
tals, one only needs to think about the process of
medication reconciliation between care venues to
realize the lack of seamless integration of care deliv-
ery and the challenges of supporting interoperability
across the continuum. Hence, here I am proposing the
patient centric view, where the patient actively partic-
ipates in his or her care and we look at delivering care
from a patient’s point of view. This allows us to break
down some of the barriers we have struggled with on
our journeys to promote higher quality care through
the use of health information technology (HIT). Now
we need to consider how the health care system
should revolve around the patient, rather than the
patient rotating around the hospital. Considering a
patient-centric point of view when implementing and
optimizing the use of HIT provides new perspectives
on the meaning of “integrated” health care.
Patient-Centric Care
It might seem odd that a health care organization
needs to be reminded to involve the patient in his or
her care. After all, this approach would certainly be
supported from a patient’s perspective. And, of
course, the health care industry has compelling rea-
sons to incorporate a strong customer and service
focus in order to improve patient satisfaction and
impact patient loyalty. But as health care systems
Patient as Center of the Health Care Universe:
A Closer Look at Patient-Centered Care
JUDY MURPHY, RN, FACMI, FHIMSS, is Vice President-
Information Services, Aurora Health Care, Milwaukee, WI; a
HIMSS Board Member; Co-Chair of the Alliance for Nursing
Informatics; a member of the federal HIT Standards Committee;
and is a Nursing Economic$ Editorial Board Member. Comments
and suggestions can be sent to [email protected]
EXECUTIVE SUMMARY
We need to consider how the health care system
should revolve around the patient, rather than the
patient rotating around the hospital.
Considering a patient-centric point of view when
implementing and optimizing the use of health infor-
mation technology (HIT) provides new perspect.
35NURSING ECONOMIC$/January-February 2011/Vol. 29/No. 1
T
HE WORLD OF ARISTOTLE AND
Ptolemy believed that Earth
was positioned at the cen-
ter of the universe. Thanks
to Galileo and Copernicus’s studies
in the 16th century, we know this
is not true and that the sun is the
center of our universe. Pers -
pectives of health care have
undergone similar, radical changes
in perception. For centuries we
had a hospital-centric view; an
illness-based model, where the majority of care was
provided in hospitals, when we were ill. In the last
few decades, that model has migrated to a more con-
tinuum of care view; a wellness/health maintenance
model, where emphasis of care is outside the hospital
in other venues such as outpatient, ambulatory/clin-
ic, and home care (see Figure 1).
But as we all know, this is still not where we need
to be to support the highest quality care at the right
cost. Despite a focus on moving care out of the hospi-
tals, one only needs to think about the process of
medication reconciliation between care venues to
realize the lack of seamless integration of care deliv-
ery and the challenges of supporting interoperability
across the continuum. Hence, here I am proposing the
patient centric view, where the patient actively partic-
ipates in his or her care and we look at delivering care
from a patient’s point of view. This allows us to break
down some of the barriers we have struggled with on
our journeys to promote higher quality care through
the use of health information technology (HIT). Now
we need to consider how the health care system
should revolve around the patient, rather than the
patient rotating around the hospital. Considering a
patient-centric point of view when implementing and
optimizing the use of HIT provides new perspectives
on the meaning of “integrated” health care.
Patient-Centric Care
It might seem odd that a health care organization
needs to be reminded to involve the patient in his or
her care. After all, this approach would certainly be
supported from a patient’s perspective. And, of
course, the health care industry has compelling rea-
sons to incorporate a strong customer and service
focus in order to improve patient satisfaction and
impact patient loyalty. But as health care systems
Patient as Center of the Health Care Universe:
A Closer Look at Patient-Centered Care
JUDY MURPHY, RN, FACMI, FHIMSS, is Vice President-
Information Services, Aurora Health Care, Milwaukee, WI; a
HIMSS Board Member; Co-Chair of the Alliance for Nursing
Informatics; a member of the federal HIT Standards Committee;
and is a Nursing Economic$ Editorial Board Member. Comments
and suggestions can be sent to [email protected]
EXECUTIVE SUMMARY
We need to consider how the health care system
should revolve around the patient, rather than the
patient rotating around the hospital.
Considering a patient-centric point of view when
implementing and optimizing the use of health infor-
mation technology (HIT) provides new perspect ...
Why Electronic Health Records are Ill Suited for Population Health 012616infomc
Electronic health records are ill-suited for population health management for several reasons. EHRs were designed to manage patient data within individual healthcare systems and have limited ability to track health information from outside sources or support integrated care across multiple providers. Population health management requires more sophisticated technology that can perform functions like enrollment tracking, provider networking, utilization review, claims processing, and quality reporting that are beyond the scope of most EHRs. While EHRs are important for individual medical practices, organizations taking on financial risk for patient populations need systems designed for the specific demands of population health management.
Why Electronic Health Records are Ill Suited for Population Healthinfomc
Electronic health records are ill-suited for population health management for several reasons. EHRs were designed to manage patient data within individual healthcare systems and have limited ability to track health information from outside sources or support integrated care across multiple providers. Population health management requires more sophisticated technology that can perform tasks like enrollment tracking, provider networking, utilization review, and claims adjudication across different clinical systems. While EHRs are important for individual medical practices, organizations taking on financial risk for patient populations need systems with greater functionality for care coordination, quality monitoring, and financial reporting at a population level.
1) The document discusses how health information technology (HIT), such as electronic health records (EHRs) and health information exchanges (HIEs), has the potential to influence health reform efforts in the United States by reducing costs, increasing access to care, and improving quality of care.
2) The Affordable Care Act includes provisions and financial incentives to encourage widespread adoption of EHRs and use of HIT. Meaningful use criteria aim to ensure EHRs improve safety, quality, and coordination of care.
3) HIT such as EHRs and HIEs could transform healthcare by giving providers access to complete patient information, reducing medical errors, duplicative tests, and costs
In the coming years the United States will find themselves going through a number of changes within the Social Security Administration which will affect the Health Care Industry as we know it “Hospital size has long been an area of discussion and debate in the U.S. healthcare industry. Questions have consistently focused on cost management or efficiency in large versus small hospitals. A persistent question among researchers is whether efficiencies are associated with larger facilities through economies of scale, or if there are alternate scenarios that play a significant part in hospital cost and efficiency” (2009, JHM). Since the Affordable Health Care Act was established it made obtaining health care much more affordable and accessible, but at the same time there has to be some cut back.
Calculus Quiz 2 (Derivatives)Covers Units 9-13. This is a 10 quest.docxclairbycraft
Calculus Quiz 2 (Derivatives)
Covers Units 9-13. This is a 10 question, 10 point quiz consisting of multiple choice and calculated numeric answers.
You should complete the homework over these units before beginning the quiz.
You should complete the by
Thursday, November 12.
YOU MAY ATTEMPT THE QUIZ up to 3 timesIF YOU WISH to improve your score.
.
Calculus IDirections (10 pts. each) Answer each of the followin.docxclairbycraft
Calculus I
Directions: (10 pts. each) Answer each of the following questions below. In order to receive ANY credit for a question, you must SHOW YOUR WORK using proper notation and clear and concise logic. You're graded on both the accuracy of your answers AND your explanations that sufficiently support your answers. Unless otherwise stated, you're to give the EXAXCT VALUES of answers instead of decimal approximations. In order to receive ANY credit for any applied/word problem (i.e. Problems #29 - ), you MUST declare a variable (unless the variable(s) have already been declared in the problem) and set up and solve an appropriate mathematical expression that can be used to answer the question. Proper units must also be included in answers to applied problems. NO CREDIT WILL BE GIVEN FOR EITHER GUESSING OR CHECKING POSSIBLE ANSWERS WITHOUT SOLVING THE PROBLEM. YOU CANNOT USE CALCULUS TO SOLVE THESE PROBLEMS.
Finally, write ONLY FINAL ANSWERS ON THESE PAGES; you must show your work both according to homework guidelines and on YOUR OWN PAPER.
SHORT ANSWER. Write the word or phrase that best completes each statement or answers the question.
Multiply or divide as indicated. Write your answer in factored form.
1) x22 - 9x + 14 · xx22 -- 1618x x ++ 4877 1)
2)
x
-
12
x
+
32
Simplify the complex rational expression.
4
x
2
-
4
x
-
32
-
1
x
-
8
2)
1 + 1 x + 4
Find the difference quotient for the function and simplify it.
3) g(x) = 6x2 + 14x - 1 3)
Find the domain and range of the function. Write your answers using interval notation.
4)
g(z)
=
16
-
z
2
4)
Find a formula for the function graphed.
5) 5)
Determine if the function is even, odd, or neither. You must use algebra to justify your answer; otherwise, no full credit will be given. NO CREDIT is given for an answer without a mathematical explanation.
6) f(x) = x -+7 9 6)
State the domain of the composition.
7)
(
g
H
h)(x) with g(x)
=
x
+
5
and h(x)
=
8
x
+
7
7)
Compute
f(x
+
h)
-
f(x)
h
(h
J
0) for the given function
.
8) f(x) = 4x - 8 8)
9)
f(x)
=
5
x
2
+
6
x
9)
10)
f(x)
=
1
9
x
10)
Solve the equation by multiplying both sides by the LCD.
11) 32x - x 3+ 1 = 1 11)
12)
Solve the equation.
x
+
6
+
2
-
x
=
4
12)
13)
(
4
x
-
2
)
/
3
2
+
6
=
15
13)
14)
3
x
+
4
=
x
-
1
14)
Find the real solutions of the equation by factoring.
15) x3 + 8x2 - x - 8 = 0 15)
Solve the equation by making an appropriate substitution.
16) (x2 - 2x)2 - 11(x2 - 2x) + 24 = 0 16)
Solve the logarithmic equation.
17) log2(x + 7) + log2(x - 7) = 2 17)
Solve the exponential equation. Express the solution set in terms of natural logarithms.
18) 4x + 4 = 52x + 5 18)
Solve the inequality and express the solution in interval notation.
19) 7Ax - 1A L 2 19)
Solve the inequality. Write your answer using interval notation.
20) x 18- 5 > x 15+ 1 20)
Write the equation as f(x) = a(x - h)2 + k. Identify the vertex, range, and axis of symmetry of the function.
21) f(x) = x2 + 5x + 2 21)
23) log
F.
Cadence Publishes Comprehensive Book onMixed-Signal Method.docxclairbycraft
Cadence Publishes Comprehensive Book on
Mixed-Signal Methodology; The "Mixed-Signal
Methodology Guide" Provides Expert Direction
on How to Address Design, Verification and
Implementation Challenges of Modern Mixed-
Signal Designs
Publication info: M2 Presswire ; Coventry [Coventry]14 Aug 2012.
ProQuest document link
ABSTRACT
SAN JOSE, Calif. -- Cadence Design Systems, Inc. (NASDAQ: CDNS), a leader in global electronic design innovation,
today announced availability of the critically acclaimed and much anticipated comprehensive design methodology
book for chip designers and CAD engineers that focuses on current and future advanced mixed-signal design
challenges and solutions. The "Mixed-Signal Methodology Guide" provides an overview of the design, verification
and implementation methodologies required for advanced mixed-signal designs. The book brings together top
mixed-signal design experts from across the industry -- including authors from Boeing, Cadence(R), ClioSoft and
Qualcomm -- to address the complex problems facing the mixed-signal design community.
"Modern mixed-signal design require new methodologies to improve productivity, reduce design time and achieve
silicon success," said Hao Fang, engineering director at LSI. "The Mixed-Signal Methodology Guide is a thorough
reference book on advanced verification and implementation methodologies. It will be particularly useful to mixed-
signal verification engineers for its coverage of analog behavioral modeling, and assertion and metric driven
verification methodology as applied to analog and mixed-signal design."
FULL TEXT
M2 PRESSWIRE-August 14, 2012-Cadence Publishes Comprehensive Book on Mixed-Signal Methodology; The
"Mixed-Signal Methodology Guide" Provides Expert Direction on How to Address Design, Verification and
Implementation Challenges of Modern Mixed-Signal Designs
(C)2012 M2 COMMUNICATIONS http://www.m2.com
August 13, 2012
SAN JOSE, Calif. -- Cadence Design Systems, Inc. (NASDAQ: CDNS), a leader in global electronic design innovation,
today announced availability of the critically acclaimed and much anticipated comprehensive design methodology
book for chip designers and CAD engineers that focuses on current and future advanced mixed-signal design
challenges and solutions. The "Mixed-Signal Methodology Guide" provides an overview of the design, verification
and implementation methodologies required for advanced mixed-signal designs. The book brings together top
mixed-signal design experts from across the industry -- including authors from Boeing, Cadence(R), ClioSoft and
Qualcomm -- to address the complex problems facing the mixed-signal design community.
The growing complexity of today's mixed-signal designs requires major changes in design methodology to both
increase productivity and deliver high quality products on time. This wide-ranging compendium examines in depth
such topics as AMS behavioral modeling, mixed-signal me.
Calculate the energy in the form of heat (in kJ) required to change .docxclairbycraft
Calculate the energy in the form of heat (in kJ) required to change 75.0 g of liquid water at 27.0 °C to ice at –20.0 °C. Assume that no energy in the form of heat is transferred to the environment. (Heat of fusion = 333 J/g; heat of vaporization = 2256 J/g; specific heat capacities: ice = 2.06 J/g×K, liquid water = 4.184 J/g×K)
.
CAHIIM Competencies Assessed Subdomain VI.D. Human Resources Ma.docxclairbycraft
CAHIIM Competencies Assessed:
Subdomain VI.D. Human Resources Management
Create and implement staff orientation and training programs (Blooms 6)
Instructions:
You are an HIM Supervisor at a hospital and you have been asked to create a new staff training on data compliance rules. Assume that the new staff has a wide variety of background, with some new staff knowing nothing about data compliance at all. The training should be basic and introductory.
Create an outline for your training.
Requirements:
Include an introduction and summary within your outline
Length of outline should be 3-4 pages
It should be an annotated outline. This means that it should include citations within the outline and a reference page.
Your training should include the topics of HIPAA and The Joint Commission and other data compliance topics that affect hospital staff
.
C8-1 CASE STUDY 8 CARLSON COMPANIES STORAGE SOLUT.docxclairbycraft
C8-1
CASE STUDY 8
CARLSON COMPANIES STORAGE SOLUTIONS
Carlson Companies (www.carlson.com) is one of the largest privately held
companies in the United States, with more than 171,000 employees in more
than 150 countries. Carlson enterprises include a presence in marketing,
business and leisure travel, and hospitality industries. Its Carlson Hotels
Worldwide division owns and operates approximately 1,075 hotels located in
more than 70 countries. Radisson, Park Plaza, and Country Inn & Suites by
Carlson are some of its hotel brands. The hotel loyalty program is named
Club Carlson. The Carlson Restaurants Worldwide includes T.G.I. Friday’s
and the Pick Up Stix chains. The company registered approximately $38
billion in sales in 2011.
Carlson’s Information Technology (IT) division, Carlson Shared Services,
acts as a service provider to its internal clients and consequently must
support a spectrum of user applications and services. The IT division uses a
centralized data processing model to meet business operational
requirements. The central computing environment has traditionally included
an IBM mainframe and over 50 networked Hewlett-Packard and Sun servers
[KRAN04, CLAR02, HIGG02]. The mainframe supports a wide range of
applications, including Oracle financial database, e-mail, Microsoft Exchange,
Web, PeopleSoft, and a data warehouse application.
C8-2
In 2002, the IT division established six goals for assuring that IT
services continued to meet the needs of a growing company with heavy
reliance on data and applications:
1. Implement an enterprise data warehouse.
2. Build a global network.
3. Move to enterprise-wide architecture.
4. Establish six-sigma quality for Carlson clients.
5. Facilitate outsourcing and exchange.
6. Leverage existing technology and resources.
The key to meeting these goals was to implement a storage area
network (SAN) with a consolidated, centralized database to support
mainframe and server applications. Carlson needed a SAN and data center
approach that provided a reliable, highly scalable facility to accommodate
the increasing demands of its users.
Storage Requirements
Prior to implementing the SAN and data center approach, the central DP
shop included separate disc storage for each server, plus that of the
mainframe. This dispersed data storage scheme had the advantage of
responsiveness; that is, the access time from a server to its data was
minimal. However, the data management cost was high. There had to be
backup procedures for the storage on each server, as well as management
controls to reconcile data distributed throughout the system. The mainframe
included an efficient disaster recovery plan to preserve data in the event of
major system crashes or other incidents and to get data back online with
little or no disruption to the users. No comparable plan existed for the many
servers.
C8-3
As Ca.
Caffeine intake in children in the United States and 10-ytre.docxclairbycraft
Caffeine intake in children in the United States and 10-y
trends: 2001–20101–4
Namanjeet Ahluwalia, Kirsten Herrick, Alanna Moshfegh, and Michael Rybak
ABSTRACT
Background: Because of the increasing concern of the potential
adverse effects of caffeine intake in children, recent estimates of
caffeine consumption in a representative sample of children are
needed.
Objectives: We provide estimates of caffeine intake in children in
absolute amounts (mg) and in relation to body weight (mg/kg) to
examine the association of caffeine consumption with sociodemo-
graphic factors and describe trends in caffeine intake in children in
the United States.
Design: We analyzed caffeine intake in 3280 children aged 2–19 y
who participated in a 24-h dietary recall as part of the NHANES,
which is a nationally representative survey of the US population
with a cross-sectional design, in 2009–2010. Trends over time be-
tween 2001 and 2010 were examined in 2–19-y-old children (n =
18,530). Analyses were conducted for all children and repeated for
caffeine consumers.
Results: In 2009–2010, 71% of US children consumed caffeine on
a given day. Median caffeine intakes for 2–5-, 6–11-, and 12–19-y
olds were 1.3, 4.5, and 13.6 mg, respectively, and 4.7, 9.1, and 40.6
mg, respectively, in caffeine consumers. Non-Hispanic black chil-
dren had lower caffeine intake than that of non-Hispanic white
counterparts. Caffeine intake correlated positively with age; this
association was independent of body weight. On a given day,
10% of 12–19-y-olds exceeded the suggested maximum caffeine
intake of 2.5 mg/kg by Health Canada. A significant linear trend
of decline in caffeine intake (in mg or mg/kg) was noted overall for
children aged 2–19 y during 2001–2010. Specifically, caffeine in-
take declined by 3.0 and 4.6 mg in 2–5- and 6–11-y-old caffeine
consumers, respectively; no change was noted in 12–19-y-olds.
Conclusion: A majority of US children including preschoolers con-
sumed caffeine. Caffeine intake was highest in 12–19-y-olds and
remained stable over the 10-y study period in this age group. Am J
Clin Nutr 2014;100:1124–32.
INTRODUCTION
Caffeine is a commonly consumed stimulant present naturally
in or added to foods and beverages. Caffeine consumption in
children has received considerable interest because of the con-
cern of adverse health effects. Caffeine intake of 100–400 mg has
been associated with nervousness, jitteriness, and fidgetiness
(1, 2). Because of the continued brain development involving
myelination and pruning processes, children may be particularly
sensitive to caffeine (3, 4). There has been some evidence that
has linked caffeine intake in children to sleep dysfunction, el-
evated blood pressure, impairments in mineral absorption and
bone health, and increased alcohol use or dependence (1, 5–7).
In addition, the routine use of caffeinated sugar-sweetened
beverages may contribute to weight gain and dental cavities (8).
Caffeine toxicity in children has also.
Cabbage patch hip dance move, The running man hip hop dance move, th.docxclairbycraft
Cabbage patch hip dance move, The running man hip hop dance move, the humpty dance hip hop move and the butterfly hip hop dance move. Describe each using the attachment in the assignment which provides certain words and descriptions. each style of dance ( cabbage patch, running man, the humpty dance, butterfly) has to have description or analysis using B.A.S.T.E See the attachment
use the attachment to describe each hip hop dance move
.
CA4Leading TeamsAre we a teamHi, my name is Jenny .docxclairbycraft
CA4:
Leading Teams
Are we a team?
Hi, my name is Jenny McConnell. I am the newly appointed CIO of a medium-sized technology company. Our company recruits top graduates from schools of business and engineering. Talent, intellect, creativity – it’s all there. If you lined up this crowd for a group photo, credentials in hand, the “wow” factor would be there.
Our company is spread over a dozen states, mostly in the Northwest. The talent pool is amazing across the board, both in IT and in the rest of the company. But when the CEO hired me, he said that we are performing nowhere near our potential. On the surface, the company is doing fine. But we should be a
Fortune 500
organization. With this much talent, we should be growing at a much faster rate. The CEO also said that I was inheriting “a super team with disappointing performance.” His task for me was to pull the IT stars into a cohesive team that would meet company needs for new IT systems and services much faster and more effectively.
Without making our superstars feel that they were being critiqued and second-guessed, or indicating “there’s a real problem here,” I wanted to gather as much information and feedback as possible from the 14 team members (regional CIOs and department heads) who report to me. I held one-on-one meetings in order to give a voice to each person, allowing each individual to provide an honest assessment of the team as well as areas for improvement and a vision for the future of team efforts.
I was surprised by the consistency of remarks and opinions. For example, a picture emerged of the previous CIO, who was obviously awed by the talent level of the team members. Comments such as “Bob pretty much let us do what we wanted” and “Bob would start the meeting and then just fade into the background, as if he found us intimidating” were typical. The more disturbing comment, “Bob always agree with
me
,” was expressed by most of the team members at some point in our conversation. It was as if the regional heads believed that the CIO wanted them to succeed by doing as they thought best for themselves.
I queried members about the level of cooperation during meetings and uncovered areas of concern, including the complaint that others at the table were constantly checking their iPads and smartphones during meetings. One department head told me, “You could turn off the sound while watching one of our meetings, and just by the body language and level of attention, tell who is aligned with whom and who wishes the speaker would just shup up. It would be comical if it weren’t so distressing.”
Such remarks were indicative of a lack of trust and respect and a breakdown of genuine communication. One team member told me, “I recently encountered a problem that a department head from another region had successfully solved, but the information was never shared, so here I am reinventing the wheel and wasting valuable time.” It was apparent that these so-called high performers were .
C7-1 CASE STUDY 7 DATA CENTER CONSOLIDATION AT GUARDI.docxclairbycraft
Guardian Life, a large life insurance company, has undertaken two major data center consolidation initiatives. The first in the early 2000s consolidated 4 data centers into 2 locations and reduced servers by 40% while cutting staff by 60%. A second initiative in 2010 consolidated the remaining 6 data centers into a primary owned center and leased modular pod, while moving applications to cloud services. This reduced costs while improving business continuity and efficiency.
C9-1 CASE STUDY 9 ST. LUKES HEALTH CARE SYSTEM Hospitals have been .docxclairbycraft
C9-1 CASE STUDY 9 ST. LUKE'S HEALTH CARE SYSTEM Hospitals have been some of the earliest adopters of wireless local area networks (WLANs). The clinician user population is typically mobile and spread out across a number of buildings, with a need to enter and access data in real time. St. Luke's Episcopal Health System in Houston, Texas (www.stlukestexas.com) is a good example of a hospital that has made effective use wireless technologies to streamline clinical work processes. Their wireless network is distributed throughout several hospital buildings and is used in many different applications. The majority of the St. Luke’s staff uses wireless devices to access data in real-time, 24 hours a day. Examples include the following: • Diagnosing patients and charting their progress: Doctors and nurses use wireless laptops and tablet PCs to track and chart patient care data. • Prescriptions: Medications are dispensed from a cart that is wheeled from room to room. Clinician uses a wireless scanner to scan the patient's ID bracelet. If a prescription order has been changed or cancelled, the clinician will know immediately because the mobile device displays current patient data. C9-2 • Critical care units: These areas use the WLAN because running hard wires would mean moving ceiling panels. The dust and microbes that such work stirs up would pose a threat to patients. • Case management: The case managers in the Utilization Management Department use the WLAN to document patient reviews, insurance calls/authorization information, and denial information. The wireless session enables real time access to information that ensures the correct level of care for a patient and/or timely discharge. • Blood management: Blood management is a complex process that involves monitoring both patients and blood products during all stages of a treatment process. To ensure that blood products and patients are matched correctly, St. Luke’s uses a wireless bar code scanning process that involves scanning both patient and blood product bar codes during the infusion process. This enables clinicians to confirm patient and blood product identification before proceeding with treatment. • Nutrition and diet: Dietary service representatives collect patient menus at each nursing unit and enter them as they go. This allows more menus to be submitted before the cutoff time, giving more patients more choice. The dietitian can also see current patient information, such as supplement or tube feeding data, and view what the patient actually received for a certain meal. • Mobile x-ray and neurologic units: St. Luke’s has implemented the wireless network infrastructure necessary to enable doctors and clinicians to use mobile x-ray and neurologic scanning units. This makes it possible to take x-rays or to perform neurological studies in patient rooms. This minimizes the need to schedule patients for neurology or radiology lab visits. The mobile units also enable equipment to be brought to t.
C9-1 CASE STUDY 9 ST. LUKES HEALTH CARE SYSTEM .docxclairbycraft
C9-1
CASE STUDY 9
ST. LUKE'S HEALTH CARE SYSTEM
Hospitals have been some of the earliest adopters of wireless local area
networks (WLANs). The clinician user population is typically mobile and
spread out across a number of buildings, with a need to enter and access
data in real time. St. Luke's Episcopal Health System in Houston, Texas
(www.stlukestexas.com) is a good example of a hospital that has made
effective use wireless technologies to streamline clinical work processes.
Their wireless network is distributed throughout several hospital buildings
and is used in many different applications. The majority of the St. Luke’s
staff uses wireless devices to access data in real-time, 24 hours a day.
Examples include the following:
• Diagnosing patients and charting their progress: Doctors and
nurses use wireless laptops and tablet PCs to track and chart patient
care data.
• Prescriptions: Medications are dispensed from a cart that is wheeled
from room to room. Clinician uses a wireless scanner to scan the
patient's ID bracelet. If a prescription order has been changed or
cancelled, the clinician will know immediately because the mobile device
displays current patient data.
http://www.stlukestexas.com/
C9-2
• Critical care units: These areas use the WLAN because running hard
wires would mean moving ceiling panels. The dust and microbes that
such work stirs up would pose a threat to patients.
• Case management: The case managers in the Utilization Management
Department use the WLAN to document patient reviews, insurance
calls/authorization information, and denial information. The wireless
session enables real time access to information that ensures the correct
level of care for a patient and/or timely discharge.
• Blood management: Blood management is a complex process that
involves monitoring both patients and blood products during all stages of
a treatment process. To ensure that blood products and patients are
matched correctly, St. Luke’s uses a wireless bar code scanning process
that involves scanning both patient and blood product bar codes during
the infusion process. This enables clinicians to confirm patient and blood
product identification before proceeding with treatment.
• Nutrition and diet: Dietary service representatives collect patient
menus at each nursing unit and enter them as they go. This allows more
menus to be submitted before the cutoff time, giving more patients
more choice. The dietitian can also see current patient information, such
as supplement or tube feeding data, and view what the patient actually
received for a certain meal.
• Mobile x-ray and neurologic units: St. Luke’s has implemented the
wireless network infrastructure necessary to enable doctors and
clinicians to use mobile x-ray and neurologic scanning units. This makes
it possible to take x-rays or to perform neurological studies in patient
rooms. This min.
C361 TASK 2 2
C361 TASK 2 2
C361 Task 2
WGU
Evidence-Based Practice and Applied Nursing Research
C361
Eve Butler
July 28, 2019
Running head: C361 TASK 2 2
C361 Task 2
A.1 Healthcare problem
Worldwide estimates have shown that greater than 1.4 million patients have acquired nosocomial infections. Adherence to hand hygiene policies are shown to be the most effective way to help prevent these healthcare-associated infections; sadly research shows that healthcare workers have suboptimal compliance with their facilities hand hygiene policies due to lack of education and compliance monitoring. Patients in our healthcare settings are under the assumption that we are doing our best to promote their healing when in fact 7% of them will be subjected to a nosocomial infection with that rate climbing to 10% in developing countries (Finco et al., 2018).
A.2 Significance of the problem
The cost of care that is associated with nosocomial infections is estimated to be over ten billion dollars putting a burden on both patients and health organizations alike. It is estimated that 38% of all infections are caused by cross-contamination due to noncompliance with hand hygiene policies. These infections lead to approximately 99,000 deaths a year in the United States alone (Sickbert-Bennett et al., 2016).
A.3 Current healthcare practices related to the problem
Most healthcare facilities have an educational program that simply teaches how to achieve proper hand hygiene and use the WHO five moments of hand hygiene as their standard. However, this does not educate the healthcare workers on why it is important, nor does it address the far-reaching consequences for noncompliance. Along with the lack of foundational education, most facilities do not monitor for compliance.
A.4 How the problem affects the organization and patients’ cultural background
Inadequate hand hygiene leading to nosocomial infections can affect the organization's cultural background by leading to dissatisfaction in the workplace as staff becomes frustrated by their feelings of inadequacy and helplessness in dealing with patients getting sicker instead of better. The staff may also be feeling stress in the burden of caring for sicker patients. The patient's cultural background may be affected as they may be feeling despair or depression at their inability to get better, and some may feel it is punishment according to their cultural or religious beliefs.
B. Two research evidence sources and two non-research evidence sources considered
In searching for my research evidence sources, I start with the Western Governors University Library online. Once in the library, a boolean phrase was used, which allowed me to search for research articles that contain more than one topic in the same paper. Phrases I used in this search were “nosocomial infections,” “hand hygiene compliance,” and “ hand hygiene education.” With these phrases, thousands of articles were available to peruse.
One of the res.
C6-1 CASE STUDY 6 CHEVRON’S INFRASTRUCTURE EVOLUT.docxclairbycraft
C6-1
CASE STUDY 6
CHEVRON’S INFRASTRUCTURE
EVOLUTION
Chevron Corporation (www.chevron.com) is one of the world’s leading
energy companies. Chevron’s headquarters are in San Ramon, California.
The company has more than 62,000 employees and produces more than
700,000 barrels of oil per day. It has 19,500 retail sites in 84 countries. In
2012, Chevron was number three on the Fortune 500 list and had more than
$244 billion in revenue in 2011 [STAT12].
IT infrastructure is very important to Chevron and to better support all
facets of its global operations, the company is always focused on improving
its infrastructure [GALL12]. Chevron faces new challenges from increased
global demand for its traditional hydrocarbon products and the need to
develop IT support for new value chains for liquid natural gas (LNG) and the
extraction of gas and oil from shale. Huge investments are being made
around the world, particularly in Australia and Angola on massive projects of
unprecedented scale. Modeling and analytics are more important than ever
to help Chevron exploit deep water drilling and hydrocarbon extraction in
areas with challenging geographies. For example, advanced seismic imaging
tools are used by Chevron to reveal possible oil or natural gas reservoirs
beneath the earth’s surface. Chevron’s proprietary seismic imaging
http://www.chevron.com/
C6-2
technology contributed to it achieving a 69% discovery rate in
2011[CHEV12].
Supervisory Control and Data Acquisition (SCADA)
Systems
Chevron refineries are continually collecting data from sensors spread
throughout the facilities to maintain safe operations and to alert operators to
potential safety issues before they ever become safety issues. Data from the
sensors is also used to optimize the way the refineries work and to identify
opportunities of greater efficiency. IT controls 60,000 valves at Chevron’s
Pascagoula, Mississippi refinery; the efficiency and safety of its end-to-end
operations are dependent on advanced sensors, supervisory control and data
acquisition (SCADA) systems, and other digital industrial control systems
[GALL12].
SCADA systems are typically centralized systems that monitor and
control entire sites and/or complexes of systems that are spread out over
large areas such as an entire manufacturing, fabrication, power generation,
or refining facility. The key components of SCADA systems include:
Programmable logic units (PLCs) that and remote terminal units (RTUs)
connected to sensors that convert sensor signals to digital data and
send it to the supervisory system
A supervisory computer system that acquires data about the process
and sends control commands to the process
A human-machine interface (HMI) that presents process to the human
operators that monitor and control the process.
Process meters and process analysis instruments
Communication infrastructure connecting.
C125C126 FORMAL LAB REPORTFORMAL LAB REPORT, GeneralA f.docxclairbycraft
C125/C126 FORMAL LAB REPORT
FORMAL LAB REPORT, General
A formal lab report is required in conjunction with some of the experiments in each chemistry course. It is your chance to demonstrate to your professor or TA how well you understand the experiment and the chemical principles involved. A formal report is different than a term paper. It should be written in a scientific style, which is not the same style used for English or philosophy papers.
The keys to effective technical writing are organization, brevity, clarity, and an appreciation of the needs of the reader. You must write clearly and be thorough, but concise. Do not ramble. The best way to avoid rambling is to first prepare an outline of the report and stick to it. Always use complete sentences. Bulleted lists are okay in a lab notebook but are unacceptable in a formal report. Formal reports must be typed. Use 1.5 line spacing, 1-inch margins, 12 pt font and 8.5x11 inch paper. Only use third person, past tense. Also, proofread well.
The general structure of a formal lab report follows that of a scientific paper. It is:
Title and Author (s)
Introduction
Experimental Information
Data and Calculation
Results and Discussion
Conclusion
References
Results and discussion sections are combined into one single section. Different instructors may have specific formats that they want you to follow. You should always defer to the instructions given to you by your course. Presented here are general guidelines for writing formal lab reports and scientific papers.
Before writing your first report, visit the library and examine several journal articles. Pay close attention to the style of the prose and the contents of each particular section. Several common journals to investigate are:
The Journal of the American Chemical Society
The Journal of Physical Chemistry
Analytical Chemistry
Biochemistry
Initialed and dated laboratory notebook pages of the experiment must be submitted. While report sheets may be a joint effort, formal reports must be individually written. A schedule of reports and dates on which they are due is given in the course laboratory schedule. We highly recommend that reports be completed prior to the day of submission to allow time to proofread, and thus avoiding loss of points due to last minute problems. Lost data or the inability to print reports is not acceptable excuses for incomplete or missing reports. You will be informed when notebook pages will be collected before the report is due.
FORMAL LAB REPORT - Title and Author(s)
State the title of the experiment, your name, the date and your laboratory section number, if applicable. Also state the name of your lab partner(s). This information should be at the top of the first page.
FORMAL LAB REPORT – Introduction
The Introduction states the purpose of the study and introduces the reader with new ideas and topics. It also provides any background necessary to acquaint the read.
C10-1 CASE STUDY 10 CHOICE HOTELS INTERNATIONAL .docxclairbycraft
C10-1
CASE STUDY 10
CHOICE HOTELS INTERNATIONAL
Within the hospitality industry, there has traditionally been a division
between networks that serve guest functions and those that serve
operations and administration, both with respect to data transmission and
voice transmission. In recent years, most hotel and motel chains have
moved in the direction of consolidating multiple functions on networks that
used to be dedicated to one use. Tighter integration of voice and data and of
guest and operations/administration networking is a fast-growing trend.
Choice Hotels International (www.choice.com) is a good example of this
trend.
Choice Hotels International (NYSE: CHH) is one of the largest and most
successful lodging companies in the world. It franchises more than 6,100
hotels, representing more than 490,000 rooms, in the United States and
more than 30 countries and territories. The company's best known brands
include Comfort Inn, Comfort Suites, Quality, Sleep Inn, Clarion, Cambria
Suites, MainStay Suites, Suburban Extended Stay Hotel, Econo Lodge and
Rodeway Inn.
In-House Networking Functions
Choice supports two distinct networking functions. A central Web site
enables customers to reserve rooms at any Choice franchise
http://www.choice.com/
C10-2
accommodation. The central reservation system, known as Profit Manager,
automatically finds the most appropriate hotel based on location, price
range, or standard. Individual hotels also take bookings, so there needs to
be a way for hotels and the central system to remain synchronized.
Choice networks also support its franchisees. Choice is in fact a
relatively small company in terms of personnel (about 2000 employees) and
does not own or operate any hotels. All of the establishments under its brand
names are independently owned and pay Choice licensing fees and a royalty
on all sales. In return, they receive a variety of services, including
marketing, quality control, and inventory management. Many of these
services are offered via network, such as allowing managers to order
supplies online and check booking status. This support network is similar to a
corporate intranet but has a higher reliability requirement. The 6100 hotel
managers are, in effect, Choice's customers, not employees. Thus, the
standards for reliability and performance of the network are high.
In the late 1990s, Choice began to focus on providing a state-of-the-art
global reservation system. At this point, the synchronization of local and
online reservations was done manually. Each hotel provided Choice with a
fixed block of inventory to sell over the central reservation system, with an
average of 30% of capacity. Once that 30% was sold, Profit Manager listed
the hotel as fully booked, even though there might be plenty of rooms
available from the other 70%. The reverse problem also occurred: If the
local reservation system had so.
C11-1 CASE STUDY 11 CLOUD COMPUTING (IN)SECURITY .docxclairbycraft
This document discusses security issues and concerns regarding cloud computing. It outlines how cloud computing allows businesses to access applications and infrastructure over the internet as utility services. However, migrating systems to the cloud raises security risks around unauthorized access, data loss, and availability. The document recommends that businesses research cloud providers' security mechanisms like encryption, authentication, and virtualization to protect data before moving critical systems to the cloud. National Institute of Standards and Technology (NIST) guidelines also provide best practices for selecting cloud providers that can adequately address security risks.
C1-1 CASE STUDY 1 UNIFIED COMMUNICATIONS AT BOEING .docxclairbycraft
C1-1
CASE STUDY 1
UNIFIED COMMUNICATIONS AT BOEING
The Boeing Company (http://www.boeing.com/), headquartered in Chicago,
Illinois, is the world’s largest manufacturer of military aircraft and
commercial jetliners. Boeing has more than 159,000 employees working in
70 different countries who require effective communication to develop and
build some of the world’s most complex products using components from
more than 22,000 global suppliers.
The company’s workforce is one of the most highly educated in the
world. Most employees hold a college degree and many hold advanced
degrees. Collectively Boeing employees have very broad and deep
knowledge that can be harnessed to solve problems and design next
generation products.
Like many major corporations, Boeing has experienced an uptick in the
number of employees who work remotely or travel the majority of each work
week. Boeing’s engineers number in the thousands and are purposely
scattered worldwide to support the company’s global operations.
Boeing organizes its employees into work and project teams. Given the
company’s size and geographic footprint, many of Boeing work’s teams
include globally dispersed members. Engineers on the same team may be
separated by multiple time zones and thousands of miles. Time zone
differences and distance frequently present teams with communication
challenges when they are faced with time sensitive issues that must be
resolved quickly.
http://www.boeing.com/
C1-2
Additional communication issues are associated with the sheer breadth
and depth of Boeing’s knowledge base. When faced with questions about a
particular part included in one of Boeing’s new airliners, an engineer can be
challenged to identify the right person in the company to contact for
answers.
Collaboration Technologies
Boeing knows that continual innovation is important to its long term success.
It also recognizes that effective communication among its employees,
customers, and suppliers is an important enabler of continual innovation.
Boeing has traditionally relied on a variety of systems to facilitate
collaboration among its employees and business partners. As illustrated in
Figure C1-1a, Web conferencing, audio conferencing, desktop sharing, and
mobile voice and data services have been used by Boeing employees to
facilitate communication among geographically dispersed team members.
Historically, these capabilities have been provided by different third-party
providers who were selected on the basis of their ability to provide high-
quality communication services at competitive rates.
By the mid-2000s, Boeing had begun its migration toward unified
messaging and unified communications. At that time, instant messaging (IM)
was one of the more popular messaging services used Boeing employees. At
Boeing, IM has traditionally been supplemented by Web and audio
conferencing services as well as by de.
C09 07222011 101525 Page 88IT leader who had just been.docxclairbycraft
C09 07/22/2011 10:15:25 Page 88
IT leader who had just been hired and would be focused on developing a long-term IT
strategy for the company.
This chapter shows how to develop a strategy for your IT organization and avoid
getting overwhelmed with day-to-day issues. Many CIOs get caught up in tactical
issues and never take the time to establish a future strategy for the organization. The
process is not new or difficult, but many CIOs fail to devote the time to this area and
end up like Fred.
OVERVIEW
Developing an IT strategy is critical for IT leaders. Unless your organization has
developed an understanding of your future goals and objectives, you will not be
successful in leading it forward. In the same manner that you must first decide where
you want to live and build your dream house before engaging the architect and building
contractors, you need to develop a future strategy in order to successfully build your
IT organization.
This chapter is written for someone who has never developed an IT strategy in the
past or needs to revise an existing strategy to align with the company’s future direction.
We first review the methodology you can use to develop your strategy and then go
through the actual steps necessary to complete the strategy. It is important to note that
this is a collaborative process between the IT organization and its business partners. You
must actively engage them during the process and solicit their input during the
development of the strategy. The IT strategy should be considered a component of
an effective business strategy. Finally, we recommend that your strategy is a living
document that is updated on a regular basis to support the evolving nature of your
business. If you decide to enter a new market, offer new products or services, or change
your business model, the IT strategy must be revised to support the business.
IT STRATEGY METHODOLOGY
The methodology for creating your IT strategy consists of three steps, and development
of your improvement road map encompasses three critical elements, as shown in
Figure 9.1.
The first step is to understand the current state of the IT organization. Key questions
for determining current state include:
& Has the organization been successful in meeting the needs of the business?
& Are the relations between the IT organization and its business partners collaborative?
& Does the business feel that investments in the IT organization are providing the
desired benefits?
It is important to take an objective view of how the organization is operating today
and not assume that things are going great.
88 & Process
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C053GXML 10192012 214425 Page 131cC H A P T E R.docxclairbycraft
C053GXML 10/19/2012 21:44:25 Page 131
c
C H A P T E R
5
Privacy and Cyberspace
Of all the ethical issues associated with the use of cybertechnology, perhaps none has
received more media attention than concern about the loss of personal privacy. In this
chapter, we examine issues involving privacy and cybertechnology by asking the
following questions:
� How are privacy concerns generated by the use of cybertechnology different from
privacy issues raised by earlier technologies?
� What, exactly, is personal privacy, and why is it valued?
� How do computerized techniques used to gather and collect information, such as
Internet “cookies” and radio frequency identification (RFID) technology, raise
concerns for personal privacy?
� How do the transfer and exchange of personal information across and between
databases, carried out in computerized merging and matching operations,
threaten personal privacy?
� How do tools used to “mine” personal data exacerbate existing privacy concerns
involving cybertechnology?
� Can personal information we disclose to friends in social networking services
(SNS), such as Facebook and Twitter, be used in ways that threaten our privacy?
� How do the use of Internet search engines and the availability of online public
records contribute to the problem of protecting “privacy in public”?
� Do privacy-enhancing tools provide Internet users with adequate protection for
their online personal information?
� Are current privacy laws and data protection schemes adequate?
Concerns about privacy can affect many aspects of an individual’s life—from
commerce to healthcare to work to recreation. For example, we speak of consumer
privacy, medical and healthcare privacy, employee and workplace privacy, and so forth.
Unfortunately, we cannot examine all of these categories of privacy in a single chapter. So
we will have to postpone our analysis of certain kinds of privacy issues until later chapters
in the book. For example, we will examine some ways that medical/genetic privacy issues
are aggravated by cybertechnology in our discussion of bioinformatics in Chapter 12, and
131
C053GXML 10/19/2012 21:44:25 Page 132
we will examine some particular employee/workplace privacy issues affected by the use
of cybertechnology in our discussion of workplace surveillance and employee mon-
itoring in Chapter 10. Some cyber-related privacy concerns that conflict with cyberse-
curity issues and national security interests will be examined in Chapter 6, where
privacy-related concerns affecting “cloud computing” are also considered. In our
discussion of emerging and converging technologies in Chapter 12, we examine
some issues that affect a relatively new category of privacy called “location privacy,”
which arise because of the use of embedded chips, RFID technology, and global
positioning systems (GPS).
Although some cyber-related privacy concerns are specific to one or more spheres or
sectors—i.e., employment, healthcare, and so f.
How to Manage Your Lost Opportunities in Odoo 17 CRMCeline George
Odoo 17 CRM allows us to track why we lose sales opportunities with "Lost Reasons." This helps analyze our sales process and identify areas for improvement. Here's how to configure lost reasons in Odoo 17 CRM
it describes the bony anatomy including the femoral head , acetabulum, labrum . also discusses the capsule , ligaments . muscle that act on the hip joint and the range of motion are outlined. factors affecting hip joint stability and weight transmission through the joint are summarized.
LAND USE LAND COVER AND NDVI OF MIRZAPUR DISTRICT, UPRAHUL
This Dissertation explores the particular circumstances of Mirzapur, a region located in the
core of India. Mirzapur, with its varied terrains and abundant biodiversity, offers an optimal
environment for investigating the changes in vegetation cover dynamics. Our study utilizes
advanced technologies such as GIS (Geographic Information Systems) and Remote sensing to
analyze the transformations that have taken place over the course of a decade.
The complex relationship between human activities and the environment has been the focus
of extensive research and worry. As the global community grapples with swift urbanization,
population expansion, and economic progress, the effects on natural ecosystems are becoming
more evident. A crucial element of this impact is the alteration of vegetation cover, which plays a
significant role in maintaining the ecological equilibrium of our planet.Land serves as the foundation for all human activities and provides the necessary materials for
these activities. As the most crucial natural resource, its utilization by humans results in different
'Land uses,' which are determined by both human activities and the physical characteristics of the
land.
The utilization of land is impacted by human needs and environmental factors. In countries
like India, rapid population growth and the emphasis on extensive resource exploitation can lead
to significant land degradation, adversely affecting the region's land cover.
Therefore, human intervention has significantly influenced land use patterns over many
centuries, evolving its structure over time and space. In the present era, these changes have
accelerated due to factors such as agriculture and urbanization. Information regarding land use and
cover is essential for various planning and management tasks related to the Earth's surface,
providing crucial environmental data for scientific, resource management, policy purposes, and
diverse human activities.
Accurate understanding of land use and cover is imperative for the development planning
of any area. Consequently, a wide range of professionals, including earth system scientists, land
and water managers, and urban planners, are interested in obtaining data on land use and cover
changes, conversion trends, and other related patterns. The spatial dimensions of land use and
cover support policymakers and scientists in making well-informed decisions, as alterations in
these patterns indicate shifts in economic and social conditions. Monitoring such changes with the
help of Advanced technologies like Remote Sensing and Geographic Information Systems is
crucial for coordinated efforts across different administrative levels. Advanced technologies like
Remote Sensing and Geographic Information Systems
9
Changes in vegetation cover refer to variations in the distribution, composition, and overall
structure of plant communities across different temporal and spatial scales. These changes can
occur natural.
Executive Directors Chat Leveraging AI for Diversity, Equity, and InclusionTechSoup
Let’s explore the intersection of technology and equity in the final session of our DEI series. Discover how AI tools, like ChatGPT, can be used to support and enhance your nonprofit's DEI initiatives. Participants will gain insights into practical AI applications and get tips for leveraging technology to advance their DEI goals.
The simplified electron and muon model, Oscillating Spacetime: The Foundation...RitikBhardwaj56
Discover the Simplified Electron and Muon Model: A New Wave-Based Approach to Understanding Particles delves into a groundbreaking theory that presents electrons and muons as rotating soliton waves within oscillating spacetime. Geared towards students, researchers, and science buffs, this book breaks down complex ideas into simple explanations. It covers topics such as electron waves, temporal dynamics, and the implications of this model on particle physics. With clear illustrations and easy-to-follow explanations, readers will gain a new outlook on the universe's fundamental nature.
How to Fix the Import Error in the Odoo 17Celine George
An import error occurs when a program fails to import a module or library, disrupting its execution. In languages like Python, this issue arises when the specified module cannot be found or accessed, hindering the program's functionality. Resolving import errors is crucial for maintaining smooth software operation and uninterrupted development processes.
This presentation was provided by Steph Pollock of The American Psychological Association’s Journals Program, and Damita Snow, of The American Society of Civil Engineers (ASCE), for the initial session of NISO's 2024 Training Series "DEIA in the Scholarly Landscape." Session One: 'Setting Expectations: a DEIA Primer,' was held June 6, 2024.
A review of the growth of the Israel Genealogy Research Association Database Collection for the last 12 months. Our collection is now passed the 3 million mark and still growing. See which archives have contributed the most. See the different types of records we have, and which years have had records added. You can also see what we have for the future.
This presentation includes basic of PCOS their pathology and treatment and also Ayurveda correlation of PCOS and Ayurvedic line of treatment mentioned in classics.
By Thomas C. Ricketts and Erin P. FraherReconfiguring Heal.docx
1. By Thomas C. Ricketts and Erin P. Fraher
Reconfiguring Health Workforce
Policy So That Education,
Training, And Actual Delivery
Of Care Are Closely Connected
ABSTRACT There is growing consensus that the health care
workforce in
the United States needs to be reconfigured to meet the needs of
a health
care system that is being rapidly and permanently redesigned.
Accountable care organizations and patient-centered medical
homes, for
instance, will greatly alter the mix of caregivers needed and
create new
roles for existing health care workers. The focus of health
system
innovation, however, has largely been on reorganizing care
delivery
processes, reengineering workflows, and adopting electronic
technology
to improve outcomes. Little attention has been paid to training
workers
to adapt to these systems and deliver patient care in ever more
coordinated systems, such as integrated health care networks
that
harmonize primary care with acute inpatient and postacute long-
term
care. This article highlights how neither regulatory policies nor
market
forces are keeping up with a rapidly changing delivery system
2. and argues
that training and education should be connected more closely to
the
actual delivery of care.
H
ealth care professionals are be-
ing challenged to find new ways
to organize care and develop
systems that hold providers ac-
countable for the quality, cost,
and patient experience of care.1 The once in-
cremental pace of change is accelerating, and
there is evidence that long-standing paradigms
are dramatically shifting.2 For example, the rela-
tively slow acceptance of prepaid and managed
care systems is being replaced by the rapid adop-
tion of bundled and risk-based payment mod-
els.3,4 Early adopters of accountable care organi-
zations (ACOs) are finding that their workforce
is shifting from acute care to community- and
home-based settings with increasing roles for
physicians, nurses, social workers, patient navi-
gators and outreach coordinators, and other
clinicians in providing enhanced care coordina-
tion, better medication management, and im-
proved care transitions.5
The training of health professionals, however,
lags behind these reforms because it remains
largely insulated from change behind the walls
of schools of medicine, dentistry, pharmacy, and
nursing. Medical training is done primarily in
hospitals, while the greatest challenges are
found in coordinating care in multiple out-
4. Surgery, University of North
Carolina at Chapel Hill.
1874 Health Affairs November 2013 32:11
Overview
Downloaded from HealthAffairs.org on February 23, 2020.
Copyright Project HOPE—The People-to-People Health
Foundation, Inc.
For personal use only. All rights reserved. Reuse permissions at
HealthAffairs.org.
shape the clinical workforce as a “dream”7 or
subject to “hand-to-hand” combat.8 The “hands”
in thiscase weredescribedby KevinGrumbach as
the “heavy hand” of government regulation and
the “invisible hand” of market forces that con-
stantly pushed the United States into a rolling
series of surpluses followed by shortages.8 The
“dream,” as Uwe Reinhardt saw it, was that reg-
ulation and control could actually work. He of-
fered in its place a change in policy to expose
physicians to the actual costs of their training
while pushing them to the right places and spe-
cialties with judiciously targeted tax-financed
loan repayment.7
In much of the rest of the world, coordinated
workforce planning that develops national and
regional goals has long been accepted as a legiti-
mate policy exercise. This work is achieved by
pairing technical workforce experts and policy
5. makers with clinicians and patients to guide the
structure of the health workforce—in both num-
bers and skill mix—to meet the needs of delivery
systems and thepopulation.9 IntheUnited States
a mix of government policies and professional
guidelines combine with strong market forces to
shape the health care workforce; the latter al-
most invariably dominates but with a recogni-
tion among most stakeholders that regulation is
necessary.10
As a result, the United States has forgone any
substantial investment in workforce planning
except for the veterans’ health system.11 The
United States has left it up to states, professional
associations, employers, payers, and other
stakeholders to negotiate their interests via the
market and the political process. The result is a
complex and uncoordinated web of training in-
stitutions efforts, licensing board rules, place-
ment programs such as the National Health
Service Corps, and payment regimes. These are
not compared or evaluated to determine if they
are producing the right people for the right work
to meet patients’ needs.
With many observers asking if there will be
enough providers to meet the needs of rapidly
innovating systems, this laissez-faire system is
now in flux. The Centers for Medicare and
Medicaid Services has funded numerous pilots
to identify new models for workforce develop-
ment and payment to support health system in-
novation. These pilots, however, are relatively
isolated and have not been linked in any system-
atic way to broader systems or structures that
6. govern the way we train, regulate, or deploy
the health workforce.
The earlier Health Affairs thematic issue raised
many familiar, unanswered questions, including
a fundamental one: How many of what kinds of
professionals with what competencies are need-
ed to care for our population? This issue asks the
same questions but adds another: What has
changed over the past ten years?
The Affordable Care Act has created a new
vocabulary to describe networks of providers
tied together to offer enhanced care coordina-
tion. The ACO and the patient-centered medical
home have become seemingly ubiquitous mod-
els for holding systems accountable for the care
provided to patients across community, ambula-
tory, and acute care settings. These emerging
models of integrated care have been abetted by
increasing market concentration in health care
delivery systems.
ACOs, which take on risk by having a portion
of their reimbursements tied to the outcomes of
care for a predetermined Medicare population,
are seeking to reduce costs and improve care by
ramping up screening and preventive care and
the coordination of services. This restructuring
will have far-reaching implications for how clin-
ical work is organized and compensated, with
more work shifting to lower-paid and allied
health workers who provide care in less costly
community- and home-based settings.
7. Teams And Workforce
Almost all of the new arrangements include
plans or structures that call for more “team-
based care” and make use of “enhanced” roles
for various professions, despite a lack of consen-
sus on what those two terms really mean. Teams
have been described as groups of people whose
roles continuously shift in response to internal
and external forces, including patient expecta-
tions; policy and payment changes; organiza-
tional factors; geographic proximity of other
providers; and professional regulation, training,
and attitudes.12,13 Broadly conceptualized, roles
within teams fall into two categories: lower-cost
health professionals acting as substitutes for
higher-cost ones (for example, nurse practi-
tioners for physicians), or lower-cost health
professionals functioning as supplements who
extend and enhance the work of others (for
example, navigators to coordinate care or dis-
charge planners to help patients make the tran-
sition from acute to postacute care). Despite the
numerous calls for more team-based models of
care, relatively little attention has been given to
how to prepare physicians, nurses, therapists,
technicians, and others already in the workforce
to practice in accountable or reformed teams.
Health care professionals have been seen more
as parts of a puzzle that need to be carefully fit
together into a transformed system of care than
as fungible resources that can be crafted or re-
made to help build a truly reformed and more
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effective health care delivery system. For exam-
ple, although the use of electronic health records
(EHRs) has burgeoned with the implementation
of the federal program to certify and reward the
meaningful use of health information technolo-
gy, there is limited understanding of how health
professionals can work with EHRs to change the
flow of work or how work should be reconfigured
and reallocated among team members. EHRs are
shaping the work of clinicians as much as they
are being adopted for and adapted to current
practices. To be optimally effective, EHRs re-
quire broad and rapid adoption, practitioners
must pay constant attention to data entry, and
care patterns have to be reengineered to accom-
modate EHRs’ use.14,15
Projecting Supply, Demand, Need,
And Requirements
That workforce projections are controversial
should come as no surprise; any projection will
inevitably be ambushed by unknown or un-
expected factors and events that affect future
workforce supply and demand. The surprising
thing is that projections, whether based on em-
pirical models or “expert” opinion, are criticized
for not correctly predicting the future when their
purpose is almost always to change policies and
9. practices. Projections, when accepted as roughly
correct, are often followed by policy shifts that,
in turn, change the future supply or pipeline of
workforce production.
Projections turn out to be wrong either be-
cause it is not known how many physicians there
are16 or because there is a lack of understanding
of the true relationship between physician
supply and health outcomes.17 They are, in one
sense, “projectiles” shot across the bows of
policy makers to stimulate action; they paint a
picture of what is likely to happen if some desir-
able policy is not implemented. If a policy is
changed, then the projection is likely to turn
out wrong because it helped cause changes in
the factors that drove the model.
For example, the Graduate Medical Education
National Advisory Committee’s 1980 projection
of a physician surplus was used to justify cut-
backs in federal support to medical education,
thus changing medical school growth trends.
That policy shift reduced production and even-
tually led to a perceived shortage.18 The more
recent Association of American Medical Colleges
forecasts of shortages of physicians have similar-
ly prompted the expansion of existing and the
opening of new medical schools and have put
strong pressure on the debate over how to sup-
port graduate medical education to provide the
additional training necessary to produce practic-
ing physicians.19
Recent work has focused on developing dy-
10. namic projection models that are amenable to
changes in the assumptions on which they are
based and that allow policy makers to simulate
the effects of potential policy scenarios20 on
workforce supply and demand. This type of work
is supported by the National Center for Health
Workforce Analysis in the Department of Health
and Human Services, but the center struggles
with a lack of both up-to-date inventories of ex-
isting health professionals and a common data
set to measure practitioner capacity or simply
identify the location of practice.21,22
The modeling field in the United States and
other countries23 is moving toward using projec-
tions not as a method for generating one “right”
answer but as a way to educate health profession-
als and their associations, policy makers, and
other workforce stakeholders about the com-
plexity of projecting future workforce needs
and the effects of the policy options they have
at hand. Engaging stakeholders—particularly
clinicians—in themodeling process cangenerate
numerous desirable results, including a better
understanding of how rapid health system
change affects workforce deployment and im-
proved communication between the professions
and policy makers. Having clinicians involved in
modeling can also serve as a check on the “face
validity” of model outputs and can generate clin-
ical input in areas where data inputs are weak.
Stakeholders engaged in modeling can also help
identify ways to redesign care processes to ad-
dress workforce shortfalls or surpluses.
Models and projection thus cannot provide a
11. single “right” answer in a system that is rapidly
changing. The important thing is to have a model
that can be used to simulate the effect of policy
change and educate stakeholders about the
effects of policy options. For example, a model
might show that increasing graduate medical
education slots will likely have a relatively small
effect on the overall match of supply to need
compared to increasing productivity and delay-
ing retirement.
Efforts to model the nursing workforce have
been complicated by nursing’s persistent sine-
wave pattern of shortages prompting policy ac-
tions that, in turn, stimulate rapid growth lead-
ing to surpluses.24 Analyses of nurse supply and
demand remain doggedly unconnected to physi-
cian workforce projections. There are no exam-
ples of national models that simultaneously
project the supply of both professions despite
their substantial overlap in providing care.
Combining the two in projections is now an im-
perative given nurses’ complementary and sup-
plementary roles in delivering or supporting
Overview
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12. many of the new services required by ACOs and
patient-centered medical homes, such as care
coordination, patient navigation, transition
care, and population health management.
An obvious link would be in the production
and deployment of nurse practitioners and their
impact on the “effective supply” of primary care
practitioners,25,26 but including “nonphysicians”
in physician supply-demand calculations has
proved difficult. For example, in the develop-
ment of an index to identify shortage areas for
federal support, an intense battle was fought in a
special “negotiated rulemaking” committee
mandated by the Affordable Care Act over how
to count nurse practitioners and physician assis-
tants in a formula for proposed new Health
Professional Shortage Areas and Medically
Underserved Populations.27 Advocates from the
nurse practitioner and physician assistant pro-
fessions felt strongly that they should be as-
signed a weight of at least 0.75 full-time-equiva-
lent of a primary care physician to account for
their contribution to community-based primary
care. Counting them would often increase the
local supply above a shortage threshold, making
the community or population lose its designa-
tion and thus its eligibility for federal support.
Productivity In The Health Care
Workforce
The promise of technology as the way to improve
the quality of care and lower costs, especially via
the EHR, has been promoted on the basis of its
potential to improve productivity in the system
13. by making care more efficient and effective.28
This is essentially an economic calculus: Can
more be done and done better and at lower cost?
That question remains to be answered.
What the United States has done is rapidly
increase the number of people and types of work-
ers who are delivering care. Employment in the
health care sector grew rapidly between 2000
and 2010—at a rate of greater than 3 percent
annually—and even faster growth has been
projected for the following decade, but there
are signs of a slowdown in that growth.29 This
is in contrast to overall employment, which
shrank by 0.2 percent per year in the first decade
of this century and is projected to grow by only
1.3 percent during 2010–20.
Employment growth in ambulatory health
services has been strong at 3.3 percent per year,
with an anticipated increase to 3.7 percent.
These labor inputs may be growing faster than
patient care needs, thus making the overall
workforce less productive and efficient. On the
other hand, that same expanding workforce may
be generating greater value by improving out-
comes through better coordination and greater
intensityof care.Whetherthesystem isbecoming
more or less efficient in terms of value for money
because of the addition of new specialties or new
professions has seldom been asked30 and even
less often answered.31
Professions Unto Themselves
14. The United States accepts in policy and practice
the idea of “sovereign” and self-regulating pro-
fessions that have substantial control over their
place in the health care system. This approach
has meant that workforce policy has been largely
shaped around the demands of the professions
and not around the needs of the patients. The
question of whether the professions should con-
trol entry into their respective realms through
self-regulation remains largely out of the main-
stream of debate but is raised from time to time
by libertarian thinkers.32 There are very intense
battles over scope-of-practice rules, with ad-
vanced-practice nurses making strong claims
on primary care, nurse anesthetists being chal-
lenged over their contributions by anesthesiolo-
gists, and the development of dental therapists’
work being challenged by dentists. These con-
flicts are becoming sharper despite a body of
evidence that shows that most of these work
and professional roles are effective in saving
money and maintaining or improving quality.33
New and different types of health profession-
als—community health workers, patient navi-
gators, health coaches, care coordinators, and
more—are attempting to create their own space
in the health care delivery system as their con-
tributions to the new payment and organiza-
tional models become more apparent. The
emergence of new professions runs counter to
theories of how health care workers should func-
tion in teams adapting and “upskilling” existing
professional or paraprofessional roles to meet
patients’ needs.34
15. The progressive division of labor and the crea-
tion of specialized labor categories that are able
to do one focused job more efficiently than a
range of work has been the pathway to greater
productivity in manufacturing and other sectors
but to a lesser extent in health services. In the
health care realm, increasing specialization is
reflected in the growing complexity of how a
hospital is staffed to care for patients—a process
that has given us hospitalists, intensivists, noc-
turnalists, and other types of practitioners who
are defined by their functional role as much as by
their disciplinary specialization.35 The prolifera-
tion of new professions and professional roles
does not necessarily lead to greater efficiency
because, as David Meltzer and Jeanette Chung
◀
3%
Employment growth
Employment in the health
care sector grew more
than 3 percent a year
during 2000–10, compared
to a 0.2 percent annual
shrinkage in overall
employment growth in the
same decade.
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point out, there are real costs associated with
coordination.35 Those costs have not been calcu-
lated or even anticipated in most of the calls for
reorganization using teams.
The rise of additional specialists and profes-
sions within the health care “team” in new mod-
els of care have made Irving Zola and Stephen
Miller’s description of long-term care common-
place:“In thecourse of…long term disorders, the
doctor recedes further and further into the back-
ground, eventually assuming the role of occa-
sional medical consultant.With this, the physio-
therapist, visiting nurse, dietician, prosthetist
becomes essentially ‘the doctor’ not only in
terms of primary day-to-day management, but
in terms of the transference relationship as
well.”36
The career paths for physicians, nurses, and
even dentists are multiplying. They involve serial
training in fellowships to acquire new techni-
ques and skills; adapt to shifts in practice focus;
and, more often, prepare them for a return or
to introduce them to a type of practice that is
more flexible—essentially a return to a generalist
role.37 At the simplest level of care, the nature of
laborfordirect careworkerswho feed,move,and
clean patients has become dominated by part-
time jobs with fewer and fewer benefits.38 To
achieve true integration, teams must accommo-
date the multiple needs of the people working
17. around the patient, including highly trained
physicians who seek professional satisfaction
andhigh rewards aswell as unlicensed personnel
whose formal connection to the system is tenu-
ous but whose practical training and skills are
often crucial in generating quality care and pa-
tient satisfaction.
The pressure to coordinate, or perhaps simply
serve as a traffic cop controlling, the flow of
practitioners around the patient, has emerged
as a true challenge. Atul Gawande’s description
of hismother’s careduring her knee replacement
gives a sense of what a contemporary hospital-
based team is like: It is large, potentially irratio-
nal, and likely to grow.39 We know far less about
what makes for an effective team of ambulatory
caregivers when it comes to managing transi-
tions for patients with complex chronic illnesses
from community to acute care settings and back.
If the workforce needs of the future are to be
adequately assessed, it is necessary to first get
a better handle on who will make up the work-
force in each setting in the future.
Training And Education As Field Of
Reform
Training professionals for the future of team-
based care has been recognized as a real chal-
lenge. The Institute of Medicine is currently
supporting a committee, the Global Forum on
Innovation in Health Professional Education, to
explore how best to promote “transdisciplinary
professionalism.” The group recognizes the
challenges of integrating the diverse cultures
18. and skill sets of the various professions, the
problem of teaching “followership” and leader-
ship, and the practical problem of measuring
how well a team works.
The National Center for Interprofessional
Practice and Education has been funded by the
Health Resources and Services Administration
to do similar work. These efforts follow on a
series of precursor programs in interdisciplinary
training that never quite found traction in for-
mal policy or in health professions training.40
Thecentraltask for reformedhealth care delivery
may indeed be to create and sustain teams of
different professional pedigrees. The question
is whether teams can be constructed around a
template or whether it must happen in practice
with ad hoc teams forming around the patient
and their needs.
Innovations In Training And
Education
The ways in which health care professionals are
taught are changing rapidly. Additionally, there
is pressure to streamline pathways into profes-
sions.41 Online courses, clinical simulators, and
learning teams have made education more flexi-
ble. Still, little is known about what constitutes
efficient and effective clinical training.42 The true
costs of preparing health professions are being
revealed by the rapid growth in the number of
private, including for-profit, health professions
institutions that have sprung up to meet demand
from prospective students.43 These include oste-
opathic medical schools and physician assistant
19. programs and umbrella “Health Science”
schools that provide training for nurses, thera-
pists, and technicians. Public community col-
leges in some states fill this niche, but the market
Training professionals
for the future of
team-based care has
been recognized as a
real challenge.
Overview
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has also responded vigorously to train workers,
especially allied health workers, for reformed, if
not fully coordinated, systems.44
The “safety net” of public clinics, hospitals,
and private charity caregivers is one place where
innovation in role assignment and integration of
multiple professions has been welcomed,45 but
the benefits are difficult to calculate. Community
health centers (also known as federally qualified
health centers) have become testing grounds for
a new approach to graduate medical education
through the Teaching Health Centers Program.46
20. Through this program, the new centers are
funded as temporary demonstrations whose
long-term outlook depends on future appropria-
tions.47 They do offer a new approach to meeting
the growing need for locations to provide grad-
uate medical education given the recent rapid
rise in the number of US medical school gradu-
ates and the apparent “bottleneck” that has
slowed growth in residency training and thus
physicians’ progression into the workforce.
Revolutionary changes in the nature and form
of health care delivery are reverberating back-
ward into medical education as leaders of the
new practice organizations demand that the ed-
ucational mission be responsive to their needs
for practitioners who can work with teams in
more flexible and changing organizations. In
the face of this pressure, the traditional response
of health educators—that they should have au-
tonomy in defining the educational mission—is
no longer viable. Instead, more explicit, formal,
and systemic linkages between practice and ed-
ucational institutions that are coordinated with
maintenance of certification and licensing are
inevitable.48 There are proposals to base certifi-
cation and licensure on actual performance and
patient care outcomes instead of on simply meet-
ing additional education and training require-
ments. 49 This new pressure to make medical
education at all levels more accountable to public
and patient needs means that we must measure
how medical education affects medical care out-
comes, not just the outputs of the programs and
21. institutions.
Conclusion
We often hear how the United States has a non-
system of health care—a faircharacterization of a
very adaptable sector of the economy that com-
bines rigid professional norms, rapid shifts in
staffing and deployment of workers to capture
funding streams, and the constant creation of
new work roles and employment opportunities.
It is largely these characteristics of the workforce
that have both constrained the coordination of
health care and allowed the system to grow very
rapidly. To blunt rising costs, it seems necessary
to find ways to temper this professional and oc-
cupational exuberance to achieve both greater
efficiency and effectiveness.
To anticipate these changes and prepare the
workforce for new roles, it will be necessary to
invest in workforce planning but not solely at the
macro level of overall supply. Investments are
needed in research and implementation studies
to help foster greater understanding about the
actual content of care that is required in the new
systems. Investments in research are also needed
to identify how best to allocate new caring roles
among a set of professions and disciplines that
are trained and deployed in a coordinated fash-
ion. Workforce planning needs to be more “bot-
tom up” as it seeks to identify the “right kind”
and the “right number” of workers. ▪
This work was supported in part by
contracts with the American College of
Surgeons and the Physicians Foundation.
22. The authors thank Laura Trude and Kelly
Quigley of the Health Workforce
Information Center at the University of
North Dakota for their assistance.
NOTES
1 Berwick DM, Hackbarth AD.
Eliminating waste in US health care.
JAMA. 2012;307(14):1513–6.
2 Berwick D. Escape fire: designs for
the future of health care. San
Francisco (CA): Jossey-Bass; 2004.
3 Marmor T, Oberlander J. …
RESEARCH Open Access
Workforce planning and development in
times of delivery system transformation
Patricia Pittman1* and Ellen Scully-Russ2
Abstract
Background: As implementation of the US Affordable Care Act
(ACA) advances, many domestic health systems are
considering major changes in how the healthcare workforce is
organized. The purpose of this study is to explore
the dynamic processes and interactions by which workforce
planning and development (WFPD) is evolving in this
new environment.
23. Methods: Informed by the theory of loosely coupled systems
(LCS), we use a case study design to examine how
workforce changes are being managed in Kaiser Permanente and
Montefiore Health System. We conducted site
visits with in-depth interviews with 8 to 10 stakeholders in each
organization.
Results: Both systems demonstrate a concern for the impact of
change on their workforce and have made
commitments to avoid outsourcing and layoffs. Central
workforce planning mechanisms have been replaced
with strategies to integrate various stakeholders and units in
alignment with strategic growth plans. Features
of this new approach include early and continuous engagement
of labor in innovation; the development of
intermediary sense-making structures to garner resources,
facilitate plans, and build consensus; and a whole system
perspective, rather than a focus on single professions. We also
identify seven principles underlying the WFPD processes
in these two cases that can aid in development of a new and
more adaptive workforce strategy in healthcare.
Conclusions: Since passage of the ACA, healthcare systems are
becoming larger and more complex. Insights from
these case studies suggest that while organizational history and
structure determined different areas of emphasis, our
results indicate that large-scale system transformations in
healthcare can be managed in ways that enhance the skills
and capacities of the workforce. Our findings merit attention,
not just by healthcare administrators and union leaders,
but by policymakers and scholars interested in making WFPD
policies at a state and national level more responsive.
Keywords: Workforce planning and development, Human
resources in health, Healthcare delivery reform, System
change, Loosely coupled systems, Labor-management
24. partnerships, US Affordable Care Act
Background
As the implementation of the 2010 Affordable Care Act
(ACA) advances in the United States, many healthcare
organizations are taking bold measures to reorganize
their delivery systems and finding that in order to do so,
changes must be made to the healthcare workforce [1].
While different healthcare organizations in the United
States, be they public or private, are at very different
points in this process, commonly popular concepts in-
clude moving staff to new ambulatory and home care
settings [2]; creating new jobs relating to care coordin-
ation and outreach to the sickest patients [3]; designing
new modes of delivering care in response to consumer-
ism [4]; adopting team-based care and task shifting
based on the principal of practicing at the top of license
and education [5]; requiring new roles and skills as part
of the adoption of health information technologies
(HIT); and the use of data for decision-making [6].
Understanding what workforce changes are occur-
ring and how they are being managed is key not just
for healthcare leaders but for policymakers as well.
Traditional methods of projecting provider shortages
and justifying the allocation of public funding to
expand various professional pipelines are giving way
* Correspondence: [email protected]
1Milken Institute School of Public Health, The George
Washington University,
2175 K Street, NW, Suite 500, Washington, DC 20037, United
States of
America
Full list of author information is available at the end of the
26. types of health workers at an aggregate level but how
are organizations making choices about ways to recon-
figure their workforce and, ultimately, what kinds of
local, state, and federal policies are most supportive of
workforce transformations that advance both workers’
well-being and the value of their services.
We know from the literature reviewing the hospital re-
structuring of the 1990s that workforce change manage-
ment faces many challenges. The critiques of this era
were many, but chief among them, according to Walston
and colleagues, were the following: goals for change
were not clear, too many changes were implemented too
quickly, there was a lack of communication with em-
ployees, a lack of engagement with physicians and
unions, there was a poor understanding of the local
site differences by management leading to a one-size-
fits-all approach, and, lastly, that training needs were
not anticipated [9].
In a review of the international literature on workforce
planning and development (WFPD), Curson and col-
leagues suggest that the problem goes deeper. They
argue that workforce policies lack the capacity to re-
spond to new demands for system change [10]. The
reason, they point out, is that most workforce planning
do not take account of political dynamics among the
range of stakeholders outside the control of human re-
source administrators, be they at the organizational or
the policy level.
It is with these critiques in mind that we are interested
in understanding how two leading health systems in the
United States, with a historic commitment to developing
and retaining their workforce and to managing change
through labor-management partnerships, are responding
27. to the demands of the post-ACA environment. The aim
is to explore how they are determining what changes are
needed and how they are implementing those changes in
practice. Their experiences may provide insights for
other organizations, as well as for policymakers charged
with ensuring that the healthcare workforce is able to
meet population needs.
Our first case focuses on Kaiser Permanente (KP), an
integrated system that has historically served the em-
ployer market on the West Coast. It has been at the
forefront of systems that emphasize value over volume
and among the organizations most advanced in the use
of HIT to improve the patient care process. In addition,
KP has one of the most successful models of labor-
management partnerships (LMP) in the nation.
The second system is the Montefiore Health System,
headquartered in the Bronx, NY, an organization with al-
most 20 years of experience with shared risk contracts
with payers. Like KP, they have extensive experience with
care coordination, they are in the process of expanding
to new markets, and they have a LMP. They differ from
KP in that their patient population is predominantly
poor and Spanish speaking, and an extraordinary 80 %
of their revenue is coming from Medicaid and Medicare.
Conceptual framework
The objective of this study is to go beyond descriptive
groupings of health workforce changes to explore the dy-
namic processes and interactions by which staffing models
emerge. To frame our inquiry, we draw on the literature
on health workforce planning and development and the
theory of loosely coupled systems (LCS) [11].
For the purposes of this paper, we define WFPD as the
28. macro level processes and practices that enable the sys-
tem to change and adopt new staffing arrangements and
respond with timely and appropriate education, training,
and certification programs. Schrock has suggested that
WFPD policies span the continuum of skill formation,
employment networks, and career advancement [12].
This means not simply examining the supply and distribu-
tion of personnel in different categories but also under-
standing educational and training pathways, management
of performance, and the regulation of working conditions.
Dussault and Dubois argue that the traditional ap-
proach to WFPD is a linear, sequential, and protracted
skill formation process through which healthcare pro-
viders hand off demand projections to education institu-
tions and certifying bodies that in turn, supply the
requisite workforce [13]. Weick reasons that this form of
sequential task interdependence induces rule-based
action and cognitive processes that are not equipped to
tackle ambiguous problems like providing a skilled
workforce for care models that are in a constant state of
flux [14]. This and other complex, non-routine problems
require controlled cognition or slow, deliberative, and
explicit thinking that is more often associated with
reciprocal interdependence coordinated by an iterative
process of negotiation and mutual adjustment among
relatively autonomous units and subsystems. [14]
Dussault and Dubois describe an alternative approach
that is emerging in healthcare that coordinates the
efforts of a diverse range of institutional actors through
adaptive processes that respond to specific, local polit-
ical, economic, cultural, and social contexts where
healthcare is delivered [13]. This approach is understood
29. Pittman and Scully-Russ Human Resources for Health (2016)
14:56 Page 2 of 15
as a political exercise in which values and differences are
made explicit, compromises are made, and actions are
justified. Orton and Weick further suggest that there is a
need to move beyond the traditional focus on static
organizational elements, like structure, resource alloca-
tion, and technology, and turn instead to a focus on the
dynamic relationship among them [15].
Organizational scholars developed the concept of
“loose and tight coupling” as one way to examine com-
plex organizational structures and relationships [16–19].
The focus of this approach is on hierarchy and inter-
dependence among elements within and between organi-
zations and how variability in these features enables
different operational strategies and responses to shifts in
the external environment [17]. In tightly coupled sys-
tems, individual units and organizations are linked to-
gether through formal structures and procedures and
they respond to change through centralized control
mechanisms that reduce variation and close the system
off from the effects of external forces. In loosely coupled
systems, on the other hand, the links among the compo-
nents are weak and a high level of autonomy exists
among the interdependent parts of the system [20].
While the variation in the way similar functions are or-
ganized and managed may make it difficult to integrate
activities, theorists argue that it enables flexibility and
openness to change in the environment [15].
According to the theory of LCS, all systems are both
tightly and loosely coupled because there is variation in
30. how subunits are linked and rely on each other (couple-
d)—as well as in the number and strength of their con-
nections (lose or tight) [15, 17, 21]. Therefore, any
subsystem may be closed to outside forces to ensure for
stability (tight), while another subsystem may remain
open to outside forces to enable flexibility (loose) [15].
This paradoxical nature of LCS makes it difficult for
researchers to conceptualize and study [16], yet we
would suggest that its application to the US healthcare
system during this period of intense transformation
holds explanatory potential. Healthcare systems are sim-
ultaneously being asked to expand coverage and access,
while being financially incentivized to extend the con-
tinuum of care to address the social determinants and
provide ongoing care management. As a result, there
are significant pressures on traditional care models and
staffing arrangements, leading in turn to the emer-
gences of new patterns of “coupling,” both within and
across healthcare organizations. Further, we submit that
the effectiveness of the transformation occurring in
healthcare today may hinge on new, more adaptive
methods to prepare the healthcare workforce to
perform in a more complex system of care, where job
tasks, team interactions, and work locations are con-
tinuously changing.
To analyze changes in WFPD, we borrow from Weick’s
typology of strategies for changing LCS [11] and from the
descriptions on a new approach to WFPD in healthcare
put forth by Curson et al. [10] and Dussault and Dubois
[13] to identify a set of principles that together, may serve
as a new adaptive WFPD framework aligned with the
needs of a rapidly changing deliver system.
Methods
31. We use a case study design to explore how two major
health systems undergoing significant system transform-
ation are managing the process of workforce change. We
selected Kaiser Permanente (KP) and Montefiore because
they are well known for their innovative approaches to in-
tegrating healthcare yet they are significantly different
from each other with regard to their organizational histor-
ies, structures, and patient populations.
We conducted site visits to both organizations in the
spring and summer of 2015, conducting interviews with
8–10 people at each site including executives, human re-
source managers, the heads of innovation and care coord-
ination programs, and union and LMP representatives.
Some interviews were held in group settings, while others
were individual. We also conducted planning and follow-
up phone calls with some of the participants. Interviews
were taped and transcribed. We also reviewed current
organizational documents, including training plans, re-
ports, and collective bargaining agreements, as well as
prior studies on each system [9, 22, 23].
Data analysis proceeded through several steps. First,
the research team conducted a review of each case,
including the historic development of the system and
significant drivers of change, as well as the strategies,
structures, and resources informants reported as being
central to the competiveness of the system and the
sustainability of the workforce in the post-ACA environ-
ment. To support this analysis, the research team devel-
oped a series of inductive and deductive codes, which
we used to extract relevant data from the case docu-
ments and interview transcripts. Next, the researchers
jointly analyzed the coded data to developed individual
case profiles. These profiles were validated by key infor-
mants from each case. Finally, we conducted a constant
32. comparative method to identify cross-cutting themes
and principles to explain the workforce planning and de-
velopment strategy emerging within the two systems.
Results
Case study 1: Kaiser Permanente
Kaiser Permanente (KP) was established in 1938 as a
comprehensive medical system for the workers and their
families at Kaiser steel mills and shipbuilding facilities
across California and in Portland, OR. In 1945, after
WWII ended and many shipyards closed, KP opened
Pittman and Scully-Russ Human Resources for Health (2016)
14:56 Page 3 of 15
membership to the general public. The KP unions played
an instrumental role in this expansion by helping KP
market to unionized employers in areas where the com-
pany had a presence. Today, it operates as a Health
Maintenance Organization (HMO) with 8.3 million
health plan members in seven regions: Northern and
Southern California, Colorado, Georgia, Hawaii, Mid-
Atlantic, and the Northwest. Each region is made up of
two separate entities, the Kaiser Foundation Health Plans
and the Permanente Medical Group (PMG), a physician-
owned corporation that owns and operates KP’s medical
facilities. The PMG contracts with the Foundation to
serve KP health plan members. A key feature in this
model is that physicians are employed by KP. The na-
tional program office includes a variety of support func-
tions, including human resources, labor relations,
information technologies (IT), finance, and patient care
services (nursing).
The KP Labor-Management Partnership (LMP) was
33. formed in 1997. At the time, KP faced competitive
pressures leading executives to demand deep union
concessions. In response, many of the KP unions of-
fered the company a choice: continued harsh labor-
saving tactics and escalating labor strife, including a
strike, or a partnership to address the fiscal crisis and
improve the quality of care at KP. The company
agreed to the partnership [24]. The governance struc-
ture consists of the LMP Strategy Group, with one
representative from each of three sectors: Physicians,
Management and Labor, and each region maintains
its own tripartite LMP council.
By 2015, the LMP included 12 international and 28
local unions representing 105 000 KP employees or
about half of the total KP workforce, across six of the
seven regions. Hawaii is not part of the partnership, and
not all KP unions are involved in the partnership, most
notably absent is the California Nurses Association.
KP also has a network of functional units to support
the design and management of change and WFPD
strategies. The LMP staff is integrated into these units,
and labor representatives are highly engaged in their
activities. These units include the following:
� National Workforce Planning and Development
(housed in national human resources (HR))
provides opportunities to the KP workforce to
optimize skills and competencies and manages two
LMP education trusts: the Ben Hudnall Memorial
Trust and SEIU/UHW Joint Employer Education
Fund.
� National Innovations Network including patient care
34. services, workforce planning, and IT functions as a
loosely coupled “future-sensing” group that
examines technology trends, creates proof of
concepts and proof of technology, and develops
pilots.
� Unit-based teams (UBT) are natural work groups of
frontline workers, physicians, and managers who
solve problems and enhance quality.
Drivers of change
KP’s history of pre-paid, member-based service is critical
to understanding the company’s current competitive
situation. KP is well positioned to grow in a post-ACA
era in which policies to advance integration has prolifer-
ated. Growth has been especially dramatic in the South-
ern California Region, where new individuals that joined
via the Health Exchange grew by 4 % per year (from 2 to
6 %). This rapid influx of new members has been most
pronounced among younger and healthier individuals as
compared to members in KP’s traditional employer-
based plans.
KP leadership knew that they needed to understand
the implications of this shift in demand and have held
focus groups with their newest members. Results have
led the company to reorient business strategy around
three priorities, as follows:
1. Convenience. Millennials are demanding “care
anywhere and how we want it.” Increased access,
convenience, and enhanced experience of healthcare
are therefore major priorities for the organizations.
2. Affordability. Because the individual market is more
35. price sensitive than the group market, there is a
heightened awareness that they must reduce the
cost of care in order to continue to expand in this
market.
3. Value. At the same time, new healthcare consumers
expect more value or increased and enhanced
services, and this is driving a number of efforts
focused on the care experience.
Change strategies
Three strategic initiatives have emerged in response to
these drivers. The LMP and the national innovation
units are integrated into all three, as are KP members’
views, as represented through surveys, focus groups, and
ethnographic studies.
� Perform, Grow, Lead is KP’s strategic plan. It
emphasizes affordability targets, meeting rising
customer expectations, and transforming care.
Guiding principles include the following: One KP,
which calls for a common care experience across all
regions, and the KP people strategy, which
articulates the desired characteristics of the KP
workforce as “innovative, engaged, change ready,
healthy, and accountable.”
Pittman and Scully-Russ Human Resources for Health (2016)
14:56 Page 4 of 15
� Vision 2025 is an ongoing initiative to understand
what healthcare consumers will look like and how
KP can position itself to meet needs in a rapidly
changing healthcare market. It develops care models
36. and offers strategic road maps to guide planning and
change. Health information technologies are central
to this strategy, including the use of social media to
keep its members informed and healthy and new
mobile technologies to enhance staff communication
and reporting. Remote diagnostic tools will also be
more available to patients for common ailments like
strep throat, to allow self-testing and more rapid
recoveries. In the next 5 to 7 years, they see
increased use of remote monitoring technology,
sensors, and virtual care, as well as health analytics
to enhance the nurse role in triage and care
management [23]. As one interviewee put it, “…if it
can be automated, it will be.”
� Reimagining Ambulatory Design (RAD) is an
initiative of the Southern California Region that may
spread across KP. Its goal is to design a new
ambulatory care delivery model aligned to the
principles of consumerism. In extensive research
with members, the leads of this effort discovered
that “…people wanted access to care in a much
more radically different way… It has to do with
much more embedding of services into the
community, into the home, into work…and much
more local access for simple things.” This “life-
integration vision” has sparked several experiments
to redesign and relocate KP clinical operations in
Southern California.
Workforce planning and development strategies
Human resource (HR) leaders and the Coalition of
Kaiser Permanente Unions (CKPU) staff report that early
on the focus of WFPD was on creating consistent work-
force metrics and analytics to help the regions forecast
future staff and skill needs. They now view these tools
37. as necessary but insufficient. A regional HR leader
described the change:
So, at first…we forecasted membership growth,
utilization, supply, turnover, retirement, we looked at
the local labor markets, we connected with a
university for economic analysis of the projected
nursing workforce, and the fluctuations around the
economy. And then we realized that most forecasting
is based on the previous year, or the previous three, or
the previous five years, projecting forward. But if
you’re in the midst of complete transformation of
how you’re providing care, how accurate are those
numbers? …We need to understand what kinds of
jobs (are coming); we need to understand how work is
transforming. So, it really started in 2012 to 2013, (we
have been) trying to get a movement towards a kind
of qualitative approach to understanding change.
Key to this new approach is that it is integrated with
KP’s strategic growth initiatives. As one HR leader ex-
plained, “workforce development is being driven by the
business need.” Part of this emanates from the “affordabil-
ity” imperative, which both HR and labor representatives
agree has given finance a larger role in the company. At
the same time, HR leaders describe the emerging WFPD
approach as “maturing,” by which they mean that finance
is one important player but that they also take into ac-
count other interests. Indeed, HR leaders view themselves
as “intermediaries” who help senior leaders understand
the strategic value of the workforce in the context of the
drive toward labor-cost-saving solutions.
The LMP, which was further strengthened in the 2015
National Agreement, has several mechanisms that inte-
38. grate labor and innovative WFPD strategies into the
strategic change processes. First, for collective bargain-
ing, they use an “interest-based approach,” rather than
traditional, positional bargaining. Both sides emphasize
that there is full transparency in this process—manage-
ment shares information on the company’s financial situ-
ation, competitive standing, and other data related to
the subjects of bargaining and labor provides insight into
the affect of change on the workforce. This open ex-
change results in accommodation, as illustrated by the
Employment and Income Security Agreement (EISA),
which stipulates that any innovation or change at KP
must include a plan for retaining the effected employees.
A second LMP mechanism consists of the negotiated
programs to support innovation and the implication of
change for the workforce. The national agreement delin-
eates the mission and values of joint programs, sets aside
funds, and directs LMP staff and company to consist-
ently integrate the programs across all KP regions.
Examples of these national efforts include Total Health,
which advances wellness, health, and safety in the work-
place; unit-based teams, which identify quality improve-
ment and cost containment solutions at the ground
level; and the National Taft-Hartley Education and
Training Trusts, described above.
Lastly, an important characteristic of the LMP govern-
ance and planning structures is that it is holistic and aims
to permeate every level of the system. In theory, every
manager has a designated labor partner with whom they
are encouraged to engage in strategic and operational de-
cisions that affect the workforce. Both sides report that
this works better in some regions than others, but where
it does work, they say that the engagement is ongoing and
includes strategic decisions that affect not only the work-
39. force but also the future direction of the company.
Pittman and Scully-Russ Human Resources for Health (2016)
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Jobs for the Future, an initiative in the Southern
California region, illustrates how these mechanisms
work together to integrate labor and WFPD strategies
into the strategic change processes at KP. The project
grew from the HR leader’s intermediary strategy of
showing up and intently listening at meetings related to
the RAD project, a strategic change initiative aimed at
redesigning ambulatory care. According to this leader,
he quickly convinced the VP overseeing the project of
the value of labors’ early involvement, and soon after, a
LM committee was formed to explore the proposed
innovation and its impact on the jobs and workers.
Rather than focus on the contentious questions of
workforce impacts, the committee first set out to de-
velop a holistic view of the redesign (new care models,
technologies, facilities, etc.) in order to target the oper-
ational initiatives that would have significant impact on
jobs. Though the HR lead reported that some labor and
management participants fell into traditional roles and
knee-jerk reactions, he observed that these positions
quickly gave way as the committee became more en-
gaged in the processes to redesign the care models and
workflows.
Next, the committee developed a rigorous method-
ology to assess the impact on jobs and formed LM sub-
committees to apply the method to the redesign of
specific work areas. In the end, the committee proposed
40. three new jobs: a roving receptionist of the future that
would take on multiple roles of patient greeter/way
finder/educator, a multifunctional healthcare worker that
would staff new small walk in clinics and perform patent
care and diagnostic functions, and a patient navigator
who would facilitate the extension of care into the arena
of social determinants by helping to coordinate commu-
nity resources. Each of these new roles transgresses
existing occupational, as well union boundaries and
jurisdictions.
The difference between the new with the old approach
to labor relations managing change at KP are explained
by the HR leader as he reflected on this project:
The traditional way of doing it is you’re assigning
labor relations people who don’t understand the
operations and all the technology and innovations.
They’re not included in those conversations. So they
go to the bargaining table, and the labor person has
only been told that there is either going to be a layoff,
or a change in jobs, and we are doing this because of
the need for affordability, or because we need to cater
to the customer. They are like, what!!??? So it is just
kind of set up for an antagonistic type of
relationship…because there hasn’t been this pre-work,
conversations and joint learnings about why this
change is really happening, how it will improve care.
There is a big disconnect between …
SPECIAL COMMUNICATION
How Evolving United States Payment Models
41. Influence Primary Care and Its Impact on the
Quadruple Aim
Brian Park, MD, MPH, Stephanie B. Gold, MD, Andrew
Bazemore, MD, MPH,
and Winston Liaw, MD, MPH
Introduction: Prior research has demonstrated the associations
between a strong primary care founda-
tion with improved Quadruple Aim outcomes. The prevailing
fee-for-service payment system in the
United States reinforces the volume of services over value-
based care, thereby devaluing primary care,
and obstructing the health care system from attaining the
Quadruple Aim. By supporting a shift from
volume-based to value-based payment models, the Medicare
Access and Children’s Health Insurance
Program Reauthorization Act may help fortify the role of
primary care. This narrative review proposes a
taxonomy of the major health care payment models, reviewing
their ability to uphold the functions of
primary care, and their impacts across the Quadruple Aim.
Methods: An Ovid MEDLINE search and expert opinion from
members of the Family Medicine for
America’s Health payment and research tactic teams were used.
Titles and abstracts were reviewed for
relevance to the topic, and expert opinion further narrowed the
literature for inclusion to timely and
relevant articles.
Findings: No payment model demonstrates consistent benefits
across the Quadruple Aim across a
limited evidence base. Several cross-cutting lessons from
available payment models several recommen-
dations for primary care payment models, including the
following: implementing per member per
42. month– based models, validating risk-adjustment tools,
increasing investments in integrated behavioral
health and social services, and connecting payments to patient-
oriented and primary care-oriented met-
rics. Along with ongoing research in emerging payment models,
data systems integrated across health
care and social services settings using metrics that can capture
the ideal functions of primary care will
be critical to the development of future payment models that
most optimally enhance the role of pri-
mary care in the United States.
Conclusions: Although the ideal payment model for primary
care remains to be determined, lessons
learned from existing payment models can help guide the shift
from volume-based to value-based care.
To most effectively pay for primary care, future payment
models should invest in a primary care infra-
structure, one that supports team-based, community-oriented
care, and measures the delivery of the
functions of primary care. ( J Am Board Fam Med 2018;31:588
– 604.)
Keywords: Delivery of Health Care, Family Medicine, Health
Expenditures, Primary Health Care
Forty years ago, in the milestone “Declaration of
Alma Ata,” all member nations of the World
Health Organization declared that achieving health
for all was dependent on a foundation of primary
care.1 A quarter century later, Dr. Barbara Starfield
added to the evidence base, demonstrating that
primary care produces higher quality of care, im-
This article was externally peer reviewed.
43. Submitted 26 September 2017; revised 11 March 2018;
accepted 13 March 2018.
From the Department of Family Medicine, Oregon
Health & Science University, Portland, OR (BP); Eugene S.
Farley, Jr. Health Policy Center, University of Colorado
School of Medicine, Denver, CO (SBG); Robert Graham
Center for Policy Studies in Family Medicine and Primary
Care, Washington, D.C. (AB, WL).
Funding: none.
Conflict of interest: none declared.
Corresponding author: Brian Park, MD MPH, Department
of Family Medicine, Oregon Health & Science University,
3181 SW Sam Jackson Pk Rd, Mailcode FM, Portland, OR
97239 �E-mail: [email protected]).
588 JABFM July–August 2018 Vol. 31 No. 4
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proves health outcomes, increases access, lowers
costs, and attenuates disparities.2,3,4 She attributed
the positive impact of primary care on health sys-
tems to the “4 Cs,” which define its function: first
contact, continuity, comprehensiveness, and coor-
dination (Figure 1).4 Subsequent research has dem-
onstrated that supporting these 4 Cs are the ele-
ments of primary care that help health systems
achieve the Quadruple Aim of improving patients’
experience of care, population health, and physi-
cian satisfaction, while reducing costs.5,6,7,8
48. Starfield’s work and the healthcare system’s
longstanding inattention to primary care may ex-
plain the ongoing failure of the United States to
achieve its Quadruple Aims, given the inadequate
system level support for primary care.9,10,11,12,13,14
Its predominant fee-for-service (FFS) payment
model has long been thought to undermine or
insufficiently support the 4 Cs that explain primary
care’s positive effects.15,16,17 Under pure FFS pay-
ment models, clinicians are reimbursed retroac-
tively for services, incentivizing higher volume,
treatment rather than prevention, and fragmenta-
tion of care without regard for quality or cost. Such
models reward greater numbers of services ren-
dered (ie, volume) rather than the quality and cost
of care provided to patients (ie, value).18,19
Payers, public and private, are experimenting
with shifting from paying for volume to paying for
value. The Affordable Care Act included provisions
that advance primary care and value-based pay-
ment, including the creation of the Center for
Medicare and Medicaid Innovation (CMMI), which
has tested innovative payment and delivery system
models aimed at improving value.20,21,22 Five years
after the Affordable Care Act, the Medicare Access
and Children’s Health Insurance Program CHIP Re-
authorization Act (MACRA) passed. Under MACRA,
providers1 will select 1 of 2 incentive tracks: the al-
ternative payment model (APM; see Table 1) or the
Merit-Based Incentive Payment System (see Table
2).23 Both programs provide incentives for improving
quality and reducing costs.
49. As value-based payment spreads, better under-
standing of existing models can guide which ap-
proaches deserve ongoing implementation and re-
search efforts. This narrative review of the literature
proposes a taxonomy of the major health care pay-
ment models, highlights their distinguishing charac-
teristics (Table 3), and reviews their impacts across
the Quadruple Aim (Table 4). We also discuss the
impact of each payment model in supporting the 4
Cs of primary care; given the lack of widespread use
and standardized metrics in measuring these pri-
1Eligible clinicians provide care for at least 100 Medicare
patients and bill for greater than $30,000 of Medicare Part B
services.
Table 1. Scheduled Adjustments in APM Eligibility Criteria
under Medicare Access and Children’s Health
Insurance Program Reauthorization Act
Year Eligibility
2019 and 2020 �25% of total Medicare revenue is from a
qualified, eligible APM
2021 and 2022 �50% of total Medicare revenue OR
�25% of total Medicare revenue and 50% of all-payer revenue
(eg, Medicaid, private insurers)
is from a qualified, eligible APM
2023 and beyond �75% of total Medicare revenue OR
�25% of total Medicare revenue and 75% of all-payer revenue
is from a qualified, eligible APM
APM, alternative payment model; OR, odd ratio.
50. Figure 1. The 4 Cs of Primary Care.
• Contact: Accessibility as the first contact with the health care
system
• Comprehensiveness: Accountability for addressing a vast
majority of personal health
care needs,
• Coordination: Coordination of care across settings, and
integration of care for acute
and (often comorbid) chronic illnesses, mental health, and
prevention, guiding access
to more narrowly focused care when needed,
• Continuity: Sustained partnership and personal relationships
over time with patients
known in the context of family and community.
doi: 10.3122/jabfm.2018.04.170388 U.S. Payment Models’
Impact on the Quadruple Aim 589
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mary care attributes24, when relevant, we consider
the hypothetical impacts of each model when for-
mal metrics were not used. Based on these findings,
we provide policy and research recommendations
for payment reform to best advance primary care.
Methods
Starfield Summit I: Advancing Primary Care
Research, Policy, and Patient Care
The first iteration of this narrative review was con-
ducted before the inaugural Starfield Summit
55. (http://www.starfieldsummit.com) on April 24 to
26, 2016, in Washington, D.C. It was intended to
inform and capture informant input from the Sum-
mit’s nearly 150 invited primary care leaders
(PCPs), researchers, and health care leaders to dis-
cuss and enable research and policy agenda-setting
around primary care payment, measurement, and
teams.25
Literature Review
We first conducted a literature search26 on primary
care payment, enriched through expert consulta-
tion before, during, and after the Summit. In
March 2016, an Ovid MEDLINE search was con-
ducted using the search terms “payment” and “pri-
mary care.” The search was limited to articles pub-
lished in English since 2010, yielding a total of 391
results2, with 97 articles ultimately included in the
review. Exclusion criteria included the following:
inclusion in a subsequent systematic review, up-
dated evidence available (ie, more recent article
from the same demonstration), not focused on pay-
ment models, not focused on Quadruple Aim
and/or the 4 Cs, and non-US evaluations that were
subnational. Additional articles and gray literature
were identified from the expert opinions of mem-
bers of the Family Medicine for America’s Health
payment and research tactic teams and a “snowball”
method of reviewing the references of the search
results. The literature was summarized for each
model, and key demonstrations or projects were
selected, with agreement from at least 2 authors
from the writing group, to highlight examples.
Results
56. Fee-For-Service
Under FFS, a provider is retrospectively paid a
predefined amount for each service. Consequently,
providers are incentivized to increase volume with-
out bearing financial risk for quality or costs; in-
surers bear high financial risk in this arrangement.
In 1992, the Centers for Medicare and Medicaid
Services (CMS) began using the Resource-Based
Relative Value Scale to set a fee schedule for dif-
ferent services, which has been criticized for dis-
proportionately weighing specialist care and proce-
dures over primary care.27,28 Despite concerns over
the limitations of FFS, its inclusion in a payment
model may enhance the use of services that are
low-cost and underutilized29, such as vaccines in
low immunization areas, where increased volume is
desirable for population health.
Traditional (Or Full-Risk) Capitation
In response to rising costs from FFS, health main-
tenance organizations (HMOs)3 emerged in the
1980s to coordinate care and reduce use30 by capi-
tating payments.26 In traditional capitation, provid-
ers are paid a prospective amount to cover all ser-
vices within a specific period of time, most often as
a per member per month (PMPM) fee. Payments
vary by age-group and sex and are determined
based on prior average costs of care under FFS.31,32
A capitated fee can cover all primary care services,
all outpatient services, or all health care services,
2In the case that a more recent report on a demonstration
project was published between the time of the initial litera-
ture search and submission of this manuscript, we replaced
the prior report with the most up-to-date evidence.
57. 3HMOs and other managed care models also include
other mechanisms for cost control (e.g., narrow provider
networks and pre-authorization of services). For the pur-
poses of this paper, we have examined this model as a
surrogate for capitated payment, though we acknowledge
other mechanisms were in place to contribute to outcomes.
Table 2. Scheduled Payment Adjustments in Merit-Based
Incentive Payment System
Adjustment 2019 2020 2021 2022 and beyond
Baseline payment adjustment �4% �5% �7% �9%
Maximum payment adjustment for high performers �12% �15%
�21% �27%
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including inpatient and outpatient. In contrast to
FFS, capitation incentivizes cost control. Capita-
tion may also exist as part of blended models with
mixed PMPM payments and FFS, or in a further
risk-adjusted form mixed with pay-for-perfor-
mance in comprehensive primary care payment;
these models are discussed in a later section. In
contrast to FFS, capitation shifts financial risk to
the provider, while the payer has lower risk.
114. One study examined the impact of capitation on
one of the 4 Cs and finding capitated models was
associated with decreased first contact (access).33
This may reflect the incentive for providers to
avoid sicker patients (termed adverse selection or
“cherry-picking”) to reduce costs. Another possible
negative impact on the 4 Cs is a financial incentive
to inappropriately underdeliver services, leading to
decreased comprehensiveness.34 The prospective
element of capitation could benefit primary care by
enabling upfront investments in practice compo-
nents that enhance the 4 Cs (eg, care coordination)
and providing flexibility for practices to determine
how finances are spent.
Traditional capitation has demonstrated mixed
effects on cost and quality35,36,37, although most
evidence suggests a decreased use of hospitals and
other expensive resources and worse patient satis-
faction, consistent with the backlash toward HMOs
in the 1990s.38
Pay-For-Performance (P4P)
P4P supplements an underlying payment model,
most often as a bonus on top of FFS. P4P refers to
payment based on the achievement of a quality
target (eg, hemoglobin A1c [HbA1c] level �8 for
diabetic patients or delivery of cancer screening) or
improvement in performance (eg, change from
baseline for HbA1c); the latter approach may at-
tenuate variation in quality across providers, and
provide incentives for both high-performing and
low-performing practices.39
115. Limited evidence exists for the impact of P4P on
the 4 Cs. The United Kingdom’s Quality and Out-
comes Framework (QOF) found decreased conti-
nuity rates and no differences in patient-reported
perception of coordination, when compared with
preintervention periods.40 Incentivized metrics
tended to improve, whereas nonincentivized met-
rics demonstrated unchanged or worsened rates of
improvement; a limited set of targeted metrics
could thus inhibit the comprehensive function ofTa
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primary care.41,42 P4P targeted to the 4 Cs could
hypothetically support primary care; however, cur-
rent metrics focus predominantly on disease-fo-
cused and process-oriented outcomes (eg, HbA1c)
outcomes, rather than patient-centered outcomes
(eg, quality of life) or primary care attributes (eg,
continuity).41,43 Metrics for the latter remain un-
derdeveloped and under used,42 despite growing
recognition of the importance of measuring the 4
206. Cs.45 As P4P is a bonus payment, the shortcomings
of the underlying payment model often prevail.
Overall, the evidence supporting P4P has been
mixed, with inconsistent impacts across the Qua-
druple Aim.41,45,46,47,48,49,50 In 2 large systematic
reviews, 1 from QOF and 1 from the United States,
some modest yet positive impacts on rate of im-
provement for targeted quality and patient out-
comes were observed initially, but these benefits
stagnated over time, if not regressed to preinter-
vention rates.41,51 Providers reported decreased pa-
tient-centered care and continuity41, which are im-
portant predictors of provider satisfaction.52 The
return on investment of P4P may be low, given
significant time and financial costs of implementa-
tion.53
Bundled Payment/Episode-of-Care Payment
Under bundled payment, providers receive a pre-
determined payment for all services rendered for an
episode-of-care; this payment may be provided
prospectively or retrospectively. This model has
been used in hospitals (ie, Diagnosis Related
Groups), which receive a set fee for services (ie,
labor and delivery). As with capitation, providers
are at financial risk if their costs exceed the fee but
profit from cost savings. Bundled payments may be
optimal for high-cost, low-frequency conditions or
episodes (eg, hip fractures), as there is incentive to
limit the costs for the given episode, but not to
limit future episodes.30
Limited evidence exists of the impact of bundled
payment on the 4 Cs. As reimbursements for an
episode of care are bundled for multiple providers,
207. coordination across specialties is encouraged54,
with improvements demonstrated in a Netherlands
bundled-payment initiative.55 Like capitation,
global payment could support the 4 Cs by enabling
investment in a strong primary care infrastructure.
Unfortunately, bundled payments can be difficult
to implement in primary care due to issues around
defining episodes of care. Although acute condi-
tions like fractures and pregnancy have clearer be-
ginning and end points, defining what constitutes a
chronic condition episode is more challenging, a
problem …
Journal of Professional Nursing 33 (2017) 400–404
Contents lists available at ScienceDirect
Journal of Professional Nursing
Original Articles
Is health care payment reform impacting nurses' work settings,
roles, and
education preparation?
Mary Val Palumbo a,⁎, Betty Rambur b, Vicki Hart c
a University of Vermont, College of Nursing and Health
Sciences, 106 Carrigan Drive, Rowell 216, Burlington, VT
05405, United States
b University of Rhode Island, Routhier Endowed Chair for
Practice, College of Nursing, 39 Butterfield Road, Kingston, RI,
02881, United States
c University of Vermont, Office of Health Promotion Research,
1 South Prospect Street, Rm 4428, Burlington, VT 05401,
United States
⁎ Corresponding author.
210. service re-
imbursement schemas, for example, many nursing skills (such
as care
management and patient education) equate to a “labor cost,”
while
medical services are perceived as a “revenue generator.”
Payment re-
form dramatically shifts this equation, suggesting the potential
for
o), [email protected]
more nursing employment in non-acute care settings. Yet have
nurses'
work settings and roles evolved as well? This preliminary study
ex-
plores nurses' work settings in the time of reform, five years
pre-Afford-
able Care Act passage and five years post ACA passage, with
the aim of
clarifying potentially fruitful areas for curricular reform and
empirical-
ly-based nurse continuing education.
Background and Context
One element of health reform, the Affordable Care Act of 2010
(ACA),
creates a path toward universal health insurance that builds on
the
existing U.S. hybrid financing model of governmental payers
(Medicare,
Medicaid, Children's Health Insurance Program, or CHIPS, and
TriCare)
and commercial insurance. It requires that all individuals are
covered
by one of these means, either via one of the governmental
insurances
211. or commercial insurance. Commercial insurance may be
employer-
based or individually purchased. The law also requires each
state to ei-
ther create a “Health Insurance Exchange” or to participate in
the federal
exchange. The purpose of the exchanges are to enable
individuals and
small businesses to compare different health insurance plans in
an “ap-
ples to apples” manner because all plans must include the
“essential
benefit package”, i.e., services that much be covered. What
differs
among the plans is the “actuarial value” of the plans, the
amount of
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Table 1
Key provisions of U.S. Department of Health and Human
Services January 26, 2015
announcement
Timeline of Medicare Value Based Initiative Date
30% of traditional fee-for-service to value based payments By
end of 2016
212. 50% of traditional fee-for-service to value based payments By
end of 2018
85% of all tradition medicare payment to quality or value By
end of 2016
90% of all traditional medicare payment linked to quality or
value By end of 2018
401M.V. Palumbo et al. / Journal of Professional Nursing 33
(2017) 400–404
cost sharing in the form of copayment, deductible, and
coinsurance.
These are also standardized by what is termed metal levels. For
exam-
ple, in a plan with a 60% actuarial value (AV)—a bronze plan—
the in-
sured would pay roughly 40% of health costs but have a lower
monthly premium than, for example, a platinum plan, which has
an ac-
tuarial value of roughly 90%. The law subsidizes those who
meet eligibil-
ity requirements, provided they select a silver plan (AV value of
70%)
In addition to providing such onramps to health insurance, the
ACA
creates incentives for testing alternative payment models
(APMs) to ad-
dress the limitations created by traditional fee-for-service (FFS)
reim-
bursement, a payment model that fragments care by creating
payment silos rather than seamless care across the care
continuum.
Fee-for-service also fuels accelerating health care cost,
overtreatment
and overutilization while simultaneously leaving others
underserved